Volume 11 Number 01 January 2020

till date.
 Indian Journal of Public Health Research & Development
EXECUTIVE EDITOR
Prof. Vidya Surwade
Deptt. of Community Medicine, Dr Baba Saheb Ambedkar, Medical College & Hospital, Rohini, Delhi

INTERNATIONAL EDITORIAL ADVISORY BOARD NATIONAL EDITORIAL ADVISORY BOARD

1. Dr. Abdul Rashid Khan B. Md Jagar Din, (Associate Professor) 5. Prof. Samarendra Mahapatro (Pediatrician)
Department of Public Health Medicine, Penang Medical College, Penang, Malaysia Hi-Tech Medical College, Bhubaneswar, Orissa
2. Dr. V Kumar (Consulting Physician) 6. Dr. Abhiruchi Galhotra (Additional Professor) Community and Family
Mount View Hospital, Las Vegas, USA Medicine, AII India Institute of Medical Sciences, Raipur
3. Basheer A. Al-Sum, 7. Prof. Deepti Pruthvi (Pathologist) SS Institute of Medical Sciences &
Botany and Microbiology Deptt, College of Science, King Saud University, Research Center, Davangere, Karnataka
Riyadh, Saudi Arabia
8. Prof. G S Meena (Director Professor)
4. Dr. Ch Vijay Kumar (Associate Professor) Maulana Azad Medical College, New Delhi
Public Health and Community Medicine, University of Buraimi, Oman
9. Prof. Pradeep Khanna (Community Medicine)
5. Dr. VMC Ramaswamy (Senior Lecturer) Post Graduate Institute of Medical Sciences, Rohtak, Haryana
Department of Pathology, International Medical University, Bukit Jalil, Kuala Lumpur
10. Dr. Sunil Mehra (Paediatrician & Executive Director)
6. Kartavya J. Vyas (Clinical Researcher) MAMTA Health Institute of Mother & Child, New Delhi
Department of Deployment Health Research,
Naval Health Research Center, San Diego, CA (USA) 11. Dr Shailendra Handu, Associate Professor, Phrma, DM (Pharma, PGI
7. Prof. PK Pokharel (Community Medicine) Chandigarh)
BP Koirala Institute of Health Sciences, Nepal 12. Dr. A.C. Dhariwal: Directorate of National Vector Borne Disease
Control Programme, Dte. DGHS, Ministry of Health Services, Govt. of
NATIONAL SCIENTIFIC COMMITTEE India, Delhi

1. Dr. Anju D Ade (Professor) Print-ISSN: 0976-0245-Electronic-ISSN: 0976-5506, Frequency: Quarterly

Community Medicine Department, SVIMS, Sri Padamavati Medical College,Tirupati, (Four issues per volume)
Andhra Pradesh.
Indian Journal of Public Health Research & Development is a double blind
2. Dr. E. Venkata Rao (Associate Professor) Community Medicine, peer reviewed international journal. It deals with all aspects of Public Health
Institute of Medical Sciences & SUM Hospital, Bhubaneswar, Orissa. including Community Medicine, Public Health, Epidemiology, Occupational
3. Dr. Amit K. Singh (Associate Professor) Community Medicine, Health, Environmental Hazards, Clinical Research, and Public Health Laws
VCSG Govt. Medical College, Srinagar – Garhwal, Uttarakhand and covers all medical specialties concerned with research and development
for the masses. The journal strongly encourages reports of research carried
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Belgaum Institute of Medical Sciences, Belgaum, Karnataka
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9. Dr. Md. Amirul Hassan (Associate Professor)
Community Medicine, Government Medical College, Ambedkar Nagar, UP
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Editor
11. Dr. BR Hungund (Associate Professor) Pathology, JNMC, Belgaum.
12. Dr Sartaj Ahmad, PhD Medical Sociology, Associate Professor, Dr. R.K. Sharma
Swami Vivekananda Subharti University Meerut UP India Institute of Medico-legal Publications
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Microbiology Department, B.J. Medical College, Ahmedabad, Gujarat,India

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1. Prof. Sushanta Kumar Mishra (Community Medicine)
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 I
Indian Journal of Public Health
Research & Development
www.ijphrd.com

Contents
Volume 11, January 01 January 2020

1. Study protocol: A Randomised Controlled Trial on Effectiveness of a Worksite Health Intervention

on Common Musculoskeletal Problems and Work-Related Quality of Life (WRQoL) among Female
Workers in the Garment Manufacturing Sectors.................................................................................................1
A. Santham Lilly Pet, Timsi Jain, Bobby Joseph, Pethuru Devadason, Gayathri M

2. Health of the Elderly in India: A Socio-Legal Study..........................................................................................7

Aarti, J.K.Mittal

3. General Awareness of Diabetes Mellitus among a Hospital Population in Chennai: A Survey.......................12

Sridhar M., Abilasha Ramasubramanian

4. Vitamin D Deficiency in Rural Area of Gautam Buddh Nagar: An Observational Study................................16

Vijay Deepak Verma, Ajai Kumar Garg, Suresh Babu, Ashish Satyarthi

5. Identifying the Status of Menstrual Hygiene Management...............................................................................20

Amrita Shilpi, Rajasree Roy, Gobina, Spriha Roy

6. Effect of Strengthening of Scapular Stabilizers in Treatment of Rounded Shoulder Posture in Dental

Students.............................................................................................................................................................27
Ankita M. Patil, Sayali Gijare

7. Elder Abuse in Indian Setting–A Misconception or a Reality– A Deductive Analysis....................................31

Anusha Rashmi, Linda Sequeira, Prianka Shashi Kumar, Rashmi

8. A Study on Women Entrepreneurs Dealing Through Stress.............................................................................35

Archana R.V., K. Vasanthi Kumari

9. Effect of Bilateral Scapular Muscles Strengthening on Dynamic Balance in Post Stroke Individuals.............38
Arpan Dhoka, G. Varadharajulu

10. In Vitro Antibacterial and Anticancer Study of Bioactive Compounds Isolated from Punica Grantum Peel..45
Arunava Das, J. Bindhu, M. Bharath, Nithin Johnson, M. Jeevanantham

11. A Study on Utilization of Primary Health Care Services among the People Residing in a SEMI-
URBAN AREA.................................................................................................................................................53
B. Charumathi, D. Jayashri, S. Manisha, Aadithya, C. Hemanthkumar, Timsi Jain

12. An Empirical Relationship between Stress and Job Performance: A Study with Private School Teachers.....57
D.S. Premalatha, S. Subramanian
II
13. Decision Tree Ensemble Techniques to Predict Thyroid Disease.....................................................................61
Dhyan Chandra Yadav, Saurabh Pal

14. A Descriptive Study to Assess the Knowledge on Child Birth Preparation among Primigravid Mothers
in a Selected Tertiary Care Hospital at Kelambakkam, Kanchipuram District, Tamilnadu, India...................68
J. Chrislin Jebisha, R.J. Joey Persul, D. Joaniepriya

15. Lateral Periodontal Cyst Masquerading Dentigerous Cyst: A Rare Case Report.............................................72
Jagannath Patro, Swagatika Panda, Sreepreeti Champatyray, Alkananda Sahoo, Neeta Mohanty

16. Investigation of a Food Poisoning Outbreak in a Private Hostel in Kanchipuram District, Tamilnadu...........76
Jayashri Damodharan, Prashanth Rajendiran, Charumathi Boominathan, Muthulakshmi Muthiah,
Gomathy Parasuraman, Ruma Dutta, Timsi Jain

17. A Review on Process of Data Mining Approaches in Healthcare Sectors........................................................81

K. Baalaji, V. Khanaa

18. Prevalence of Musculoskeletal Pain among Manual Drummers and Electric Pad Drummers.........................86
K. Jothi Prasanna, S. Rahul Prabhu

19. Effectiveness of Low Level Laser Therapy Versus Ultrasound Therapy with Plantar Fascia Streching
in Subjects with Plantar Fasciitis.......................................................................................................................93
K. Koteeswaran, Ramya K., Rajeshwari, Manikumar Muthiah, Sankara Kumaran Pandian

20. Evaluation of Temporomandibular Disk Position In Symptomatic Temporomandibular Disorder

Patients With Gnathological Splint Therapy Using Mri...................................................................................98
K. Sridhar, M.S. Kannan, Faisaltajir, Gnanashanmugam

21. Antimicrobial Efficacy of Triphala as Root Canal Irrigating Solution in Infected Primary Teeth: An
Ex Vivo Study.................................................................................................................................................105
Kiran N.K., Nagalakshmi Chowdhary, Y. Sharada Devi Mannur, Neethu Elsa Varghese, Arvind
Sridhara, Pavana M.P.

22. Association between Urinary Cotinine Levels and Buccal Mucosal Micronuclei Cells of Smokeless
Tobacco Chewers Attending a Tertiary Care District Hospital.......................................................................109
Kiran S. Nikam, Kanchan C. Wingkar, Rajesh K. Joshi, Rajashekar K. Kallur

23. Balanced Diet: Knowledge and Practice of Adolescents................................................................................115

Krupa Reji, Leema Jacob, Liby Kuriakose, Linsha K., Maria Augustine, Maria George, Priya
Reshma Aranha

24. Influence of Self-Efficacy on Student Engagement of Senior Secondary School Students............................120

Kundan, Bilkees Abdullah

25. Psychological Effects of Trauma to Anterior Teeth........................................................................................126

Lakshmi Nidhi Rao, Aditya Shetty, Mithra N. Hedge

26. Effect of Aerobic Exercises on Selected Physiological Variables among College Long Distance Men
Athletes............................................................................................................................................................132
M. Senthil Kumar, P.R. Nagaraj, Ampili

27. A Descriptive Study to Assess the Knowledge on Pre-Menopausal Symptoms among Middle Aged
 III
Women in a Selected Village at Kanchipuram District, Tamilnadu, India.....................................................136
M. Deepan Babu, S.Vasuki, K.Sangeetha, D. Joaniepriya

28. Health Care Services Under Consumer Protection Laws of Union Territories of Jammu and Kashmir:
A Socio-Legal Mapping..................................................................................................................................140
M.Z.M. Nomani, Ajaz Afzal Lone, Alaa K.K. Alhalboosi, Aijaj A. Raj, Zubair Ahmed

29. Comparison of Morphological Features of Second Cervical Vertebra between Genders Using
Computed Tomography...................................................................................................................................146
Madhavan T.S., Sharath S., Rahul P. Kotian

30. Acceptance of PBL by Students to Learn Pre-Clinical Sciences....................................................................152

Malini Dutta, K. Aditya, Dilip Mathai

31. Effect of Dance Therapy on Stress and Anxiety in Working Women.............................................................158

Manali B. Badave, Khushboo Bathia, Smita Kanase, Amrutkuvar Jadhav

32. A Study on Effect of Favorite Film Songs on Heart Rate Variability (HRV) and Heart Rate (HR) with
Moderate Exercise...........................................................................................................................................163
Manibalanvijayaraman

33. A Proximate Analysis of Phytochemical in Sonalum Trilobatum after the Addition to Leavened Yeast
Goods with Sensory Evaluation......................................................................................................................168
Manivel K., John R. William, Moyeenudin H.M.

34. Satisfaction Level of Physiotherapy Students in North India..........................................................................173

Manoj Malik, Charu Gera, Jaspreet Kaur, Vandana Yadav

35. Prevalence of Lumbar Lordosis in Middle-Aged Females..............................................................................179

Manpreet Bajaj, S. Anandh

36. Radiographic Evaluation of Different Combinations of Zinc Oxide as an Obturating Material in

Pulpectomy: A Comparative in Vivo Study....................................................................................................184
Kiran N.K., Nagalakshmi Chowdhary, Megha Kumar, Pavana M.P., Aravind Sridhara

37. Development of “Young Planning Clinic” Program as a Prevention Early in Adolescent Attitude in
Martapura River Areas....................................................................................................................................190
Meitria Syahadatina N., Atikah Rahayu, Fauzie Rahman, Fahrini Yulidasari, Dian Rosadi, Nur Laily,
Hadianor

38. Patterns and Determinants of Utilization of Healthcarein Urban Field Practice Area of a Tertiary Care
Institute, Hyderabad.........................................................................................................................................195
Moniza Maheen, Fawwad M. Shaikh, Vaseem Anjum, A. Chandrasekhar

39. Awareness & Practice of Road Safety Measures among Under Graduate Medical Students of a
Medical College in Bengaluru, Karnataka......................................................................................................199
Shyam A.C., Mubarak Nadeer

40. The Effect of Eye-Hand Coordination Device on Coordination in Subjects with in-Coordination................203
MuzahidKadir Sheikh, Suraj B. Kanase

41. Prevalence of Depressive Symptoms among Incognizant Patients Visiting a Hospital..................................208

IV
A. Vinita Mary, N. Manikandan, K. Pavithra, M. Nathiya, R. Kesavan

42. Intelligent System for Physically Challenged Person in Virtual Prototype Environment...............................213
N. Prabhakaran, N.D. Bobby, M. Munireddy, G.S. Sivapriya

43. Health Insurance Utilisation Pattern in Two Districts of Karnataka...............................................................218

Nagaraj Shet, Ghulam Jeelani Qadiri, Sunita Saldanha, Gayathri Kanalli S., Prajna Sharma

44. Study of Knowledge, Attitude and Practise (KAP) Regarding Swachh Bharat Mission Among High
School Students in Field Practise Area of Medical College in Dakshina Kannada, Karnataka......................224
Nanjesh Kumar S., Jithin, Harshitha, Rashmi Kundapur, Sanjeev Badiger, Pavan Kumar

45. Association of Personality Traits, Life Satisfaction, Subjective Happiness and Oral Health Status in
School Teachers of Vikarabad.........................................................................................................................228
N. Sindhu Reddy, M. Monica, T. Abhinav Nithin, P. Parthasarathi Reddy, Irram Abbas Hameed, B.
Prathibha

46. Effect of Structured Exercise Programme on Pulmonary Function and Physical Performance in
Geriatric Population.........................................................................................................................................234
Gaurav S. Chandolkar, Javid H. Sagar, Govindhan Vardharajulu

47. Comparative Evaluation of Depth of Cure of Bulk-fill Composite Resin and Alkasite Restorative
Material by Vicker’s Hardness Test................................................................................................................238
Gowrish Bhat, Namrata Khanna, Mithra Nidarsh Hegde, Vandana Sadananda

48. Population Growth and its Impact on Public Health in India: A Legal Analysis............................................243
Hiranmaya Nanda, Shyamantak Misra

49. Evaluation of Malondialdehyde, Glutathione Peroxidase and Defensin Levels in Patients with and
without Periodontitis........................................................................................................................................247
J. Hemashree, Sreedevi Dharman, Selvaraj

50. Effect of Neurodynamic Sliding Technique on Hemiplegic Stroke Subjects with Hamstring Tightness.......252
J. Anandhraj, A. Kumaresan

51. To Compare the Flexural Properties of Three Commercially Available Heat Cure Denture Base Resins
After Water Immersion Over a Period of Three Months: An in Vitro Study..................................................256
Neha Chugh, Pradeep Sheriger, Dhanasekar Balakrishnan, Aparna Ichalangod Narayan

52. Effect of Weight Bearing and Neurobic Exercises on Bone Health and Physical Function in Elderly
Individuals.......................................................................................................................................................262
Neha Dighe, S. Anandh, G. Varadharajulu

53. Knowledge, Attitude and Practice of Biomedical Waste Management in Nursing Staff of a Private and
a Government Tertiary Care Teaching Hospital: A Comparative Study.........................................................268
Nishitha K., Alice Matilda Mendez, Nisha B., Timsi Jain

54. WTO and its Impact on Indian Pharmaceutical Production: A Legal Perspective.........................................274
Nitesh Kumar Srivastava

55. Prevalence and Molecular Characterization of Glucose-6-Phosphate Dehydrogenase Deficiency

among Brahmins and Muslims of Manipur, India...........................................................................................279
 V
Nongthombam Achoubi, Mohammad Asghar, Anand Kumar Gyanendra Singh Wahengbam, Soibam
Jibonkumar Singh, Kallur Nava Saraswathy, Benrithung Murry

56. Efficacy of Technology Basded Method to Improve Knowledge on Health Promoting Behaviour
towards Maternal Hypothyroidism among Primi Mothers with Hypothyroidism..........................................284
P.M. Arulmozhi Baskaran, Prasanna Baby

57. Effect of Water Aerobic and Aerobic Exercise on VO2 Max Parameter among College Men Students........290
P.R. Nagaraj, R. Senthil Kumar

58. Assessment of Different Types of Malocclusion Using IOTN Index and Geographic Information
System: A Cross-sectional Observational Study.............................................................................................294
Bhagyalakshmi Avinash, Balasubramanian S., Ravikumar S., Suma Shekar, Avinash B.S.

59. Hair Mercury Exposure and Hypertension among Community Artisanal and Small Scale Gold Mining
in Banten, Indonesia........................................................................................................................................300
Budi Hartono

60. Effect of Lavender Oil Massage on Pain among Patients with Knee Osteoarthritis.......................................305
Enas Mahmoud El Sayed, Hanan Ahmed Al Sebaee, Heba Ahmed Mohammed, Zeinab Osman Nawito

61. How Soon Can You Expect to Get Pregnant after Discontinuing Reversible Contraceptive Method?
A Survival Analysis of the 2017 Indonesia Demographic and Health Survey Data.......................................311
Maria Gayatri, Budi Utomo, Meiwita Budiharsana

62. Reviving the Lost Extremity: A Case Report..................................................................................................316

Nitika Gupta, Jeewan Bachan Dhinsa, Urvashi Sukhija, Sanjeev Mittal

63. Lower Extremity Perfusion among Patient with Type 2 Diabetes Mellitusin a Tertiary Care Hospital,
Kochi...............................................................................................................................................................320
Reshma K. Sasi, Rafia Islam, Anjana Sunil, Anju Markose

64. A Glimpse of Manual Scavanging in India.....................................................................................................326

Shailla Cannie, Aasavri Cannie

65. Out of Pocket Spending for Natal Care Services: A Comparative Analysis among High and Less
developed States in India.................................................................................................................................330
A.K. Ravisankar

66. Current Research in Neuropathology and Pharmacotherapy of Alzheimer’s Disease: A Review..................335

Amit Yadav, Prabhat Kumar Upadhyay, Manish Kumar, Vishal Kumar Vishwakarma, A. Pandurangan,
Pradeep Mishra

67. In Vitro Anticancer Study of Bioactive Compound Isolated from Musa Extract (Musa Acuminata)............341
Arunava Das, J. Bindhu, P. Deepesh, G. Shanmuga Priya, S. Soundariya

68. Optimized Feature Selection and Classification in Microarray Gene Expression Cancer Data......................348
B. Lakshmanan, T. Jenitha

69. Evaluation of Autonomic Dysfunction in Underweight, Normal Weight, Overweight and Obese
Patients with Chronic Obstructive Pulmonary Disease...................................................................................354
Desai Nabil, Jyoti Ganai, Shobitha M., Nabi N.
VI
70. Effect of Exercise Program in Reducing Risk of Fall in Elderly People.........................................................360
Elizabeth J. Shende, Pranjali M. Gosavi, S. Anandh, Yogita A. Pawar

71. Regenerative Endodontics-The Future? A Questionnaire Based Study..........................................................364

Farhan Ariwala, Mahalaxmi Yelapure, Mithra N. Hegde, Darshana Devadiga, Upasana

72. Breast Cancer Screening: Are ‘At Risk Population’ Known by Public Health Nurse Practitioners?.............370
G.M. Venkatesh, M. Sundar

73. Credibility of Health Care Advertising-An Empirical Understanding of its Multi-Dimensional

Structure and Scale Validation with Special Reference to Children’s Health Food Drinks...........................375
Indu Manish Kumar

74. Association of Epicardial Adipose Tissue Thickness with Resting and Post-Exercise Cardiac Output
in Overweight and Obese Individuals.............................................................................................................381
Sridevi, Kalyana Chakravarthy Bairapareddy, Bhamini Krishna Rao, Arun G. Maiya, Gopala Krishna
Alaparthi, Krishnananda Nayak

75. The Effectiveness of Health Belief Model as an Educational Intervention in Improvement of Oral
Hygiene: A Systematic Review.......................................................................................................................386
Nesa Aurlene, Sunayana Manipal, Rajmohan, Prabu D.

76. Do Stress and Resilience among Undergraduate Nursing Students Exist?.....................................................391

Priscilla Roselyn Sam, Premila Lee

77. Antibacterial Activity of Combination between Probiotic Milk and Mango Honey Against
Streptococcus Mutans......................................................................................................................................395
Inaaroh Waachidah Azzulfiyyah, Isnaeni, Noor Erma

78. Prevalence of Premarital Sex among Adolescents in Kulende, Sango in Ilorin South Local Governmrnt
Area, Kwara State, Nigeria..............................................................................................................................400
Oniyangi, Shuaib Olanrewaju, Jamiu Abdul Qudus Tosin, Umar Ibrahim Babangida, Ahmad Makama
Getso, Sindama Helen

79. Perceived Effect of Sleep Deprivation on the Health of Undergraduates in Kwara State University,
Malete, Nigeria................................................................................................................................................405
Oniyangi, Shuaib Olanrewaju, Jamiu Abdul Qudus Tosin, Umar Ibrahim Babangida, Ahmad Makama
Getso, Sindama Helen

80. Noise Relationship with Complaints of Disorders of Hearing in Crafts Industry with Iron in Parigi
Moutong District..............................................................................................................................................410
Abdul Hamid, Abdul Rohim Tualeka

81. The Role Of Cultural Social Factor In Decision Making Of Choosing Female Family Planning
Contraception...................................................................................................................................................414
Abdul Jalil Amri Arma, Surya Utama, Iskandar Muda

82. Epidemiology of Hypercholesterolemia among Adults in Samara City.........................................................419

Abid Ahmad Salman Al‑Mahmood, Ehan Abdulhadi Hussein Al‑Sharifi, Asia Abed Al‑Mahmood

83. Corn Silk Based Ethosomal Gel: A New Treatment for Periodontitis in Diabetic Albino Rats a
 VII
Prelimenary Study...........................................................................................................................................425
Riuwpassa I.E., Kim YR, Tenrilili A.N.A., Untung J.S., Djamaludin N.S., Achmad M.H.

84. Circuit Training to Increase Cardiorespiratory Endurance in Male Basketball Players..................................431

Agung Wahyu Permadi, I. Made Wisnu Adhi Putra, Endang Sri Wahjuni

85. Relationship between Self‑Care for Fluid Limitation and Interdialytic Weight Gain among Patients
with Hemodialysis at Ratu Zalecha Hospital, Martapura................................................................................437
Agus Rachmadi, Ita Ratnasari, Nursalam, Arief Wibowo

86. Effect of Preoperative Biofeedback on Anal Continence After Fistula in Ano Surgery.................................442
Ahmed Farag, Hany M.S. Mikhail, Ahmed S. Khalifa, Mohamed T. Mostafa, Abdrabou N. Mashhour

87. Relation between Human Epididymis Protein 4 and Endometrial Pathology in Women with
Postmenopausal Bleeding................................................................................................................................447
Ahmed L. Aboul Nasr, Ghada A. Abdel Moety, Mostafa S. Salem, Marwa M. Elsharkawy, Nada
Kamal, Ahmed M. Maged

88. Evaluation of Eye Relaxation to Decrease Eye Strain in PT Japfa Comfeed Indonesia Unit Sragen.............453
Aisy Rahmania, Noeroel Widajati, Abdul Rohim Tualeka

89. Effectiveness of Dorsata Honey Suplement on Interleukin‑3 Levels in Breast Cancer Patients Who
Underwent Chemotherapy...............................................................................................................................457
Aji Kurniawan, Daniel Sampepajung, Salman Ardy Syamsu, Prihantono Prihantono

90. Effect of Blood Sampling Method During a Mating Time in Male Camels (Dromedary Camels)................463
Alaakamil Abdulla, Ali Habeeb Jaber AL‑bdeery, Basim Hameed Abed Ali

91. Hyaluronidase Versus Magnesium Sulphate as Adjuvants to Bupivacaine in Ultrasound Guided

Supraclavicular Brachial Plexus Block in Upper Limb Surgeries..................................................................469
Amany K abo Elhusein, Mamdouh Hassan, Nagat A. Ali

92. Influence of Social Cultural Capital and Marketing on Skin Whitening Products Use among Higher
Education Female Students in the Northeast of Thailand...............................................................................476
Anawat Phutongnak, Wongsa Laohasiriwong, Kittipong Sornlorm

93. Knowledge Management Based Performance Improvement on Certified Health Workers in Health
Center of South Sulawesi................................................................................................................................482
Andi Mansur Sulolipu, Ridwan Amiruddin, Sukri Palutturi, Ridwan M. Thaha, Arsunan A.A.

94. Determinants that Influence Relationship between Motivation and Job Satisfaction of Health Workers
at Primary Health Care in Indonesia................................................................................................................486
Armedy Ronny Hasugian, Jaslis Ilyas, Besral, Adang Bachtiar

95. Risk Factors for Obesity in Patients with Hypertension..................................................................................492

Aylinda Wahyuni Putri, Ratu Ayu Dewi Sartika

96. The Role of Social Support on Coping Stress in Type‑2 Diabetes Mellitus Patients with Gangrene
Complications..................................................................................................................................................498
Ayu Aisah Zuraidah, Arif Nur Muhammad Ansori, Suhailah Hayaza, Ilham Nur Alfian, Suryanto,
Nurul Hartini
VIII
97. The Relationship of Work Instructions Compliance with Safe Behavior of Production Part Workers in
PT X.................................................................................................................................................................502
Ayu Prima Kartika, Windi Wulandari, Noeroel Widajati, Abdul Rohim Tualeka

98. The Relationship of Age and Work Period with Hearing Disorders on Workers Which are Exposed
to Noise Above Threshold Limit Value of Loom Part Weaving Ajl Department in Pt Bintang Asahi
Tekstil Industry................................................................................................................................................507
Bella Oktavia, Rezania Asyfiradayati, Abdul Rohim Tualeka

99. Health Literacyon Weighing Control and Use of Weight Loss Products among Working‑age Women
in the Northeast of Thailand............................................................................................................................512
Chalee Yaworn, Wongsa Laohasiriwong, Kittipong Sornlorm

100. Awareness Regarding Heart Diseases among Middle Aged Adults in a Rural Area of Rupandehi District..517
Chanda Sah, Priyanka Gyawali

101. Correlation of Osteocalcin Urine Levels with Bone Mass Density in Menopause Women in H. Adam
Malik General Hospital Medan.......................................................................................................................521
Cherry Kumalasari, M. Fidel Ganis Siregar, Deri Edianto, Christoffel L. Tobing, M. Fahdhy, Cut
Adeya Adella

102. Benefit of Thai Hermit Exercise on MCI Patients’: A Randomized Controlled Trial....................................527
Chomlak Kongart, Yuttachai Likitjaroen, Surasak Taneepanichskul, PhD

103. Relationship of Individual Characteristics and Noise Intensity with Subjective Hearing Loss to
Workers at Pt. X..............................................................................................................................................534
Cut Suci Almadiana T., Sumihardi, Abdul Rohim Tualeka

104. The Role of Matrix Metalloproteinase‑9 (MMP‑9) and Tissue Inhibitor Metalloproteinase‑1 (TIMP‑1)
Level in Dengue Hemorrhagic Fever..............................................................................................................539
Dasril Daud, Nina Cicci Hasnani, Husein Albar

105. Ethanol Extract with Black Cumin (Nigella Sativa) Against sFlt‑1 Level and VEGF Serum on
Laboratory Mice with Preeclampsia................................................................................................................544
Deasy Irawati, Hidayat Suyuti, Titi Maharrani, Fitriah, Ani Media Harrumi, Suryaningsih, Nursalam

106. Effect of Nutritional Status, Hemoglobin Levels and Psychosocial Emotional Behavior with Cognitive
Function of Female Teenager..........................................................................................................................550
Diana Septaria Abidin, Roedi Irawan, Windhu Purnomo

107. Life Experience of Adolescents with Thalassemia: A Qualitative Research with Phenomenological
Approach.........................................................................................................................................................555
Dini Mariani, Sri Mulatsih, Fitri Haryanti, Sutaryo

108. The Effect of Metabolic Syndrome on Systolic Function of Left Ventricle Using Echocardiographic
Examination.....................................................................................................................................................560
Doaa H. EL‑Farook, Hatem A. Sarhan, Manal M. Mohamed, Ahmed EL‑Barbary, Khaled A. Khaled

109. The Role of Mean Arterial Pressure (MAP) Roll Over Test (ROT) and Body Mass Index (BMI) in
Preeclampsia Screening in Indonesia..............................................................................................................566
Dwi Putri Rahayu Tampubolon, Lilik Herawati, Nursalam, Ernawati
 IX
110. Strategic Contribution of Health Services in the Indonesia‑Malaysia Border to The National Resilience:
Analysis of Implementation in the West Kalimantan Province......................................................................570
Dwi Rachmatullah, Dumilah Ayuningtyas, Raden Roro Mega Utami

111. Survival Analysis of Chronic Kidney Failure with a History of Degenerative Disease.................................575
Efri Tri Ardianto, Alinea Dwi Elisanti

112. Capital Knowledge Concept: Accounting Behavior and Health Management in Indonesia..........................581
Entar Sutisman, Bambang Tjahjadi, Hamidah

113. Early‑Onset Neonatal Sepsis in Low‑Birth‑Weight and Birth‑Asphyxia Infants at Haji Hospital
Surabaya, Indonesia.........................................................................................................................................586
Euvanggelia Dwilda Ferdinandus, Berliana Devianti Putri

114. Humanoid Robot Integration in Rehabilitation of Musculoskeletal Conditions.............................................591

Fayz S. Al‑Shahry, Rayan F. Al‑Shehri

115. Does Give Malnourished Pregnant Mothers with Supplementary Feeding Biscuit Can affect Pregnancy
Outcomes?.......................................................................................................................................................597
Henrick, Andi Imam Arundhana Thahir, Khartini Kaluku, Elsye Theresia, Saifuddin Sirajuddin, Veni
Hadju, Abdul Razak Thaha

116. Heavy Metals Concentration and Biochemical Parameters in the Blood and Nails of Industrial Workers....602
Kameran Sh. Husien, Mohsin O. Mohammed, Tamara N. Ahmed

117. Impact of Workplace Violence Educational Program on Self Confidence for Nursing Staff Working
in Psychiatric Hospital.....................................................................................................................................607
Mohga Fathy Abd Elmoteleb Ali Hamza, Afaf Abd Elhamed Abd Elrahman

118. The Association of Glutathion Peroxydase‑1 Serum and Sensorineural Hearing Lossin MDR TB
Patients with Kanamycin Therapy...................................................................................................................612
Ratna Anggraeni, Arif Darmawan, Febri Wisudawan F.

119. Post‑Traumatic Growth with Police Officer: System Review (Focused on Korean and Foreign Studies).....618
Seung Woo Han

120. HIV Stigma among Clinical Medical Students in East Java, Indonesia..........................................................623
Firas Farisi Alkaff, Adila Taufik Syamlan, Presstisa Gifta Axelia, Jovian Phillip Swatan, Sulistiawati

121. Effectiveness of Falls Prevention Education on its Prevention Behavior among Older Adults: A
Systematic Review..........................................................................................................................................629
Goh Jing Wen, Devinder Kaur Ajit Singh, Suzana Shahar

122. Development of “Young Planning Clinic” Program as a Prevention Early in Adolescent Attitude in
Martapura River Areas....................................................................................................................................635
Atikah Rahayu, Fauzie Rahman, Fahrini Yulidasari, Meitria Syahadatina N, Dian Rosadi, Nur Laily,
Hadianor.

123. Chipping Resistance of Nanosilica Treated Zirconia Cores Veneerd with Porcelain after Thermocycling
and Cycling Loading.......................................................................................................................................640
Hanaa F Mahmoud, Yaser F Gomaa, A Nour A Habib
X
124. Assessment of Fracture Force of CAD‑CAM‑fabricated Occlusal Veneer Restorations with Different
Thicknesses......................................................................................................................................................646
Hanaa Saber Rabeae, Cherif Adel Mohsen, Shams Waaz Amgad

125. The Analysis of the Dynamics of the Willingness‑to‑Pay Indicator for the Use of Innovative
Technologies in Healthcare Calculated on the Basis of the Purchasing Power Parity of the Population
in the Post‑Soviet Countries............................................................................................................................652
Hanna Panfilova, Alla Nemchenko, Liusine Simonian, Oleg Gerush, Natalia Bogdan, Oksana Tsurikova

126. Molecular detection of C5a Peptidase (scpB) Gene in Group B Streptococcus Isolated from Pregnant
Women and the Correspondence with Adverse Pregnancy Outcome.............................................................659
Hassan Saad Sakap, Jabbar S. Hassan, Sahar Hisham Abdul Razak

127. Role of MnSODVal16Ala Gene Polymorphism in Changing the Level of Serum Metals in Workers
Exposed to Heavy Mmetals in Al‑Nasiriyah City...........................................................................................665
Hayder Hussein Jalood, Afrah Abid Maktoof, Hassan R. Al‑Rekaby

128. Relative Hypoxia in Immunized Mice Spleen Macrophages as Indicated by Hypoxia Inducible
Factors, Cytoglobin and Peroxisome Proliferator Activated Receptor Gamma Coactivator (PGC)‑1α.........671
Hijrah Asikin, Ninik Mudjihartini, Sri Widia A. Jusman, Mohamad Sadikin, Sarifuddin Anwar

129. The Emerging Risk of Interaction Between Complementary Alternative Medicines and Cardiovascular
Medicines.........................................................................................................................................................676
Huda S. Husni

130. Effect of Exercises Using a Pressing Tool on Some Biochemical and Skilled Variables of Tennis Players.. 682
Hussein Ali Hussein Al Kufi

131. Evaluation of Angiopoietin One and Angiopoietin Two with Missed Abortion............................................686
Hussien Saeed Masood, Sami Akreem Zbaar, Bushra Mustafa Mohamed

132. Predictive Value of Toprs Score in Outcome of Pediatric Patient in Emergency Installation........................692
Idham Jaya Ganda, Fitriya Idrus, Dasril Daud

133. Cellular Phone and Laptop Radiation Effects on Subjective Complaints in Informatics Students.................697
Isna Qadrijati, Haris Setyawan, Seviana Rinawati, Tutug Bolet Atmojo, Rizka Andhasari Santoso,
Akbar Fadilah, Realita Sari

134. Comparing the Effectiveness of Video‑Assisted Teaching and Simulation on Nurses’ Knowledge in
Performing Cardiopulmonary Resuscitation...................................................................................................702
Jatim Sugiyanto, Karyono Mintaroem, Titin Andri Wihastuti

135. Association of Exon Deletion of MXI1 Gene with Cervical Abnormalities and Cancers Incidence in
Some Iraqi Married Women............................................................................................................................707
136. Curcumin and 6‑Shogaol Increase Hemoglobin F Levels by Inhibiting Expression of STAT3 mRNA
Gene in K562 Line Cell...................................................................................................................................712
Joko Setyono, Ahmad Hamim Sadewa, Edy Meiyanto, Mustofa.Mustofa

137. Introduction of Probiotic Type of Yogurt for the Treatment of Dysbiosis of Patients with
Lymphogranulomatosis Under Poly Chemotherapy of Beacopp‑II Protocol.................................................718
Kaliberdenko V.B., Kuznetsov E.S., Morozova M.N., Malev A.L., Zakharova A.N., Shanmugaraj K.,
 XI
Balasundaram K.

138. Influence of Mental Health and Social Relationships on Quality of Life among Myanmar Migrant
Workers in the South of Thailand....................................................................................................................721
Kanit Hnuploy, Wongsa Laohasiriwong, Kittipong Sornlorm, ThitimaNutrawong

139. Lumbosacral MRI Findings in Chronic Lower Back Pain..............................................................................727

Kermanj Ismail Bakr, Israa Mohammed Sadiq

140. Joint Effect Obesity and Oral Contraceptive Use towards Hypertension among Women in Thirteen
Provinces in Indonesia.....................................................................................................................................733
Kuuni Ulfah Naila El Muna, Helda

141. Tithonia Diversifolia vs Catechin: Role in Regulating Blood Glucose, Malondialdehyd, and Super
Oxide Dismutase Level on Rat Induced Diabetes Mellitus and High‑Fat Diet...............................................739
Lailatul Muniroh, Rondius Solfaine, Indra Rahmawati

142. Comparison between the Antioxidant Activity of Volatile Oil and Hydrosol in Eucalyptus
Camaldulensis (Young and Adult) Leaves......................................................................................................745
Lamiaa A. Gharb

143. Selfcare Behaviour of the Diabetic Patients in a Primary Health Center in Bali............................................750
Made Mahaguna Putra, Kusnanto, Candra Panji Asmoro, Tintin Sukartini, Tjahja Bintoro, Ni Made
Dwi Yunica Astriani, Putu Indah Sintya Dewi

144. Cut off Point of Insulin‑Like Growth Factor‑I (IGF‑1) for Prediction of Child Stunting...............................755
Masrul, Doddy Izwardy, Ricvan Dana Nindrea, Ikhwan Resmala Sudji, Idral Purnakarya

145. Effect of Generative Learning Strategy with Visual Technologies in Learning Some Basic Skills and
Motor Abilities for 5‑6‑Years Kindergarten Children.....................................................................................761
Mayadah Khalid Jasim

146. The Effect of Self‑Regulated Learning Strategy in Motor Hyperactivity and Learning the Performance
of Skill of Jump Shot in Basketball for Freshmen High School Students.......................................................766
Mayadah Khalid Jasim, Shaymaa Jasim Mohammed

147. Influence Organizational Citizenship Behavior (OCB) on Performance Nurses Public Health Centre
in the District Tuban........................................................................................................................................771
Miftahul Munir

148. Combined Exercise Effects on Lipid Profiles in Hypertensive Patients..........................................................775

Mitiku Daimo, Soumitra Mondal, Mahmud Abdulkader, Dhamodharan Mathivanan

149. Ego State Therapy (EST) and Systemic Desensitization (SD) to Reduce School Refusal among Senior
High School Students......................................................................................................................................781
Mochamad Nursalim, Nur Hidayah, Adi Atmoko, Carolina L. Radjah

150. Implant Materials Used for Orbital Floor Reconstruction...............................................................................787

Mohamed Esmail Khalil, Mohamed Farag Khalil, Raafat Mohyeldeen Abdelrahman, Ahmed
Mohamed Kamal Elshafei, Tamer Ismail Gawdat

151. Expression of Amylin and Preptinin Iraqi Patients with Type 2 Diabetes Mellitus........................................793
XII
Mohammed I. Hamzah, Israa A. Abdul Kareem, Mohammed Albayati

152. Evaluate The Correlation Between Antioxidant Capacity And Interferon Γ Level With The Disease
Activity Of Sle Patients In Iraqi Woman.........................................................................................................799
Mohammed T. Alaanzy, Jinan M.J. Alsaffar, Ahmed Abdul Bari

153. Comparative Effect of Mulligans Mobilisation Versus Stabilisation Exercise on Chronic Nonspecific
Low Back Pain: A Pilot Study.........................................................................................................................804
Mohan Kumar G., Jibi Paul, Sundaram M.S., Mahendranath P.

154. Factors Associated with Work Fatigue in Workers of the Nipah Building Construction Project Makassar..810
Muh. Arfandi Setiawan, Awaluddin, Andi Wahyuni, Abdul Rohim Tualeka

155. Quality Evaluation of Health Services at Community Health Centers: through Accreditation Surveys
in Indonesia......................................................................................................................................................815
Muhammad Tahir, Ridwan Amiruddin, Sukri Palutturi, Fridawaty Rivai, Lalu Muhammad Saleh,
Owildan Wisudawan B

156. Hypoglicemic and Antioxidant Activity of Yellow Pumpkin (Curcubitamoschata) in Diabetic Rats............821
Muji Rahayu, Menik Kasiyati, Atik Martsiningsih, Budi Setiawan, Furaida Khasanah

157. Association of Diabetes Mellitus and Estrogen Hormone Levels with Vaginal Candidiasis.........................826
Netti Suharti, Almudri, Ricvan Dana Nindrea, Silfina Indriani

158. P24 Antigen Quantification of Indonesian Patients Infected with HIV‑1 CRF01_AE...................................831
Ni Luh Ayu Megasari, Devi Oktafiani, Elsa Fitriana, Nasronudin,, Soetjipto,

159. Effect of Black Seed (Nigella Sativa) Extract on Release of Some Minerals from Human Enamel: An
in Vitro Study..................................................................................................................................................836
Nibal Mohammed Hoobi, Raya R. Al‑Dafaai, Baydaa Hussain

160. Efficacy of Catharanthus Roseus Extract Against Dengue Virus Type 2 Infection in Vitro..........................841
Noor Zarina Abd Wahab, Norefrina Shafinaz Md. Nor, Nazlina Ibrahim

161. Psychometric Evaluation of a Feedback Conception Scale: Building Positive Feedback Practises of
Charge Nurses in Public Hospitals..................................................................................................................845
Nor Hasnida Che Md Ghazali*, Mohd Nazir Md Zabit, Mahizer Hamzah

162. Factors Associated with Hypertension among Adults in West Java, Indonesia..............................................850
Nurul Wahyu Wadarsih, Ratu Ayu Dewi Sartika

163. Correlation of Interleukin-6 with Serum Estradiol Mean Levels in Menopause Women at Rsup H
Adam Malik Medan.........................................................................................................................................856
Nutrisia Latjindung, M. Fidel Ganis Siregar, Hanudse Hartono, Sarma N. Lumbanraja, Deri Edianto,
Iman Helmi Effendi

164. High Bride Price as Determinant of Marital Stability among Akwa-Ibom People in Surulere Area,
Lagos State, Nigeria........................................................................................................................................862
Oniyangi, Shuaib Olanrewaju, Jamiu Abdul Qudus Tosin & Owo, Blessing, Umar Ibrahim Babangida
& Ahmad Makama Getso, Sindama Helen

165. Psychosomatic Impact of Social Networking Sites on Society and its Subtle But Real Consequences.........867
 XIII
Abhimanyu Chopra, J.K. Mittal

166. Detection of Extended-Spectrum-Beta-Lactamase (ESBL) Producing Escherichia Coli in Meat

Chicken from Traditional Market in Surabaya, East Java, Indonesia.............................................................872
Dhandy Koesoemo Wardhana, Mustofa Helmi Effendi, Nenny Harijani, Hong-Kean Ooi

167. Health Problems of Prospective Brides in Rural Area of East Java, Indonesia..............................................877
Nunik Puspitasari, Sri Sumarmi, Yuly Sulistyorini

168. Cytotoxic Activity and Selectivity Index of Solanum Torvum Fruit on T47D Breast....................................883
Nunuk Helilusiatiningsih, Yunianta, Harijono, Simon Bambang Wijanarko

169. The Relationship between Father Involvement with Growth and Social-Emotional Development in
Preschool Children..........................................................................................................................................889
Nur Hijrah Tiala, Fitri Haryanti, Akhmadi

170. Auditory evaluation with Pure Tone Audiometry and DPOAE in Kanamycin Treatment of Multidrug-
Resistant Tuberculosis.....................................................................................................................................896
Nyilo Purnami, Aditya Brahmono, Bakti Surarso

171. Assessment of Coronary Heart Disease Risk among Diabetes Mellitus Survivor in Community Health
Center Purwosari Indonesia.............................................................................................................................901
Okti Sri Purwanti Agus Sudaryanto, Ahmad Faris Muntaha, Agus Sudaryanto

172. Effectiveness of Providing Self-Management Education to Deal With Emesis Gravidarum on

Decreasing Nausea Vomiting Pregnancy (NVP) at Private Practice Midwives Puskesmas IV Denpasar
Selatan Work Area...........................................................................................................................................906
Ni Nyoman Deni Witari, Ni Made Dewianti

173. The Effectiveness of Progressive Muscle Relaxation with Benson Relaxation on the Sleep Quality in
Hemodialysis Patients......................................................................................................................................911
Theresia Uli Porman Purba, Ridha Dharmajaya, Cholina Trisa Siregar

174. Characteristics of Patients with Diabetic Foot Ulcers and Predictors of Surgical Intervention in Basrah,
Southern Iraq...................................................................................................................................................916
Abdulhussein K. Marzoq, Rafid Abduljabbar Mohammed, Omran S. Habib

175. Low CD4 Level Increased the Risk of Cognitive Impairment in the HIV Patient..........................................922
Nurul Azizah, Abdulloh Machin, Muhammad Hamdan

176. Antibacterial Effect of the Combination of Probiotic Milk and Calliandra Honey against Streptococcus
Mutans that Causes Tooth Cavities.................................................................................................................927
Uswatun Chasanah, Isnaeni, Nuzul Wahyuning Dyah

177. Reproductive Health Behavior of Street Youth Guided by Karya Putra Indonesia Mandiri Foundation
in Central Jakarta Region................................................................................................................................932
Prihayati, Hansrizka Raisna, Ridwan Amiruddin, Owildan Wisudawan B.

178. Trend of Malaria Cases in Maluku Province 2012-2016................................................................................936

Prisilia Oktaviyani, Budi Hartono, Ranti Ekasari

179. A Qualitative Study: Perceptions of Premarital Sexual Behavior Among Teenage Girls..............................944
XIV
Mia Fatma Ekasari, Eros Siti Suryati, Raden Siti Maryam, Ahmad Jubaedi, Rosidawati, Tien Hartini,
Santun Setiawati

180. Hazard and Risk Analysis by Implementing Hiradc Method in the Laboratory of Medical-Surgical at
Faculty of Nursing Universitas Airlangga.......................................................................................................949
Radhia Maya R.P., DaniNasirul H., PutriAyuni Alayyannur, Tjipto Suwandi, Rizky Agung Firnando

181. A Three-Years Survival Rates of Chronic Myeloid Leukemia Patients with Targeted Therapy....................955
Rani Silondae, Tutik Harjianti, Sahyuddin Saleh, Syakib Bakri, A. Makbul Aman, Hasyim Kasim,
Haerani Rasyid

182. The Relation between Bullying Workplace, Organizational Support, and Work Engagement as
Perceived by Staff Nurses................................................................................................................................961
Rasha Mohamed Nagib Ali, Ebtsam Ahmed Mohamed

183. The Effect of Alkaloid Extract of Teucrium Polium L. Against Some Pathogenic Bacteria of Urinary
Tracts and on Pyelonephritis Induced in Rats.................................................................................................969
Rawa’a A. Kushaish, Bushra A.M. AL-Salem, Mouayed A. Hussein

184. A Study of Complications of Infants of Diabetic Mothers in Babylon Teaching Hospital for Maternity
and Pediatrics...................................................................................................................................................974
Rebee Mohsin Al-Ithary

185. The Relationship between Obesity and Dyslipidemia in Adolescents............................................................980

Ria Qadariah Arief, Ridwan Amiruddin, Syamsiah Russeng, Citra Kesumasari, Nurhaedar Jafar,
Ummu Salamah, Nugrahaeni

186. The Individual Factor and the Quality of Building’s Physical Environment in Correlation with the
Occurrence of Sick Building Syndrome (SBS) on Employees of PT. Telkom Jember..................................984
Rizki Adi Sulistyanto, Ragil Ismi Hartanti, Prehatin Trirahayu Ningrum, Abdul Rohim Tualeka

187. Public Knowledge on Over the Counter Analgesics at Private Pharmacy Store in Makassar City
Indonesia..........................................................................................................................................................989
Rizqi Nur Azizah, Hendra Herman,

188. Effect of Different Levels of Coriandrum Sativum and Piper Nigrum and their Interaction on
Production, Biochemical Parameter, Liver Enzymes, TSH and Growth Hormone for Broiler Chickens......993
S.G. Hussein, H.Q. Baker

189. Parental Style and its Relation to Adolescents’ Self-Concept and Depression...............................................999
Safaa Mohammed Zaki, Manal Hassan Abo Elmagd, Nagat Farouk Abo Elwafa

190. Diagnostic Study and Some Pathological Aspects of Parasites Associated with Appendicitis in Al-
Najaf Al-Ashraf Governorate........................................................................................................................1007
Sahira Ayed A. Al-Musawi

191. Antibacterial Activity of Zinc Oxide Nanoparticles on the Growth of Enterococcus Feacales, Candida
and Total Root Canal Microbiota (In Vitro Study).......................................................................................1011
Salah A. Hadi, Abbas S. Al-Mizraqchi

192. Assessment of Exam-related Anxiety among the Students of the High Healthy Vocations Institute at
 XV
Medical City..................................................................................................................................................1017
Sameer Allawi Khalaf, Meaad Kareem Halboos

193. Urinary Intestinal Fatty Acid Binding Protein “IFABP” as a Marker for Gut Maturation in Preterm
Babies............................................................................................................................................................1023
Samir Tamer Abd-Allah, Hanan Mostafa Kamel, Madeha Abd-Allah Sayed, Yossra Samir Fadle

194. Associations between TNF-α and Interleukin-18 and ADIPOQ Gene Polymorphisms in Iraqi Obese
Women Patients with Polycystic Ovary Syndrome.......................................................................................1028
Sarah Ibrahim Hashoosh, Asmaa A. Hussien, Salah Al Chalabi

195. C2 Lateral Mass Vertebrae Anthropometry for Evaluating C2 Straight Lateral Mass Screw Fixation........1034
Sarrah Dwiananda Mayasafira, Joni Susanto, Eko Agus Subagio

196. Correlation between Health Locus of Control with Intention to Perform Cataract Surgery in the Area
of Public Health Center of Tempurejo Jember..............................................................................................1040
Siswoyo, Baskoro Setioputro, Kushariyadi, Iqbal Luthfi Nauri

197. Implementation of Tender Loving Care-Based Growth and Development Monitoring by Health Cadres..1046
Siti Asiyah, Dewi Retno Suminar, Ahsan, Shrimarti Rukmini Devy, Moersintowarti B. Narendra

198. Regional Health Care: Does Give Benefits for Poor Communities?.............................................................1051
Siti Nuraini, Riski Isminar Ardianti, Deddy Kurniawansyah

199. Measures of Modern Society to Limit the Prevalence of Sexually Transmitted Infections..........................1056
Sizov A.A., Pashina I.V., Lischuk N.G., Alferova M.E., Lyaskovets A.V., Shahbazov R.F., Andreeva N.A.

200. Effect of Non-Computerized Cognitive Remediation and Risperidone to Improve Disability Function
in Schizophrenia............................................................................................................................................1061
Sonny T. Lisal, Saidah Syamsuddin, Anisa

201. The Effect of Olanzapine on the Improvement of the Clinical Symptom of Schizophrenia.........................1067
Sonny T. Lisal, Saidah Syamsuddin, Balgis

202. Study of Some Virulence Factors of Candida Albicans Causing Intestinal Infection...................................1073
Sozan Khaled Kadhum

203. Correlation between Protein Intake, Parity and Miscarriage History Anemic Pregnant Women in
Sukoharjo Regency, Indonesia with Low Birth Weight Incidence: A Case Control Study..........................1079
Sufia Fitriani, Eti Poncorini Pamungkasari, Suminah

204. Changes in Community Behavior and Keeping the Quality of Drinking Water Based Ranas Models........1084
Sugeng Mashudi, Ah. Yusuf, Rika Subarniati Triyoga

205. Breast Cancer and Hormonal Level Changes................................................................................................1090

Suhad Kahdum Ali

206. Socio-demographic Characteristics and Caregiver’s Quality of Life Associated with Suspected
Developmental Delay among Early Childhood in Northeast of Thailand.....................................................1096
Supattra Boonjeam, Rajda Chaichit, Benja Muktabhant, Suwit Udompanich

207. The Influence of ACTN3 Gene Polymorphism on VO2max and Sprint Speed Based on Sprint Interval
XVI
Training Intervention.....................................................................................................................................1102
Susiana Candrawati, Nur Signa Aini Gumilas, Dyah Ajeng Permatahani, Muhammad Fadhil Wasi
Pradipta, Lantip Rujito

208. Predisposing Factors to Risk of Low Birth Weight in Premature Baby in Bengkulu Indonesia..................1108
Susilo Damarini, Hadi Pratomo, Helda, Besral

209. Education and Knowledge Level Analysis of the Teachers Regarding Dental Education Program in
Primary Schools.............................................................................................................................................1113
Taufan Bramantoro, Titiek Berniyanti, Retno Palupi, Ninuk Hariyani, Fatan Fakihardi, Aulia
Ramadhani, Sarah Fitria Romadhoni

210. Revised Trauma Score (Rts) as Outcome Predictor of Head Injury Patients................................................1118
Tengku Isni Yuli Lestari Putri, Ahsan, Dhelya Widasmara

211. The Relationship between Obesity and Fasting Blood Glucose Levels in High School Teachers...............1124
Tri Setyawati, Muhammad Ikbal, Fenny Nur Afny, Muhammad Nasir,

212. A Case Study of the Health Adaptation of Former Schizophrenics in Communicating with the Bugis
Makassar Community in the South Sulawesi Province.................................................................................1129
Tuti Bahfiarti, Arianto, Muhammad Harun Achmad

213. Risk Factors Associated with HIV Infection among Male to Transvestites in Five Cities in Indonesia
in 2015...........................................................................................................................................................1135
Udin Komarudin, Tri Yunis Miko Wahyono

214. Shift Working Relationship with Blood Pressure in Excess Noise Workers Exposed NAB Spinning in
the Department of the Winding Pt Star Asahi Textile Industry....................................................................1141
Vivi Budiarti, Tina Rosa Rachmawati, Abdul Rohim Tualeka

215. Is Osteopontine of Value in Diagnosis of Knee Osteoarthritis?....................................................................1147

Walaa F. Mohammed, Faten Ismail Mohamed, Gihan M. Ahmd, Rasha A. Abdelmagied, Aliaa M.
Mounir, Mustafa Abdel- Kader

216. A Prospective Study of Effectiveness of Pre-release Intensive Program for Prisoners in Thailand.............1150
Wanna Pajumpa, Manop Kanato, Kittima Momen

217. Factors Associated with Behavior Usage of Respiratory Protective Equipment among Sugarcane
Factory Workers in Northeast of Thailand....................................................................................................1156
Wipada Panakobkit, Pornpun Sakunkoo

218. Re-evaluation of Psoriatic Patients with Metabolic Syndrome: A Case Control Study Searching for
the Highly Prevalent Criteria.........................................................................................................................1162
Wisam Majeed Kattoof

219. Effect of Dragon Fruit (Hylocereus Polyrhizus) Peel Extract on Collagen Fiber Density of Rat Socket
Healing...........................................................................................................................................................1168
Wisnu Setyari Juliastuti, Hendrik Setia Budi, Christiana Ayu Maharani

220. Guided Group Investigation, Scaffolding Task Questions and Self-Efficacy in Learning to Solve
Social Problems in Inclusive Schools............................................................................................................1173
 XVII
Wiwik Widajati, Punaji Setyosari, I Nyoman S. Degeng, Sumarmi, Mustaji

221. Perceptions of Teachers, Parents and Adolescents about HPV, Cervical Cancer and HPV Vaccination.....1179
222. Occupational History as a Predictor of Cognitive Ability in the Elderly......................................................1185
Yudhiakuari Sincihu, Felicia Sinjaya, Edith Maria Djaputra

223. The Effect Of Employment Time with the Low Back Pain Disorders on Workers in the ‘X’ Carpet
Fitting Work Unit Pasuruan...........................................................................................................................1190
Zikri Fathur Rahman, Nur Lailatul Masruroh, Noeroel Widajati, Abdul Rohim Tualeka

224. Lived Body Principle of a Nurse’s Experience in Emergency Treatment at Remote Area Kokonao,
Papua, Indonesia............................................................................................................................................1193
Zulkifli, Indah Winarni, Asti Melani Astari

225. Biliary Atresia Outcome in Egypt: A Descriptive Study..............................................................................1198

Omar N. Abdelhakeem, Gamal H. Eltagy, Alaa A. El. Sayed, M.M. Khedr

226. Manipulative Movement Based on Information Technology Games for School Children Aged 10-12
Years..............................................................................................................................................................1202
Nevi Hardika, Moch. Asmawi, James Tangkudung, Firmansyah Dlis, Abdul Sukur, Widiastuti, M.E. Winarno

227. The Influence of Job Stressor on Organizational Loyalty and Intention to Quit among Health Care Staff..1209
Mohammad Saipol Mohd Sukor, Siti Aisyah Panatik, Wan Mohd Azam Wan Mohd Yunus

228. Emotional Intelligence and Conflict Management Style among Staff in a Bank..........................................1214
Maisarah Mohd, Halimah Mohd Yusof

229. Trend on Drink Drive and Road Accident Across Asian Region: A Review Study.....................................1219
Siti Hawa Harith, Norashikin Mahmud

230. Obesity and Job Performance among Teachers in Malaysia.........................................................................1227

Mohd Hakiki Md Tohid, Zulkifli Khair

231. Does Instagram’s Like Affected Teenager Self-worth?................................................................................1233

Hayinah Ipmawati, Wiwien Dinar Pratisti

232. The Application of MOPSI Module Forbreast Cancer Patients....................................................................1237

Norhafizah Musa, Azahar Yaakub Ariffin, Siti Suhaila Ihwani, Adibah Muhtar, Abdul Hafiz Abdullah

233. A Study on Consumers Perception on Halal Certification of Dietary Supplement Products........................1242

Norazlinabinti Abdul Aziz, Hartini Saripan, Farizah Mohamed Isa, Mardiah Hayati Abu Bakar

234. Identifying Environment Aspect in Academic Enhancement Support for Student-Athlete Using Fuzzy
Delphi Method...............................................................................................................................................1249
Mohd Zulfadli Rozali, Saifullizam Puteh, Faizal Amin Nur Yunus, Thariq Khan Azizuddin Khan

235. Non-Muslim Consumer Perspective on Cosmetics and Personal Care Products..........................................1254

Nusaibah Mansor, Nurul Ajmal Mohd Shukri, Siti Norbaya Yahaya

236. Students’ Pro-Eco Behavior Related to Healt Based on Environmental Big-Five Personality and Self-
efficacy...........................................................................................................................................................1258
I. Made Putrawan, Lisa Dwi Ningtyas
XVIII
237. Visualization Program of Practical Work Manual for Biology Concepts on Health Education Topics.......1264
Amalia Sapriati, Mestika Sekarwinahyu, Ucu Rahayu, Suroyo

238. Effects on Memorized Information Quantity in Web Pages Using Bicolor Design-from the Perspective
of Color Blind People and Non-Color Blind People.....................................................................................1269
Kohei Sakamoto, Chieko Kato

239. The Effect of Work Loads on Work Satisfaction with Work Structure as a Variable of Mediation.............1274
Isworo Pujotomo, Sasmoko, A. Bandur, Nugroho J. Setiadi

240. Lecturers’ Knowledge About Environmental Issues, Personal Responsibility and Personality: Its
Effect on Lecturers’ Intention to Act in Saving our Environment................................................................1278
Agus Priadi, I. Made Putrawan, Guspri Devi Artanti

241. Biological Teachers’ Citizenship Behavior: A Confirmatory Study Involving the Effect of School
Leadership and Integrity................................................................................................................................1284
Astuti Esti Zharroh, I. Made Putrawan, Diana Vivanti Sigit

242. Biological Teachers’ Personality and Task Performance Mediated by Procedural Justice..........................1288
Ilena Amalia Luthfi, I. Made Putrawan, Mieke Miarsyah

243. How is Students’ Personality towards the Environment Predicted by Students’ Attitude and Locus of
Control?.........................................................................................................................................................1292
Damianus Daikoban, I. Made Putrawan, Diana Vivanti S.

244. The Effect of Personality and Motivation on Junior High School Biology Teacher’s Citizenship
Behavior.........................................................................................................................................................1298
Tri Ayu Astuti, I. Made Putrawan, Rusdi

245. Connecting Biological Teachers Self-Efficacy with Organizational Commitment Mediated by

Motivation.....................................................................................................................................................1304
Fera Puji Astuti, I. Made Putrawan, Ratna Komala

246. The Effect of Personality and Gender on Green Consumer Behavior...........................................................1309

Cholilawati, I. Made Putrawan

247. Keeping Teachers’ Organizational Commitment High By Considering the Role of Teachers Leadership
and Trust........................................................................................................................................................1315
Risky Hasanah, I. Made Putrawan, Diana Vivanti S.

248. School Culture and Job Satisfaction: Its Effecton Biological Teachers’ Task Performance.........................1319
Dewi Robiatun, I. Made Putrawan, Rusdi.

249. Strategies Overcome Barrier between Doctor and Patient Communication at National Heart Institute,
Malaysia.........................................................................................................................................................1323
Vimala Govindaraju, Aizai Azan Abdul Rahim

250. The Character Education Concept for Prospective Parents: Societal View..................................................1329
Mita Septiani, Basuki Wibawa, Robinson Situmorang

251. Effective Communication and Collaboration Training Evaluation for Employee Performance
Improvement at National Nuclear Energy Agency.......................................................................................1334
 XIX
Shinta TD Nawangwulan, Achmad Hufad, Jajat S. Ardiwinata, Iip Saripah, Dadang Yunus L.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 1

Study protocol: A Randomised Controlled Trial on

Effectiveness of a Worksite Health Intervention on Common
Musculoskeletal Problems and Work-Related Quality of
Life (WRQoL) among Female Workers in the Garment
Manufacturing Sectors

A. Santham Lilly Pet1, Timsi Jain2, Bobby Joseph3, Pethuru Devadason4, Gayathri M5
1Ph.D. Scholar of Saveetha University, Department of community Health Nursing, Ramaiah Institute of Nursing
Education and Research, Bangalore, India, 2Professor, Community Medicine, Saveetha University, Chennai, India,
3
Professor and Head, Community Health, St. John’s Medical College, Bangalore, India, 4Department of General
Practice, Al Nahil International Clinic, Kuwait, 5Lecturer, Department of community Health Nursing, Ramaiah
Institute of Nursing Education and Research, Bangalore, India

Abstract
Garmenting is one of the many labour intensive sector that provides gateway for developing countries in
entering into the global market. Southern production centres employ more than 80% women as part of their
workforce. Working for a long period of time without rest, absence of personal protective equipment and
inadequate provision of ergonomic facilities at workplace leads to discomfort and fatigue.

Method and Method: 150 female workers with common musculoskeletal problems and working at the
selected garment manufacturing factories and fulfilling the selection criteria will be randomly assigned to
experimental and control group. The work site health intervention will be provided to experimental group,
which involves 3 sessions for a week namely orientation to body mechanics, demonstration on neck and
lower back exercise and nutritional education. After the demonstration, the female worker will be instructed
to perform the exercise, 5 times in a week for 2 week in the workplace and thereafter for at least 3 times
in a week for a month in the home. The outcome will be assessed at end of the 2nd week and 5th week. The
control group who will not receive any intervention. The data will be analysed by frequency, percentage
distribution, mean and standard deviation. Chi-square test and independent t-test will be used to assess the
difference in various parameters.

Discussion: The result of the study may help to guide the garment workers to initiate the simple intervention
in the worksite and would also reduce the occurrence of the common musculoskeletal problems.

Keywords: Worksite Health Intervention, Musculoskeletal problem, Work-Related Quality of Life, female
Workers, Garment manufacturing sectors.

Corresponding Author: Introduction

Mrs. A. Santham Lilly Pet
Garmenting is one of the many labour-intensive
Ph.D. Scholar of Saveetha University, Department
sectors that provide a gateway for developing countries
of community Health Nursing, Ramaiah Institute of
in entering into the global market. It offers important
Nursing Education and Research, Bangalore, India opportunities to countries to start industrializing their
Ph. No: 09980111386 economies and in course of time diversify away from
Fax : 080-23604055 commodity dependence(1).
e-mail: s [email protected]
[email protected] The garment sector is a thriving industry in
2 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Bangalore, Tirupur and Chennai in the south, and in A recent ILO study estimated that 22% of the global
Delhi and surrounding NCR region in the north. While workforce, or 614.2 million workers, work more than
the northern production centres employ primarily a male 48 hours per week. According to a multi-country study
workforce, in the south more than 80% of the workforce in the clothing industry, reports that, workers had to
is women.(2) work overtime in order to earn wages. The study also
concluded that on an average factory workers worked
Women who are sewing mission operators perform more than 60 hours per week, and in 88% of cases more
their tasks sitting which involves two work tasks. The than six days in a row(7).
first one is the “sewing” task. The female worker sits on
a chair, leans forward at an angle of 45, and moves her In Bangladesh, many garment workers work 14-16
hands backward and forward and to the left and right to hours shifts each day (most often six days per week) in
move the fabric (45-100 times per minute). The arms Pakistan, 10 or more hours a day. In Thailand during
are positioned over the machine at an angle between 45 peak season, excessive overtime is common because
and 90 to the trunk. The head is positioned forward at an factory owners are reluctant to hire additional workers.
angle between 10 and 20. One of the legs moves the pedal During off-peak season, the average working hours is
of the sewing machine but the other is static. During the 7.7 to 10 hours a day. In India and Laos this overtime,
second work task, the female worker bends down to the though against the law, is compulsory(8).
right at an angle of 45 in order to get the pieces such as
zippers and the like (30-50 times per minute)(3). According to the European survey on working
conditions, 8.1% to 72.9% of workers reported exposure
A study conducted in India reported, that out of 3858 to risk factors of musculoskeletal diseases(5). Beyond
workers examined during their annual health appraisal, different recognition practices, there are indications
around 694 (18.0%) had applied leave due to illness, that musculoskeletal diseases affect the female working
of these only 104 (2.7%) had extended to more than 15 population more than the males. Further, there is a severe
days. As a common symptom, worker who performs lack of awareness about these issues.
processing jobs with a longer duration of standing may
experience discomfort in the legs, neck and shoulder. If The musculoskeletal problems and the discomfort
standing position is practiced continuously, the worker experienced by the individuals is also depend on the way
may feel discomfort and fatigue particularly in the lower an individual eat and the type of nutrients and fluids that
limb muscles, lower back, and feet. As along-term brought into the body. Certain products and treatments
consequence, prolonged standing contributes to severe may accelerate the rate in which the body heals itself.Some
health problems such as chronic venous disorders, of the treatment included are Transcutaneous Electric
circulatory problems and degenerative damage to the Nerve Stimulator, electrotherapy, acupuncture, massage,
joints of the spine, hip, knees and feet. (4). icing, and anti-inflammatories. While these treatments
are available to reduce the inflammation, however it is
Exposure to MSDs risk factors are increasing necessary to control the levels of inflammation around
in younger working population (5). Though factory the joints of the back with alternative approaches. One
workers areat risk for various health problems, the such approach that naturally adopted to reduce the
literature support makes it evident that the prevalence inflammation is by diet modification,and increase the
of musculoskeletal problem is the most common intake of natural anti-inflammatories foods in the diet.
problems among garment factoryworkers varied from There are also vitamins and dietary supplements to
15.5% to 78.89%.The most reported problem among improve musculoskeletal health. But the relationship is
those involved in sewing, cutting, and deliveringwas not studied.
back pain,with the prevalence ranging from 22.2% and
68.5%. The common causes for the musculoskeletal Work-related musculoskeletal problem are often
problems were continuous sitting for long hours, bending associated with lower level of quality of life. Very
and twisting at the waist, abnormal posture, movements few studies only have evaluated the effect of a specific
during work and continuous standing. Nutrition plays a program on the prevention of WMSD and the quality of
key role among these workers as improper or inadequate life (QL)(9).
diet leads to malnutrition, whichmay further aggravate In the last few decades, workplace ergonomics
theseproblems(6). studies focusedmore;however,limited emphasis
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 3
were made on the worksite interventions to prevent Sample: To detect a medium effect size (0.5) in
work-related musculoskeletal problems. It has also the quality of life (power 0.8; alpha 0.05) at a 2-sided
beenreviewed from the literature that there is a strong significance level of 0.05, the sample size is estimated
evidence for positive effect on management of low back was 150, which was inflated to 200 anticipating 10-20%
pain by exercise training on different population and rate. Female workers (75 in experimental group and 75
settings. in control group) in the age group of 18-60 years and
are working in the selected setting with the main task as
With the above evidences, the investigator felt the tailoring, helping; checking, cutting, designing,sewing,
need to find the Effectiveness of a Worksite Health ironing and finishing will be screened for common
Intervention on Common Musculoskeletal Problems and musculoskeletal problems. 200 female workers with the
Work-Related Quality of Life (WRQoL) among female musculoskeletal problems will be randomly chosen and
workers. assessed into experimental and control group. To recruit
the subjects the following criteria will be used.
Materials and Method
The Primary Objective Includes: Inclusion Criteria: Female Workers:
• Working for a minimum of 6-8 hours in a day
1. To determine the common musculo- skeletal
with minimum of 1year experience in the garment
problems experienced by the female workers in the
factory.
garment manufacturing sectors
• Who areable to read and write in Tamil/Kannada/
2. To assess the Work-Related Quality of Life among
English.
female workers with musculo-skeletal problems
experienced before implementation of Worksite Exclusion Criteria: Female Workers:
Health Intervention. • undergoing physiotherapy/any treatment for this
3. To evaluate the effectiveness of Worksite Health problem
Intervention on Common Musculoskeletal problems • who had undergone any surgery within a year
experienced and Work -Related Quality of Life
among female workers • who are diagnosed with structural anomalies

Study Design: The study adopts two-armed • who have spinal cord compression
randomised control trial methodology, to assess the • who are pregnant
effectiveness of the Worksite Health Intervention on
common musculoskeletal problems and work-related • suffering with post-traumatic conditions.
quality of life among females. Tool: Validity, reliability and pilot study:

Ethical Consideration: As a part of research The following standardised tools are used.
programme, Saveetha University Ethics Committee,
a. Nordic musculoskeletal questionnaire to assess the
Tamilnadu, approved the study. The ref.no: - 007/09/2017/
common musculoskeletal problem
IEC/SU, which qualified for registration in the Clinical
Trial Registry-India numberCTRI/2018/08/015168. b. SF 36V2 to assess the work-related quality of life

Setting: Out of the North, South, East and West zones Nine expert had validated the tool, 3 from
of BBMP, north zone will be selected for data collection the department of community medicine 2 from
as this zone houses majority of the garment factories physiotherapist, 3 nursing faculty with PhD and 1
of Bangalore. The garment manufacturing factories are nutritionist. In order to suit to the current setting the
concentrated in Pennya industrial estate, Rajajinagar reliability of the tools has been once again tested by
industrial estate, Yeswanthapur, Gorguntepalaya and SPSS software and the Alpha Coefficient r=0.78 for
Srirampura. Two study areas are to be selected by simple Nordic musculoskeletal questionnaire and 0.89 for
random sampling from the industrial database available. the work related quality of life, which is within the
The factories are categorised into small medium and acceptable limit. Pilot study on 15 subjects performed
large sized on the basis of the number of workers in each proved the practicability of the study.
factory.
4 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
The Intervention Program: Written consent - Neck extension in sitting
will be obtained after the oral and written information
- Side bending of the neck
given by the researcher regarding the purpose and
nature of the study, a detailed plan about the work site - Neck flexion in sitting
intervention, benefits, the risk involved, and withdrawal • Low back exercise
from the study. Confidentiality of the subjects would be
maintained. - Lying face down
- Lying face down in extension
Pre-Intervention: Female workers in the garment
factories will be assigned in to the experimental and - Flexion in lying
control group. The common musculoskeletal problems
- Flexion in sitting
and work related quality of life would be assessed.
- Flexion in standing
Approximately 40-45 minutes will be given to the
female garment workers to complete the questionnaire. - Bottom to heal stretch
After receiving the questionnaire, the data will be - Bridges
verified for the completion of data.
- Knee rolls
Work site Health Intervention: The work site health - Hamstring stretch
intervention to experimental group refers to a structured
program developed by the researcher for the female The researcher demonstrates the exercise as shown
workers in garment manufacturing sectors to change their in the Figure 1, at the workplace for 10-15 minutes and
unhealthy and ergonomic postures and to enable them the participant are asked to follow. A ready reckoner
to prevent the occurrence of common musculoskeletal would be provided to the participant.
problem. It comprises orientation to body mechanics,
Post intervention: After the training, the female
back exercise training, nutrition education involving
factory workers are asked to perform the back exercise
lecture cum demonstration by the researcher. Each
every day for at least 5 times a week for 2 weeks in the
session would last for 10-15 minutes on all days.
work place under the supervision of the researcher and at
Day 1: Orientation to body mechanics, anatomy of home for at least 3 times a week for a month. On Day 3,
spine, function of the cervical spine and normal postures the researcher will be providing education on nutrition,
to be maintained in daily life by lecture method using which includes food pyramid, function of the food,
charts and posters concept of healthy eating and anti-inflammatory diet for
30-45 minutes by lecture cum discussion method.
Day 2: Demonstration of exercises, which includes
The control group will not receive any intervention
• Neck exercise during the study period. But would receive the same
- Head retraction in sitting after completion of the data collection.

Head retraction Neck extension Side bending of neck Neck rotations/neck flexion
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 5

Lying face down in extension Bottom heal stretch Flexion in lying Hamstring stretch

Flexion in sitting Flexion in standing Bridges Knee rolls

Figure 1: Illustration of the Neck and low back exercise

Outcome Measures: Baseline data includes age, neither will be aware of the expected outcomes of the
height, weight, total family monthly income, type of study, nor the other group participating in the research
family, habits type of job, duration of the work per day, study
availability of rest period during working hours, and
option of over time. Planned statistical analysis: All the data collected
will be entered in the excel format. The data will
Primary outcome measures be analysed using SPSS version 20.0. Frequency,
percentage distribution, mean, standard deviation, Chi-
1. Musculoskeletal problems experienced and its
square test and t-rest will be employed for the difference
intensity
in the various parameters.
2. Work-related quality of life
Randomization: The list of garment factories from
Discussion
the industrial database will be categorised into small and Musculoskeletal problem is one of the common
medium sized on the basis of the number of workers in health problem experienced by the female factory
each factory. A separate list of small size factories and workers. The workers neither take care of themselves
medium sized factories will be prepared. The factories nor have time to meet the health professionals. Studies
will be clustered into two; Cluster ‘A’ small sized revealed that incidence and recurrence of pain could
factories and cluster ‘B’ medium sized factories. Using be reduced when adequate care is provided. This study
simple random sampling technique, from each cluster aims at designing a worksite health intervention that
2 factories will be allocated to intervention group and could be implemented during the working hours. The
control group. Based on selection criteria samples will intervention designed would be simple and can be done
be drawn 75 in experimental and 75 to control group. in the work place itself. Changes in the intensity of pain
in the lower back and neck would be noted before and
Blinding: Due to the nature of the research, the after the intervention. Educating on the body postures
researcher will not be blinded and may know which and nutrition helps the workers to monitor their food and
factory will be receiving the intervention. However, beverages conception. Modification in the diet helps to
the female workers participating in the research study examine the changes in the quality of life. Result of this
6 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
study may help to guide the workers to initiate the simple 4. Halim I, Omar A. A Review on health effects
intervention in the worksite reduce the occurrence of the associated with prolonged standing in the industrial
musculoskeletal problems. workplaces. Ijrras. 2011;8(July):14–21.
5. E.Schneider XI. Work-related musculoskeletal
Acknowledgement: Author thanks all the co-
disorders in the EU—Facts and figures [Internet].
authors, library and computer staffs for their valuable
2010. 1-184 p. Available from: https://osha.europa.
contribution and timely help.
eu/en/tools-and-publications/publications/reports/
Conflict of Interest: There is no conflict of interest. TERO09009ENC
6. Lillypet S, Jain T, Joseph B. Health problems
Source of Funding: Self-funding research
among garment factory workers : A narrative
literature review. 2017;6(2):114–21.
References
7. ILO. Wages and Working Hours in the Textiles,
1. Roy S. Garments Industry in India: Some Clothing, Leather and Footwear Industries
Reflections on Size Distribution of Firms. [Internet]. 2014. 35 p. Available from: http://
IhdindiaOrg [Internet]. 2009;1–30. Available from: ilo.org/sector/activities/sectoral-meetings/
http://www.ihdindia.org/Formal-and-Informal- WCMS_241471/lang--en/index.htm
Employment/Paper-5-Garment-Industry-in-India-
8. Stotz L, Kane G. Facts on The Global Garment
Some-Reflections-on-Size-Distribution-of-Firms.
Industry [Internet]. clean clothes campaign. 2015.
pdf
p. 1–21. Available from: https://cleanclothes.
2. Mani M. Garments Sector and Unionisation in org/resources/publications/factsheets/general-
India–Some Critical Issues. 2011. factsheet-garment-industry-february-2015.pdf
3. Öztürk N, Esin MN. Investigation of 9. Santos AC, Bredemeier M, Rosa KF, Amantéa V
musculoskeletal symptoms and ergonomic risk a, Xavier RM. Impact on the Quality of Life of an
factors among female sewing machine operators in Educational Program for the Prevention of Work-
Turkey. Int J Ind Ergon [Internet]. 2011;41(6):585– Related Musculoskeletal Disorders: a randomized
91. Available from: http://www.sciencedirect.com/ controlled trial. BMC Public Health [Internet].
science/article/pii/S0169814111000837 2011;11(1):60. Available from: http://www.
biomedcentral.com/1471-2458/11/60
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 7

Health of the Elderly in India: A Socio-Legal Study

Aarti1, J.K.Mittal2
1Ph.D. Research Scholar under the Supervision of Professor. J.K. Mittal, Professor Emeritus, Amity Law School,
Amity University, Uttar Pradesh, 2Professor Emeritus, Amity Law School, Amity University, Uttar Pradesh

Abstract
To study the health and social problems of the elderly and their attitude towards life. Materials and Method:
Descriptive study carried out in the Field practice area of the Department of Community Medicine in South
India. A total of 213 elderly patients (60 years old and above) who attended the outreach clinics were
interviewed using a pre-tested schedule. Findings were described in terms of proportions and percentages to
study the socio-economic status of the samples and its correlation to social problems. Results: Around 73%
of the patients belonged to the age group of 60-69 years old. Nearly half of the respondents were illiterate.
Around 48% felt they were not happy in life. A majority of them had health problems such as hypertension
followed by Arthritis, Diabetes, Asthma, Cataract, and Anemia. About 68% of the patients said that the
attitude of people towards the elderly was that of neglect.

Keywords: Elderly, Morbidity, Social and Health Problems.

Introduction this aging process. The things which don’t have life earn
currency and given a due place and reverence on account
“One who always serves and respects elderly is
of aged.
blessed with four things: Long Life, Wisdom, Fame and
Power”- Manusmriti Chapter 2:121. The thing such as old swords, old Icon, old
buildings, Cars and so forth. Are revered due to their
“Trees grow over the years, rivers wider, Likewise,
aged. On contrary, the objects which have life such as
with age, human beings gain immeasurable depth and
animals, human beings are thrown useless things. The
breadth of experience “and wisdom. That is why older
old people are not treated well and they need special
persons should be not only respected and revered; they
care and policies for their autumn days. The increasing
should be utilized as the rich source to society that they
number of aged population, due to advancement in
are.”- Kofi Annan.
medical sciences, health care etc, amount a problem on
“A society for all ages is one that does not caricature both developed as well as developing countries. The
older persons as patients and pensioners. Instead, it sees policy makers and social scientists focus their attention
them as both agents and beneficiaries of development. to abate the seriousness of the problem, which pose
It honors traditional elders in their leadership and before countries, particularly third world countries. For
consultative roles in communities throughout the understanding the problem of these aged, we have to
world.” -Kofi Annan United Nations Secretary-General know the basic concepts like aging.
1 October 1998
Aging is natural, inevitable and ubiquitous
“It is not sufficient to add years to life but the more phenomenon. Everyone should confront this process,
important objectiveis to add life to years”- if he/she lives. It is irreversible one. Literally it refers
to the effects of age. Commonly speaking, it means the
WHO Slogan S.: various effects or manifestation of old age. In this sense,
it refers to various deterioration in the organisms. Aging
The popular saying, “old is Gold’ which implies the
has been viewed differently by different persons. To
gravity of aged on the earth. All the things get aged. The
politicians and Industrialists, it means power and wealth
things around us both animate and inanimate go through
whereas to a middle class employee, it amounts to a
8 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
forced retirement. To biologists and social scientists, it Rundown figures veil the unevenness and
is a field of research on biological cells and problems complexities of the statistic progress inside India
on individual respectively. Handler defined “Aging is crosswise over Indian states with various degrees of
the deterioration of nature organism resulting from the financial improvement, social standards, and political
dependent essentially irreversible changes intrinsic to settings. Anticipated appraisals of populace structure in
all members of a species such that, with the passage of 2025 for North India hold a “pyramidal” shape, while
time. They become increasingly unable to cope with for south India, the portion of the older populace is
the stresses of the environment thereby increasing the required to grow significantly. Straight development
probability of death”. Beckar defines aging in the broader in the number of inhabitants in the older is normal in
sense as “Changes coursing in an individual as the result the following 100 years, with more extreme slopes of
of the passage of time”. He adds “Aging consists of two increment in focal and east India and leveling off of
simultaneous components of anabolic building up and supreme quantities of old in the north, south, west, and
catabolic breaking down”. Comfort regards it as “the upper east.
total effect of all changes which occur in a living being
with increasing chronological age and which render it A few important characteristics of the elderly
more vulnerable or less viable”. Birren and Renner population in India are noteworthy. Of the 8.5% of
define “aging refers to the regular changes that occur the population who are elderly, two-thirds live in
in mature genetically representative organisms living villages and nearly half are of poor socioeconomic
under representative environmental conditions as they status (2016 report by the ministry for statistics and
advance in chronological age”. According to Hurlock, programme implementation). Half of the Indian elderly
old age is the closing period in the life span. It is a period are dependents, often due to widowhood, divorce, or
when people move away from previous, more desirable separation, and a majority of the elderly are women
periods or times of usefulness. Stieglitz has rightly (70%). Of the minority (2.4%) of the elderly living alone,
observed that “aging is a part of living. more are women (3.49%) than men (1.42%). Thus, the
majority of elderly resides in rural areas, belongs to low
Aging begins with conception and terminates with SES, and is dependent upon their families.
death. It cannot be arrested unless we arrest life. We
may retire aging or accelerate it but we cannot arrest While the southern states (Andhra Pradesh,
while life goes on, because it is essentially an element Karnataka, Kerala, and Tamil Nadu) might be viewed
in living”3 as the greatest drivers of maturing in India, other Indian
states (quite Haryana, Himachal Pradesh, Maharashtra,
Demographic Profile of Elderly in India: Orissa, and Punjab) are likewise encountering an old
India, the world’s second most crowded nation, has populace blast, to a great extent in provincial regions.
encountered a sensational statistic progress in the Enormous scale investigations of the wellbeing practices
previous 50 years, involving very nearly a significantly of this developing old Indian populace are rare. In
increasing of the populace beyond 60 years old years. any case, data assembled from various overviews and
This example is ready to proceed. It is anticipated that provincial and neighborhood studies point to the high
the extent of Indians matured 60 and more seasoned will commonness of a few dangerous practices, for example,
ascend from 7.5% in 2010 to 11.1% in 2025 UNDESA tobacco and liquor use, and physical dormancy. With
(United Nations Department of Economic And Social these stressors, typically, total information contrasting
Affairs, 2008). This is a little rate point increment, yet the 52nd (1995–1996) and 60th Rounds (2004) of the
a surprising figure in supreme terms. As per UNDESA National Sample Survey (NSS) propose a general
information on anticipated age structure of the populace increment in the reports of infirmities and usage of
(2008), India had more than 91.6 million older in 2010 human services administrations among the old. Access
with a yearly expansion of 2.5 million old somewhere to administrations, be that as it may, is uneven the nation
in the range of 2005 and 2010. The quantity of old in over.
India is anticipated to arrive at 173 million out of 2026
and the share of older persons, above 60 years, in 2050, An analysis of morbidity patterns by age clearly
in India’s population is projected to increase drastically indicates that the elderly experience a greater burden
by 20 percent. of ailments (which the National Sample Survey
Organisation defines as illness, sickness, injury, and
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 9
poisoning) compared to other age groups (see National diseases afflict them: chronic bronchitis, anemia, high
Sample Survey Organisation, 2006, Fig. 1), across blood pressure, chest pain, kidney problems, digestive
genders and residential locations. The elderly most disorders, vision problems, diabetes, rheumatism, and
frequently suffer from cardiovascular illness, circulatory depression. Concurrently, the prevalence of morbidity
diseases, and cancers, while the non-elderly face a higher among the elderly due to re-emerging infectious diseases
risk of mortality from infectious and parasitic diseases. is quite high, with considerable variations across
In developed countries advancing through demographic genders, areas of residence, and socioeconomic status.
transition, there have been emerging epidemics of chronic It is projected that NCD-related disability will increase
non-communicable diseases (NCDs), most of which and contribute to a higher proportion of overall national
are lifestyle-based diseases and disabilities In contrast, disability, in step with the graying of the population.
India’s accelerated demographic transition has not However, a very significant shortcoming of most of the
been accompanied by a corresponding epidemiological above studies is the use of self-reported data, which, in
transition from communicable diseases to NCDs. As the absence of autopsies and physician examinations
indicated in Figure 15-1, the Indian elderly are more of patients, represents enormous lacunae in data on the
likely to suffer from chronic than acute illness. There is conditions affecting the elderly. More detailed studies
a rise in NCDs, particularly cardiovascular, metabolic, are needed, other than surveys, to extract information on
and degenerative disorders, as well as communicable the epidemiology of health conditions experienced by
diseases. While cardiovascular disease is the leading the elderly.
cause of death among the elderly, multiple chronic

Figure 1: Burden of illness type among Indians. SOURCE: Dror, Putten-Rademaker, and Koren (2008)

Social Factors: A more intensive take a gander 2001 registration, the sexual orientation proportion
at the writing on access to human services uncovers among the Indian old matured 60 years and more
variety over an age angle. More established Indians seasoned is 1,028 females for 1,000 guys. It is normal
have revealed higher paces of out-patient and inpatient that by 2016, 51% of India’s old will be ladies (in
visi. The age angle in older wellbeing access is overlaid provincial regions, this extent will be a lot higher). More
by social determinants of wellbeing. For one, there is ladies report weakness status when contrasted with guys,
a feminization of the old populace; as indicated by the but a far more noteworthy extent of men is hospitalized
10 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
when contrasted with females (87 versus 67 for each pathway to national wellbeing change has been imagined
1,000 matured people). by the Planning Commission in the number one spot
up to the twelfth Five-Year Plan for India. In October
Neglected well being needs are progressively 2010, a High-Level Expert Group (HLEG) was gathered
articulated among the 33.1% of the old in India who by the Planning Commission to prescribe changes in
in 2001 were accounted for to have lost their mates, of wellbeing financing, medicate obtainment, network
whom a bigger relative extent is female (half of female cooperation in wellbeing, wellbeing the executives,
old are widows versus just 15% of male older who are and physical and money related standards for wellbeing
single men). Studies have demonstrated that widows are and HR. Arranging older wellbeing in a more extensive
lopsidedly helpless against incapacity, ailment, and poor system of all inclusive access and moderateness of
medicinal services use because of various portability, Universal Health Coverage (UHC) can possibly change
business, property, and monetary limitations. the auxiliary conditions that hamper the prosperity of the
Notwithstanding sexual orientation and conjugal matured. We abridge a portion of the manners by which
status, religion, standing, instruction, financial UHC may serve these capacities, all through showing
autonomy, and sanitation have bearing on older the proof holes that will be required for these capacities
wellbeing. Tally displaying of information from the to be met.
52nd Round of the NSS shows that the quantity of Key UHC changes relevant to access incorporate the
infections endured by an old individual, determined arrangement of extra HR at the Sub-Health Center level
freely for rustic (Poisson Model) and urban populaces (per 5,000 populace), just as the presentation of an extra
(Negative Binomial Model), incorporate age, sexual Community Health Worker (like an Accredited Social
orientation, education, accessibility of drinking water Health Activist) in rustic and low-salary urban regions.
and a latrine office, and family unit month to month These changes would guarantee that notwithstanding
utilization use. Another investigation of Uttar Pradesh existing needs of maternal and youngster wellbeing,
(UP) and Maharashtra found that the older elderly (70 rising needs in NCD control, just as activity on social
years and more seasoned) were altogether more averse and physical hindrances to get to, can be tended to
to look for treatment contrasted with the 60–69 age locally (i.e., pair with Village Health and Sanitation
classification, while Muslims were somewhere in the Committees and their urban identical). Future research
range of 62% and 49% bound to look for treatment may help decide the extent of consideration at the
in UP and Maharashtra, separately, contrasted with Sub-Health Center level and the scope of promotive
Hindus. This investigation found that old in booked administrations gave at the town/network so as to take
clan/planned standing (SC/ST) classifications were 54% into account the necessities of India’s older.
more uncertain and other in reverse classes (OBC) 35%
more averse to look for treatment for existing diseases It has been proposed by the HLEG, additionally,
in Maharashtra contrasted with different ranks. At long that a fundamental bundle of consideration (including
last, secondary school graduates were twice as likely essential, optional, and tertiary-level administrations) be
in UP and multiple times as likely in Maharashtra cashless at purpose of administration using a National
to look for treatment contrasted with the uneducated Health Entitlement Card (which would likewise fill
gathering. Be that as it may, in the previously mentioned in as an identifier for Electronic Medical Records,
examination, a greater part of the older experienced conveying quiet chronicles and care-chasing profiles).
various bleakness conditions, which makes translating This arrangement will be especially valuable for the
the exhibited outcomes troublesome. The nonattendance older poor, and will require advancement and a far
of thoroughly structured examinations that evaluate the reaching exercise in information accumulation and
sorts and seriousness of different sickness conditions in assemblage on both the client and supplier sides. To this
the old further features this reality utilizing information end, methodological commitments from progressing
from a similar review, inferred that 9.5% of provincial associate examinations, for example, the Longitudinal
occupants and 4.2% of urban occupants report absence Study on Aging in India (LASI) and parallel endeavors
of access to everyday necessities of drug, near twofold universally will be very significant.
that of apparel and sustenance.
Various administrative instruments under the aegis
Broad Health Coverage: Planning and Needs: A of a recently proposed National Health Regulatory
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 11
and Development Authority will guarantee wellbeing Census information, or passing endorsements) in India
framework backing, accreditation, and nonstop don’t catch neurotic movement nor do they disaggregate
wellbeing frameworks assessment. This procedure may dreariness and inability results among the older.
profit, once more, from the developing base of research
on old clients of the wellbeing framework, who may Ethical Clearance is taken from Departmental
have a more drawn out length of collaborations with Research Committee to Amity Law School, Amity
the framework just as incredible variety regarding need University, NOIDA, U.P.
and weight, affected by changing social determinants. Source of Funding: Self
Wellbeing frameworks assessment will also need to
reflect age-explicit horribleness and mortality designs, Conflict of Interest: Nil
just as that of intersectional older gatherings (the
bereaved old, matured of religious minority status, and References
others). 1. Acharya A, Ranson K. Health care financing for the
poor: Community-based health insurance schemes
Conclusion in Gujarat. Eco and Poli Wee. 2005;141–4.
The development of the older populace in the 2. Alam M. Ageing in India: Socio-economic
coming decades will carry with it exceptional weights and Health Dimensions. New Delhi: Academic
of horribleness and mortality the nation over. As we Foundation; 2006.
have laid out, key difficulties to access to wellbeing for
3. Goswami A, Reddaiah VP, Kapoor SK, Singh B,
the Indian old incorporate social hindrances molded by
Dwivedi SN, Kumar G. Tobacco and alcohol use
sexual orientation and different tomahawks of social
in rural elderly Indian population. Ind Joul of Psy.
disparity (religion, position, financial status, shame).
2005;192–197.
Physical obstructions incorporate diminished versatility,
declining social commitment, and the constrained reach 4. National Sample Survey Organization. National
of the wellbeing framework. Wellbeing moderateness Sample Survey 52nd Round Report. New
requirements incorporate restrictions in pay, business, Delhi: Ministry of Statistics and Programme
and resources, just as the confinements of money related Implementation, Government of India; 1996. The
insurance offered for wellbeing consumptions in the Aged in India: A Socio-economic Profile, 1995–96.
Indian wellbeing framework. 5. Duggal R. Poverty and health: Criticality of public
financing. Ind Jou of Med Res. 2007; 309–317.
Among the most critical discoveries that rose in
6. World Health Organization. Reducing Stigma and
building up this audit was the inadequacy of information
Discrimination against Older People with Mental
on the weights of access and moderateness among older
Disorders. Geneva: World Health Organization and
populaces in India. A noteworthy purpose behind this is
World Psychiatric Association; 2002
standard wellbeing information gathering in India isn’t
intended to reflect or describe neurotic movement: a 7. Eldercare: Demographic downside [Internet].
procedure wherein, by goodness of being alive longer Kerala: India Today, April 2018[updated
than others, the older are bound to encounter a pathology, 2018]. Available from: www.https://www.
prompting impedance, practical impediments, and indiatoday.in/magazine/nation/story/20180507-
at last incapacity. Numerous standard information branded-corporate-elderly-care-old-age-
accumulation strategies (National Sample Surveys, homes-1221657-2018-04-26
12 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

General Awareness of Diabetes Mellitus among a Hospital

Population in Chennai: A Survey

Sridhar M.1, Abilasha Ramasubramanian2

1Undergraduate Student, 2Reader, Department of Oral Pathology, Saveetha Dental College and Hospitals,
Saveetha Institute of Medical and Technical Sciences, Chennai

Abstract
Aim and Objective: The aim of this study is to assess the awareness of diabetes mellitus and knowledge
about the various aspects of diabetes including types, treatment modalities, preventive measures and lifestyle
modification in the patient population visiting a Dental Hospital in Chennai.

Materials and Method: In this study, a questionnaire was prepared and circulated among the subjects
to determine the awareness and to inspect the knowledge about the symptoms, diagnosis and preventive
measures about Diabetes mellitus among the people. The study sample comprised of totally 100 subjects,
both males and females of age group between 20 and 50 years.

Results: According to the survey 52% of the individuals are aware about that diabetes can lead to further
complications. 82% of the individuals felt that the diabetes can be controlled by exercise. 19% of individuals
have not undergone any confirmatory tests for diabetes. 50% of the individuals were under medication
for treatment of diabetes and they experienced side effects while taking those medications. 50% of the
individuals who participated in the survey have attended a formal diabetes educational programme and they
are aware of diabetes through media,relatives and doctors.

Keywords: Diabetes, Medications, Dietary Habits, Exercise, Blood Glucose level.

Introduction which is due to combination of both the pancreas having

Diabetes is a group of disease characterised by reduced ability to produce insulin and body being
hyperglycaemia resulting from the defects in insulin resistant to action of insulin3.
secretion, insulin action or both1. According to recent Further researchers have predicted a 65% rise in
World Health Organisation (WHO),India today leads prevalence of diabetes due to population growth rate,
the world with over 32 million diabetic patients and age structure, urbanisation, unfavourably modifications
the number is projected to increase to 79.4 million by of dietary habits and lifestyles, economic and health
the year 20302. There are two types of diabetes namely transition of the country and thus actual number of
Type 1 Diabetes which is due to pancreas which stops diabetes could be as high as 52 million by 20254. And
producing the hormone insulin and Type 2 Diabetes also the type 2 diabetes is seen in early adult lifeand
seen in all age group of Indian populations. So for these
reasons WHO declared India as the “Diabetic Capital”5.
Several studies have been carried out to so as to reveal
Corresponding Author: about the diabetes its complication,medications,diet
Dr. Abilasha Ramasubramanian MDS plans and lifestyle modification for the treatment of it6.
Reader, Department of Oral Pathology, Saveetha Dental
College and Hospitals, Saveetha Institute of Medical Failure to diagnose diabetes mellitus art an early
and Technical Sciences, Chennai–600077 stage due to various factors like insufficient knowledge,
e-mail: [email protected] lack of public awareness about symptoms of diabetes,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 13
further complication of diabetes and its prevention,
short of infrastructure for proper screening camps to
identify diabetic screening and identification of high
risk individuals are those factors which make diabetes
mellitus a common disease 7. Many young diabetics
who as year’s progresses live into their old age where
they develop and suffer from chronic morbidity due to
complications of diabetes mellitus thus forcing them to
lead a life of poor quality. Many studies have identified
that main step in tackling diabetes mellitus disease
is only through providing knowledge to community
regarding the disease, symptoms, complications, Graph 2: Population measuring blood glucose levels
positive attitude towards control, prevention and various regularly
treatment modalities 8. The aim of the present study is
to assess the awareness about diabetes mellitus and its
causes, treatment modalities, lifestyle modification and
preventive measures to improve the knowledge among
the population about one of the most prevalent diseases
in the country.

Materials and Method

In this study, a questionnaire was formulated
which mainly focussed on the general knowledge about
awareness and prevention of diabetes mellitus. The Graph 3: Population aware of effects of exercise on
sample for the study includes 100 subjects including diabetes
male and females within the age group of 20 to 50
years. The questionnaire contained information like
medications for diabetes, any side effects or type of
medications received by them,about their consultancy
with physician and at last the general details about the
support and general method of control diabetes and
awareness. Questionnaire was based on questions which
determine the awareness and inspects the knowledge
about the symptoms, diagnosis and preventive measures
about Diabetes mellitus among the people. The results
were tabulated and statistical analysis was done.
Graph 4: Population having awareness about
disease complications

Graph 1: Population experiencing symptoms of

diabetes mellitus Graph 5: Population consulting a diabetician
14 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
in this survey. A study by Deepa Mohan et al found
that 75.5% of the individuals in Chennai were aware of
diabetes10. However, the same study had revealed poorer
knowledge about the complications of diabetes only
74.2% among diabetics which was similar to the results
obtained from our study.

Our survey has only basic questions which tests the

knowledge of individuals about the diabetes in questions
like types,preventive measures,treatment options etc.
Graph 6: Population aware of dietary effects on Similarly another study was conducted in Singapore by
diabetes Wee about public awareness on diabetes which showed
low scores on general knowledge but good understanding
Results of complications11. This implicatesthat majority of the
patients have not been taught about diabetes by their
From the survey, 53% of the individuals who has physicians and the same results were obtained from the
participated on the survey has visited the diabetes care survey which was obtained from the study.
provider in the last 12 months. 48% of the individuals do
not often check their blood glucose levels and they do In this survey,there is mixed responses for the
not have any machine to measure it. question regarding the frequent monitoring of blood
glucose level. A similar study is done by Kaur and others
Questions related to risk factors for diabetes revealed in chandigarh where the people are poor in tooth care
that misconceptions were present and worrisome fact and infrequent monitoring of blood sugar12.
is that only 50% of the individuals who were diabetics
were aware of the risk factors and further complications. Generally, Prevention of diabetes can be done
with help of medications and other physical activities.
Awareness about the complications that diabetescan Majority of the people who participated in the survey
lead to is there among 52% of the populations in identified that dietary habits and physical activities
which the individuals say that diabetes can lead to can help in a greater extent to control diabetes. The
respiratory,cardiac problems and some say that it may prevention has an impact by reducing both the need for
lead to death. diabetes care and to treat diabetic complications13.
Individuals were not sure that they had any In our survey, there is finding that comprehensive
confirmatory test for diabetes which is around 81% programmes, mass media, relatives, doctors can have an
and so they were not able to answer any one of the large impact as an important step in preventative health
confirmatory tests for diabetes mellitus. service which was similar to study conducted by parks
Many individuals were unaware that diabetes is in which he discussed about the social mobilisation and
a disease which has two subtypes. Only 47% of the communication in TB control programmes14.
individuals were able to differentiate two types of diabetes The results of the study represent only the tip of
Type 1 and Type 29. Individuals have an argument that the iceberg, in depth community based studies has to
they experience changes in result when consulting one be undertaken to assess the awareness, about diabetes.
or more physician which makes them uncomfortable Community level awareness programs are to be launched
to discuss about the management of diabetes. This was so as to increase the awareness about diabetes.
reported by 48% of the individuals. Patients undergoing
treatment for diabetes had an increased familial support Conclusion
for them to do so according to our results.
Awareness about diabetes is insufficient among
Discussion the population our study and hence a dearth for proper
knowledge in prevention and management of diabetes
The main aim of this study is to find out about the mellitus. This study is done in order to emphasise the
awareness and prevalence of knowledge in controlling need of increasing diabetes awareness activities in form
diabetes among the individuals who were participating
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 15
of campaigns or educational programmes in both urban 7. Raheja BS, Kapur A, Bhoraskar A, Sathe SR,
and rural area of India in order to improve the disease Jorgensen LN, Moorthi SR, et al. Diab Care Asia-
outcome and prevention of the disease. India Study: Diabetes care in India-Current status.
J Assoc Physicians India. 2001; 49: 717–22.
Conflict of Interest: None
8. Bjork S, Kapur A, King H, Nair J, Ramachandran
Source of Funding: None A. Global policy: Aspects of diabetes in India.
Health Policy. 2003; 66: 61–72.
Ethical Clearance: Informed consent for patient
9. American diabetes association. Economic
was obtained from the patient.
consequences of diabetes mellitus in the U.S in
1997. Diabetes care 1998;21(2):296-309
Reference
10. Mohan D. Raj. D, Shanthirani CS, Datta M, Unwin
1. American Diabetes Association; Diagnosis and NC, KapurA et al. Awareness and Knowledge
classification of diabetes mellitus. Diabetes Care of diabetes in chennai-the chennai urban rural
Jan 2014, 37 (Supplement 1) S81-S90. epidemiology study. J Assoc. Physicians India
2. Wild S, Roglic G, Green A, Sicree R, King H. 2005;53:283-7
Global prevelance of diabetes; estimates for the 11. Wee HL, Ho HK Li Sc. Public awareness of
year 2000 and projections for 2030. Diabetes Care Diabetes mellitus in Singapore. Singapore Med
2004; 27: 1047-53. J.2002;43:128-34.
3. OECD(2011),”Diabetes prevelance and incidence”, 12. Kaur K Singh, MM Kumar, WaliA I. Knowledge
in Health at a glance 2011: OECD Indicators, and self care practices of diabetic in resettlement
OECD colony of chandigarh. India J Med Sci 1998;
4. Ramachandran A, Snehalatha C, Baskar AD, 52:341-7.
Mary S, Kumar CK, Selvam S et al. Temporal 13. Alwan A, King H, MacKinnon M. Health education
changes in prevalence of diabetes and impaired for people with diabetes. Alexandria, Egypt, World
glucose tolerance associated with lifestyle Health Organisation regional office for eastern
transition occurring in rural population in India. Mediterranean.
Diabetologia:2004;47:860-5
14. Parks W, Pennas. T, Deane. J. Monitoring
5. Vibah Sharma. The Tribune, Chandigarh, India. and evaluating the efficacy advocacy, social
Need to spread Public Awareness on Diabetes. Nov mobilisation and communication in national TB
2004. control programmes: a guidelines on indicators.
6. Grossman S: Management of Type 2 diabetes Geneva, World Health Organisation, 2006.
mellitus in elderly, role of pharmacist in
a. Multidisciplinary health care team. J
Multidisciplhealthc 2011;4:149‑154.
16 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Vitamin D Deficiency in Rural Area of Gautam Buddh Nagar:

An Observational Study

Vijay Deepak Verma1, Ajai Kumar Garg2, Suresh Babu3, Ashish Satyarthi4
1Assistant Professor, 2Associate Professor, 3Senior Consultant, 4Resident, Department of Medicine,
Government Institute of Medical Sciences, Greater Noida

Abstract
Background: In addition to bone formation, mineralization,calcium and phosphorus metabolism, vitamin
D is also involved in maintaining normal neuromuscular function. Vitamin D deficiency is a public health
problem in our country. Its deficiency is widely prevalent in urban population. However, rural Indian
population is perceived to be at low risk of vitamin D deficiency due to their lifestyle exposing them to more
sunlight.

Aim: To study the prevalence of vitamin D deficiency in rural population of Gautam Buddh Nagar district
of national capital region.

Methodology: Consequent 80 apparently healthy subjects of either sex from both rural and urban background,
with nonspecific symptoms were studied for their demographic profile and 25(OH) vitamin D levels.

Results:25(OH) vitamin D level was 14.96 ng/ml in rural group and 16.25 ng/ml in urban group. A high
prevalence of vitamin D deficiency was observed in both rural and urban population of Gautam Buddh
Nagar.

Conclusion: Vitamin D deficiency is widely prevalent in our society including rural India. Apparently
healthy subjects of rural population particularly women with nonspecific symptoms should be evaluated for
vitamin D deficiency.

Introduction population of our country. Factors such as low sunlight

exposure, age related decrease in vitamin D synthesis in
Vitamin D deficiency is a global problem and its
the skin, and diet low in vitamin D are the main causes
deficiency is widely prevalent in urban Indian population
of vitamin D deficiency. Physical factors like clothing,
across all age groups and sections of society1,2,3. In large
sunscreens, and glass-shielding attenuate UV-B
chunk of population vitamin D deficiency is subclinical
exposure of skin and thereby, markedly reduce synthesis
which is characterized by non specific musculoskeletal
of vitamin D.
clinical manifestations4. However, there is limited
data available about deficiency of vitamin D in rural Population in rural areas generally has different
occupation and lifestyle. In rural areas, large proportion
of men and women work as farmers and are exposed
Corresponding Author: to more sunlight whereas people living in urban areas
Ajai Kumar Garg generally work indoor and do not get adequate exposure
Associate Professor, Department of Medicine, to sunlight5. People in urban areas are also involved
Government Institute of Medical Sciences, Greater in activities that avoid sun light, e.g., protection from
Noida sunlight by use of umbrella and sunscreen6,7. On the
e-mail: [email protected] other hand, melanin pigment, produced by melanocytes
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 17
on exposure to sunlight absorbs UV-B rays and thus Results
attenuates the final dose of UV-B energy reaching
In the present study out of 80 subjects 38 had rural
7-dehydrocholesterol in basal layers of epidermis.
background whereas 42 subjects belonged to urban
Therefore,melanin functions as natural sunscreen and
class. Out of 80 subjects 27 were male and 53 were
reduces the skin’s ability to synthesize vitamin D as
female. In this study 34 subjects belonged to 21-40
much as 99%. Therefore persons with dark skin are more
and 41-60 year age group each, 11 subjects belonged
likely to have vitamin D deficiency and need more direct
to >60 year age group, whereas only 1 belonged to <
sunlight to have optimum amount vitamin D synthesis
20 year age. Severe vitamin D deficiency was found in
by skin7,8.
25% (20/80), vitamin D deficiency was found in 48.75%
UV-B rays of sun trigger the photolysis of pro- (39/80) with insufficiency in 18.75% (15/80) in the study
vitamin D3 (7-dehydrocholesterol) to previtamin D3 population. Sufficient vitamin D level was found in only
in plasma membrane of keratinocytes of human skin. 7.5% (6/80) cases. 25(OH) vitamin D level was 14.96
This plasma membrane previtamin D3 is isomerized to ng/ml in rural group and 16.25 ng/ml in urban group.
vitamin D at skin temperature. Serum 25(OH)vitaminD Vitamin D deficiency in rural area was comparable to
is major circulating metabolite and standard clinical urban population and it was as common in males as in
measure of vitamin D status. 1, 25(OH)2 vitamin D females.
should not be measured to determine vitamin D status,
Table 1: Number of subjects in both the groups
as it can be normal or even elevated in patients with
vitamin D deficiency. Studies have shown that serum Patient Profile Rural Urban Total
25(OH) vitamin D level around 30 ngm/ml (75 nmol/L) Male 9 18 27
induce a minimum steady state level of PTH. Female 29 24 53
Total 38 42 80
Material and Method
The present study was conducted in the department Table 2: Average vitamin D level in ng/ml in both
of medicine, Government Institute of Medical Sciences, groups
Greater Noida for a period of one year. Consecutive
Patient Profile Rural Urban
80 patients attending medical OPD with complaints of
Male 12.44 ng/ml 14.38 ng/ml
backache, generalized bodyache, joint pain, fatigue, and
Female 15.87 ng/ml 17.52 ng/ml
muscle weakness were included in the study. Patients
Total average 14.96 ng/ml 16.25 ng/ml
with history of diabetes mellitus, chronic liver disease,
chronic kidney disease, thyroid disorders, malignancy, Table 3: Age of patients in both the groups
chronic diarrhea, or any other chronic illness, were
excluded from the study. Patients taking vitamin D or Age Group Rural Rural Urban Urban
Total
with past history of Vitamin D supplementation were in Years Male Female Male Female
excluded from the study. Patients who were bed ridden <20 1 0 0 0 1
and forced to stay indoor due to any chronic condition or 21-40 5 14 4 11 34
otherwise were also excluded from this study. Patients 41-60 4 13 7 10 34
were evaluated for demographic profile and serum >60 0 1 6 4 11
25(OH) vitamin D level.

Table 4: Severity of vitamin D deficiency in study groups

Vitamin D Status 25(OH) D (ng/ml) Rural male Rural female Urban male Urban female Total
Severe deficiency <10 2 5 7 6 20
Deficiency 10-20 5 18 7 9 39
Insufficiency 20-30 3 4 2 6 15
Adequate 30 -40 0 1 1 4 6
18 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Discussion found so they should be supplemented with vitamin D

and calcium.
India, despite being a tropical country with
abundant sunshine is found to have high burden of Financial support and sponsorship: Nil
vitamin D deficiency among the public irrespective
of their socioeconomic status. GRet. al., in one study Conflict of Interest: Nil
reported vitamin D deficiency in epidemic proportion
Ethical Clearance: Taken from institutional ethical
with a prevalence of 70-100% in general population
committee.
both in urban and rural settings across all socioeconomic
strata9. Agarwal N et.al., observed in their study that References
vitamin D deficiency was present in 83.7% of subjects
(<20 ng/ml) at baseline among Indian postmenopausal 1. Michael F. Holick. High prevalence of Vitamin
women10. High prevalence of vitamin D deficiency in D inadequacy and implications for health; www.
patients with type 2 diabetes mellitus has been observed mayoclinic procedings.com. March 2006; 81(3):
by some studies. Selvarajan S et.al., observed that 353-73.
vitamin D deficiency was prevalent among apparently 2. Selvarajan S, Gunaseelan V, Sahoo JP. Systemic
healthy Indians living in different regions irrespective review on Vitamin D level in apparently healthy
of their exposure to sun light2. Choy EY in one study Indian population and analysis of its associated
among Korean adults observed that vitamin D deficiency factors. Indian Journal of Endocrinology and
peaked in summers and higher vitamin D levels were metabolism 2017;21(5):765-75.
correlated with summer, the 60s age group, rural 3. Van Schoor NM, Lips P. Worldwide vitamin D
residence, moderate to vigorous physical activity, and status. Best Pract Res Clin Endocrinol-Metab 2011;
multivitamin supplementation. He also observed that 25(4): 671-80.
higher education and unmarried status were inversely
4. Kanekar A, Sharma M, Joshi VR. Vitamin
related to vitamin D levels in both male and female11.
D deficiency- A clinical Spectrum: Is there a
Interestingly in the present study maximum number of
symptomatic nonosteomalacic state? International
subjects with vitamin D deficiency belonged to 20-60
Journal of Endocrinology 2010, Article ID 521457.
years and fewer subjects belonged to above 60 years
of age. The possible reason for this observation may 5. Sari DK, Zaimah. Lifestyle differences in urban
be increasing awareness about vitamin D deficiency in and rural areas affected the level of vitamin D in
the society and increasing medical attention in the form women with single nucleotide polymorphism in
of calcium and vitamin D supplementation received by North Sumatera. Asian Journal of Clinical Nutrition
elderly people. Roland VK et. al., in one study conducted 2017; 9(2):57-63.
on 174 patients in Switzerland observed that vitamin D 6. Clemens TL, Adams JS, Henderson SL, Holick
deficiency was present in 71% of chronic pain patients MF. Increased skin pigment reduces the capacity of
and another 21% had insufficient vitamin D levels12. skin to synthesize vitamin D. Lancet 1982; 1(8263):
74‑6.
Conclusion 7. Matsuyoka LY, Wirtsman J, Haddad JG, Kolm P,
In this small study it is concluded that vitamin D Hollis BW. Racial pigmentation and the cutaneous
deficiency is as common in rural population as in urban synthesis of vitamin D. Arch Dermatol 1991;
population of Gautam Buddh Nagar district of national 127(4): 536-38.
capital region, although deficiency of this vitamin is 8. Weishaar T, Rajan S, Keller B. Probability of
more prevalent in females than in males. One of the Vitamin D Deficiency by body weight and race/
reasons of vitamin D deficiency in rural India could be ethinicity. J Am Board of Fam Med 2016;29:226‑32.
the decreased synthesis of vitamin D because of high 9. GR, Gupta A. Vitamin D deficiency in India:
melanin skin pigment and reduced intake of dietary Prevalence, casualities and interventions. Nutrients
products rich in vitamin D. Therefore apparently healthy 2014;6:729-75.
subjects of rural population particularly women with
10. Agarwal N, Mithal A, Dhingra V, Kaur P, Godebole
nonspecific symptoms of bodyache and weakness
MM, Shuka M. Effect of two different doses of oral
should be evaluated for vitamin D deficiency and if
cholecalciferol supplementation on serum 25(OH)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 19
vitamin D levels in healthy Indian postmenopausal adults. Asia Pac J ClinNutr 2012; 21(4): 526-35.
women: A randomized controlled trial. Indian J 12. Ronald VK, Veronoka MH, Georgios K, Nikelaus
Endocrinol Metab 2013;17:883-9. E. Vitamin D and central hypersensitivity in patients
11. Choi EY. 25(OH) D status and demographic and with chronic pain. Pain Medicine 2014;15:1609‑18.
lifestyle determinants of 25(OH) D among Korean
20 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Identifying the Status of Menstrual Hygiene Management

Amrita Shilpi1, Rajasree Roy2, Gobina3, Spriha Roy4

1Assistant Professor, Department of Political Science, 2Assistant Professor, Department of Philosophy,
3
Assistant Professor, Department of History, 4Student, Philosophy Hons, Lakshmibai College, University of Delhi

Abstract
For women, the onset of puberty is marked by menstruation. To bleed is natural and indispensable essence of
being a woman. However, innumerable myths and taboos perceive menstruation as a negative phenomenon
and lead to pessimistic attitudes toward this biological experience and women going through it. The culture
of silence around menstruation increases the perception of menstruation as something shameful that needs to
be hidden, and may reinforce misunderstandings and negative attitudes toward it. Proper menstrual hygiene
management is the most significant and crucial aspect of female health but has been grossly neglected not
just in developing countries but across the globe.

The paper presents ground assessment of the knowledge, beliefs, and source of information regarding
menstruation among the adolescent school girls and also identifies the status of menstrual hygiene among
them. This study was undertaken, under the Innovation Project of Delhi University in the year 2015-16. This
interdisciplinary undergraduate program had two components: Awareness generation and action oriented.
Awareness generation was related to providing information through workshops about menstruation among
the college going young women adolescent school girls of the secondary school. Action component was
related to production of low cost sanitary napkins by using simple technology that has been locally developed.

Keywords: Menstruation, Menstrual hygiene, Innovation Project.

Introduction assess the knowledge, beliefs, and source of information

regarding menstruation among the adolescent school
For women, the onset of puberty is marked by
girls and also to identify the status of menstrual hygiene
menstruation. To bleed is natural and indispensable
among them.
essence of being a woman. However, scores of myths
and taboos continue to perceive menstruation as a This interdisciplinary undergraduate program had
negative phenomenon1 and lead to pessimistic attitudes two components: Awareness generation and action
toward this biological experience and women going oriented. Action component was related to production
through it. The culture of ‘silence’ around menstruation of low cost sanitary napkins by using simple technology
increases the perception of menstruation as something that has been locally developed.
shameful that needs to be hidden, and may reinforce
misunderstandings and negative attitudes toward it2. Awareness Generation Component: Awareness
generation was related to providing information through
Proper menstrual hygiene management is the most workshops about menstruation among the adolescent
significant and crucial aspect of female health but has school girls of the secondary school. It was based on the
been grossly neglected not just in developing countries hypothesis that awareness generation and promotion of
but across the globe. Increased knowledge and safe low cost technologies can play a vital role in combating
practices related to menstruation right from adolescence the harmful consequences of menstrual hygiene
may help in diminishing the suffering of millions of mismanagement. The objectives were as followed
women3 (Yasmin et al: 2013).
i. Developing an acquaintance in girls with the subject
With this background the present study was of menstrual hygiene mismanagement,
undertaken, under the Innovation Project 2015-16, to
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 21
ii. Understanding on traditional practices during collecting data on the awareness levels among the target
menstruation. groups were direct personal observation supplemented
by interviews and focus group discussions. It was
iii. Myths related to menstruation.
supplemented by series of workshops and interactive
iv. Unhygienic practices and their health impacts. sessions on menstrual hygiene management.
v. Management of menstrual waste. For the Innovation Project team, there were series
vi. Products to be used during menstruation. of sessions on sanitary pad preparation. It began with
familiarizing the participants with the materials and
vii. To encourage low cost sanitation technologies
then involving them in the production. The team also
viii. To generate acceptability in community for interacted with a number of civil society organizations
handmade sanitary materials, working in this field.
ix. To develop a mechanism within the institutions with Sampling and development of structured
the help of trained population groups for production Interview Schedule: A random selection of 400 girl
and sale of sanitary pads. students from four Government Girls Secondary Schools
The study focussed on assessing the knowledge, of North Delhi (100 from each school) was done for the
beliefs, and source of information regarding menstruation data collection.
among adolescent school girls and also to identify the
Data was collected on the structured interview
status of menstrual hygiene among them. The purpose
schedule so that it could be comparable in all respects.
of the project was awareness generation, facilitation of
For this purpose items were framed following scientific
information and training on handmade sanitary napkins.
procedures of item writing and discussion with a number
From the review of literature it was clear that of experts from social work and education background.
many times social taboo4,5,6,7,8and unhelpful outlook of On the basis of the suggestions the schedule was finalized
parents and teachers in discussing the issues related to which contained the following areas:
menstruation have obstructed the access of adolescent
Demographic Characteristics, Information about
girls to the proper information about the entire
Menstruation, Knowledge and Perception regarding
phenomenon9. After a survey of Government primary
Menstruation, Practice of Menstrual Hygiene, and
and secondary schools near Chandrawal area in North
Restrictions practiced during Menstruation.
Delhi and series of interaction with several NGOs,
individuals and school authorities the team prepared a This schedule was earlier administered on a small
list of eight schools which could be approached for the sample of students of Lakshmibai College to see if
study. An informal visit to each school was made and the language was suitable for the population.
purpose of study was explained. Most of the Principals
and teachers welcomed the idea. However, one of the Interview and Focus Group Discussion: A pre-
Principals was totally apprehensive about the interaction designed pre-tested structured interview schedule was
with the students. She insisted that open discussions eventually administered on a sample of 400 schools
about ‘such things’ leave the growing up girls more going girls specified in the study as per the sampling
confused. design. They were explained about the purpose of the
study and were assured of confidentiality. A verbal
After the informal interaction, the investigators consent was obtained from the girls before administering
approached Deputy Director of Education (North the questionnaire which included questions regarding the
District) with a request for holding Awareness knowledge about menstruation, the source of information
Workshop on Menstrual Health and Hygiene among and practices followed to maintain menstrual hygiene.
students of class 6th, 7th, 8th,and 9th standard in four Investigators instructed on how to fill the schedule
Government Girls Secondary Schools of North Delhi. and adequate time was given to fill up the same. Any
With her consent, the team held awareness workshops difficulties in answering the schedule were sorted out by
and conducted focus group discussions with the girl the investigators.
students of the selected schools.
At the end of the data collection a FGD was conducted
Method of data collection: The basic method for with girls of different age groups. The discussion was
22 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
focussed on the normal physiology of menstruation, the respondents ranged between 10 to 13 years. 87.25%
importance of maintaining hygiene and safe hygienic of the respondents were aged between 11 to 12 years.
practices during menstruation. Questions and concerns One of the items of the schedule sought information
of the participants were also addressed at the end of the on the source of information about menarche. Mostly,
session. mothers are the main informants as well as confidant
of the girls at this age. However, there is always an
Result and Discussion element of concern as to how the girls are informed
As explained above, the interview schedule was about this phenomenal change in their bodies. Out of
divided into five sections. The aim was to understand 400 respondents 336 replied that mothers were the first
the perception, experience and information about informants for them. It was followed by friends/sister
menstruation. (35), teacher/health worker (20). Amongst other options,
television was an important source of information about
Menarche becomes a significant experience in menstrual hygiene (9).
girls at the threshold of adolescence10. The age of the

Figure 1

Awareness regarding menarche and menstruation self-image, grips them with the onset offirst ‘period’. It
among respondents before attaining menarche was was interesting to talk to girls about their first period and
found to be low. Out of 400 respondents, 252 knew how they felt about it. When asked about the cause of
about it after menarche. After reaching puberty, girls are menstruation, 61% of the respondents believed it to be a
faced with challenges related to menstruation. Lack of physiological process. It was interesting however to note
information, misconceptions and adverse attitudes to this that 9.5% of the total respondents believed it to be some
natural process have lead to a negative self-image among kind of curse. 27% of the respondents had no idea about
girls. This often results in a lack of self-esteem as they the cause of menstruation.
mature as women. Most often this emotion, the negative
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 23

Figure 2

Awareness level was quite low about where of absorbent material used was of primary concern. The
the menstrual bleeding originated from. 68% of the reuse of any absorbent material, most commonly, cloth,
respondents had no idea about it. There were three other could be a cause for infection if it was not properly
items in this section that showed lack of awareness about cleaned dried and stored. This study revealed that
menstruation and menstrual health. girls both cloth and sanitary pads as absorbent during
menstruation depending on the availability.
The next section of the schedule tried to understand
the common practices of menstrual hygiene. The type

Figure 3

However, some of the girls informed that they pads at low cost might increase the use of sanitary pads.
preferred cloth pieces rather than sanitary pads as
menstrual absorbent because they did not have proper The place of storage of the cloth or napkins was
undergarments to support it. Some of the teachers shared equally important for cleanliness and hygiene. The
their concern that due to lack of proper undergarments the practice of storing them was not witnessed. They
girls did not attend school during those days. It was also procured cloth or pads as and when required.
suggested that provision of undergarments and sanitary
24 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Figure 4

The proportion of the participants who used the and disposing it in routine dustbin which was used for
bathroom as a storage place was very low. solid waste disposal. However, 32% of the respondents
admitted to throwing the sanitary waste on the roadside
In the present study, the most common method of as it got dark.
disposal of the used absorbent was wrapping it in paper

Figure 5

In the present study restrictions were practiced by food being the most common restrictions.
most of the girls, visit to holy places and touching stored
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 25

Figure 6

Considering the limitations of this study in terms that enhances easy and low cost access to something as
of sampling method, additional studies may be needed essential as sanitary napkins.
using a wider geographic scope, in order to produce
sufficient and comprehensive results. This project has wide social contribution as well as
commercial implication.
Action Component: The College provided for an
Innovation Room where the project team has produced Conclusion and Future direction
Sanitary napkins at low cost. The production of the Menstrual hygiene is an issue that is quite
napkins has been done entirely by the college students (a unsatisfactorily acknowledged. It has not received
team of ten students selected for the project). ample attention in the reproductive health and Water,
Innovation shown and its future impact: Sanitation and Hygiene (WASH) sectors in developing
Contemporary political thinker, Nancy Fraser11 opines countries including India12. Its connection with and
that, “institutionalized patterns of cultural value effect on achieving many Millennium Development
constitute some actors as inferior, excluded, wholly Goals (MDGs) is hardly ever recognized13.
other, or simply invisible, hence as less than full This study has tried to tackle several issues at the
partners in social interaction, then we should speak of ground level. The low and lower middle class strata
misrecognition and status subordination”(p.29). Both more often than not lack knowledge as well as money
these cultural constructs are visible when one places for availing basic necessities as sanitary napkins.
women and the world face to face. Females mostly use old and dirty clothes due to their
Sciences rightly have the first claim to inventions impoverished background. They do not know how to
and discoveries. The Social Sciences keep exploring the manage menstruation properly. It can lead to extreme
continuity and change within the society which makes forms of infections and diseases. The introduction of
every stratum significant. the concept of handmade sanitary material to the school
students, teachers, college youth and other sections of
As members of academics, it becomes one’s the society eventually would at least help in addressing
responsibility to take such issues to the ground using the basic health issues.
awareness and information as the working tools. The
innovative techniques have evolved within the country Ethical Clearance: Taken
26 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Source of Funding: Research Council, University tribal (Gujjar) adolescent girls, Studies on Ethno
of Delhi provided the grant for undertaking this Medicine, 2009; 3(1): 43-8
Innovation Project in the year 2015-16. 7. Ahmed, R. and K. Yesmin. ‘Menstrual hygiene:
breaking the silence’, in J. Wicken, J. Verhagen, C.
Conflict of Interest: Nil
Sijbesma, C. da Silva and P. Ryan (eds.) Beyond
References Construction Use by All, 2008: IRC International
Water and Sanitation Centre and WaterAid
1. Dasgupta.A and M Sarkar: Menstrual Hygiene:
8. Joshi, D. and B. Fawcett. ‘Water, Hindu Mythology
How Hygienic is the Adolescent Girl? Indian
and an Unequal Social Order in India’, paper
Journal of Community Medicine; April 2008;
presented at the Second Conference of the
33(2):78-80
International Water History Association, August
2. Quazi S.Z., Gaidhane A., & Singh D. Believes and 2001, Bergen, Norway, 10-12 August
Practices regarding menstruation among adolescent
9. Khanna A, Goyal RS and Bhawsar R. Menstrual
girls of high school and Junior college of rural areas
practices and reproductive problems: a study of
of Thane district. Journal of DMIMSU, Dec 2006,
adolescent girls in Rajasthan. Journal of Healthcare
Vol 2,
Management, 2005;7: 91-107.
3. Yasmin S, Manna N, Mallik S, Ahmed A and Paria
10. World Health Organization. Adolescents in
B. Menstrual hygiene among adolescent school
India. A Profile. 2003. Available at: http://www.
students: An in-depth cross-sectional study in an
whoindia.org/LinkFiles/Adolescent_Health_and_
urban community of West Bengal, India. IOSR
Development_(AHD)_UNFPA_Country_Report.
Journal of Dental and Medical Sciences. 2013;5(6):
pdf
22-26.
11. Fraser, Nancy. ‘Social Justice in the Age of
4. Mudey AB, Keshwani N, Mudey GA and Goyal
Identity Politics: Redistribution, Recognition
RC. A cross-sectional study on the awareness
and Participation’. InN. Fraser and A. Honneth,
regarding safe and hygienic practices amongst
Redistribution or Recognition? A Political-
school going adolescent girls in the rural areas of
Philosophical Exchange. Verso: London and New
Wardha district. Global Journal of Health Science.
York: 2003.
2010;2(2): 225-231.
12. UNICEF WASH in Schools.2012. July http://www.
5. Drakshayani Devi K and Venkata Ramaiah P. A
unicef.org/wash/schools/
study on menstrual hygiene among rural adolescent
girls. Indian Journal of Medical Science. 1994;48: 13. Water Aid. Is menstrual hygiene and management
139-43. an issue for adolescent girls? Water Aid in South
Asia Publication; 2009. Available at: http.//www.
6. Dhingra, R., A. Kumar and M. Kour.Knowledge
wateraid.org/nepal.
and practices related to menstruation among
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 27

Effect of Strengthening of Scapular Stabilizers in Treatment of

Rounded Shoulder Posture in Dental Students

Ankita M. Patil1, Sayali Gijare2

1Intern, 2Assistant
Professor, Department of Pediatrics, Faculty of Physiotherapy,
KIMS “Deemed to be University” Karad, Maharashtra, India

Abstract
Objective: The objective of this study was to investigate the effects of scapular stabilizer strengthening in
rounded shoulder posture in male dental students.

Method: Ethical clearance was obtained from the institutional ethical committee. Total 30 Subjects were
selected as per the inclusion criteria and rests were excluded. Participants were informed about the study &
written consent was taken prior to participation. In pre test assessment, subjects were assessed by scapular
index. They were given strengthening exercises of scapular stabilizers as a treatment of rounded shoulder
posture before they start working for 30 minutes per day, 5 days a week and were continued for 4 weeks.
Post test assessment was done by using same outcome measure. Interpretation of the study was done on
the basis of comparing pre test and post test assessment. Thus, the study was concluded with the help of
statistical analysis by using paired ‘t’ test.

Results: The study showed effect of strengthening of scapular stabilizers on rounded shoulder posture in
dental students is (p>0.0001), which is extremely significant.

Conclusion: On the basis of the results of our study, it is concluded that strengthening of scapular stabilizersis
extremely significant effective in correcting rounded shoulder posture among male dental students.

Keywords: Rounded shoulder, external rotation, scapular stabilizers.

Introduction and middle trapezius muscle that function to pull the

scapulae toward spine[1].
Rounded shoulder posture is characterized by
acromion protraction in front of the line of gravity, It has been also documented in factors which are
shoulder protraction and downward rotation as well contributing to head, shoulder as well as neck pain[6].
as anterior tilt[1]. According to previous study rounded Trapezius and lower serratus anterior act as the prime
shoulder is described as abduction and elevation of movers for scapular upward rotation. Rhomboids and
the scapula and a forward position of the shoulders levator scapulae are downward rotators and serratus
which gives appearance of a hollow chest[2]. Posture anterior, rhomboids, trapezius, levator scapulae are
and comparative alignment of the body is affected due stabilizers of scapula[7]. Position and control of the
to shortening and weakness of the muscles. rounded scapula on thorax, play a critical role in the normal
shoulder posture deform the normal relationship of the function of the shoulder. While doing overhead
muscles and the bony structures which are correlated activities periscapular muscles provide stability and
to each other[3]. It is described as a result of shoulders help in pain free mobility at shoulder complex in healthy
being pulled forward by over-developed, shortened or individuals[8].
tight anterior shoulder girdle muscles such as serratus
anterior, upper trapezius etc.[4, 5] Additionally, it may Although many technical advances have arrived
also caused by weakness and lengthening of the upper in recent years, many occupational health problems
28 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
still persists in modern dentistry [9].Musculoskeletal Post test assessment was done by using same
disorders are common problem in dentists as its outcome measure. Interpretation of the study was
incidence is 63 to 93%.Some of these musculoskeletal done on the basis of comparing pre test and post test
disorders may recognized to postural abnormalities or assessment. Thus, the study was concluded with the help
poor posture specifically in demanding jobs such as of statistical analysis.
dentistry. Prevalence of rounded shoulder posture in
dentists contributes to 68.8% [10]. There are some factors Sampling method: convenient sampling
which may play important role in pathogenesis and Treatment
constant complaints are prolonged static and dynamic
Exercise protocol for activation of scapular
awkward postures and repetitive movements, physical
stabilizers:
conditioning [11]. Previous studies have acknowledged
that these postural problems may considerably influence 1. Side lying external rotation with elbow 90° flexion
the social life and result in diminished working efficacy using dumbbell.
and early retirement in dentistry [12, 13].
2. Side lying external rotation with forward flexion
It is found in early studies that, Stretching, McKenzie using dumbbell.
and Kendall exercises for shoulder girdle muscles are 3. Prone horizontal abduction at 90° with full external
commonly used in the treatment of shoulder dysfunctions rotation using dumbbell.
and correction of posture [1]. However there is limited
research available to show any significant impact of 4. Prone external rotation at 90° abduction and elbow
strengthening of scapular stabilizers in treatment of at 90° using dumbbell.
rounded shoulder posture in dental students. 5. Shoulder shrug at 0° abduction.

Strengthening exercises are defined as a systematic 6. Shoulder shrug at 30° abduction.

procedure of a muscle or muscle group lifting, lowering 7. Standing wall shrugs.
or controlling resistance for a relatively low number
of repetitions or over a short period of time [14].These All the exercises were performed 30 minutes/day
types of exercises can be performed in both closed chain for 5 days/week for continuous 4 weeks.
as well as open chain positions. Exercise interventions
Strengthening exercises of scapular Stabilizers:
aimed at strengthening of the weak that is scapular
stabilizing muscles [15].The purpose of this study was 1. Scapular retraction against handheld resistance in
to evaluate the effect of 4 weeks of strength training on prone
rounded shoulder posture by scapular index as outcome 2. T to Y to W exercises
measure. For assessing rounded shoulders, scapular
index was used [16]. 3. Scapular-clock exercise on the table
4. Scapular-clock exercises on a wall
Method
5. Corner press-out
Ethical clearance was obtained from the institutional
ethical committee. Total 30 Subjects were selected Subject Criteria: Total of 30 subjects, male interns
as per the inclusion criteria and rest were excluded. and male PG dental students working more than 5 hours
Participants were informed about the study & written were selected in the study. They were aged between 20
consent was taken prior to participation. In pre test to years. The explanations about the study procedure
assessment, subjects were assessed by scapular index. were given. The outcome measure was scapular index.
They were given strengthening of scapular stabilizers as The subjects who were not included in the study were
a treatment of rounded shoulder posture before they start dental students having history of diagnosed rheumatoid
working. The exercises were given for 30 minutes per disorders,history of any neurological disorders,Female
day, 5 days a week and was continued for 4 weeks. dental students,Trauma as well as surgery in shoulders
and spine.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 29

Results Interpretation: This graph shows that, the age

distribution in this study included is 28 in age group
1. Age Distribution in this Study:
between 20-25 and 2 in 26-30 age group.

2. Pre and Post Comparison:

Table No. 01

Pre Post
Scapular Index
70.733 72.917

Graph No. 01: Age distribution

Chart: Pre and Post Comparison

Table No. 02

Group PRE POST P value t value Remark

Scapular Index 70.733±2.337 72.917±2.567 <0.0001 8.297 Extremely Significant

Statistical Analysis: The outcome measure was students having rounded shoulders and to strengthen
assessed at the baseline. The collected data in this study their scapular stabilizers. Statistically the present study
was statistically analyzed using descriptive statistics as showed that there were significant changes in the
mean, standard deviation and percentage. The scapular outcome measure with significant difference seen in
index was analyzed by paired t’ test. T values were rounded shoulder posture mean difference (-2.183)(p
calculated in the scapular index. Statistical significance value <0.0001).In our study we analyzed that the changes
was accepted for the values of (p < 0.0001). in scapular index,after incorporating strengthening
exercises for rounded shoulder posture for 4 weeks were
Discussion significant.
There are many technical advances arrived A study conducted to investigate the specific effects
nowadays still many occupational health problems of a McKenzie exercises, Kendall exercises, self stretch
persists in dentists[9]. Musculoskeletal disorders are exercises on rounded shoulder posture and forward head
common problem in dentists as its incidence is 63 to posture. In this study, rounded shoulder posture was
93%. Prevalence of rounded shoulder posture in dentists measured by scapular index in which they found no
contributes to 68.8%[10]. A variety of factors which significant differences between the groups (p>0.05)[1].
may contribute important role in pathogenesis and
constant complaints are prolonged static and dynamic A study performed on intramuscular activation
awkward postures and repetitive movements, physical of scapular stabilizing muscles during push up plus
conditioning [11]. and proprioceptive neuromuscular exercises. The
proprioceptive neuromuscular exercises showed
In the current study, dental students between statistically significant higher level of lower trapezius
age group 20-30 fulfilling the inclusion criteria were and lower serratus anterior activities than push up plus
included. Dental students working for more than 5 hours exercises[7].
were included in this study.
A study was done on the review of the exercises that
The aim of our study was to find out the dental produce optimal muscle ratios of the scapular stabilizers
30 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
on normal shoulder which included optimal positions 6. Griegel-Morris P, Larson K, Mueller Klaus K, Oatis
and exercises for periscapular stability exercises. A CA: Incidence of common postural abnormalities
conclusion that standing exercises tend to activate the in the cervical,shoulder,and thoracic regions and
upper trapezius at higher ratio,especially during 60-1200 their association with pain in two groups of healthy
range[8]. subjects. Phys Ther 72(6):425-430,1992.
7. Du-jin park, Hyun-ok lee. The intramuscular
At the end of 4 weeks in our study,it was seen that
activation of scapular stabilizing muscles during
there were statistically significant difference between pre
push up plus and PNF exercises in a quadruped
interventional and post interventional values of scapular
position.j.phys.ther.sci, 371-374.
index in rounded shoulder posture of male dental students
after applying paired ‘t’ test, concluding that there is a 8. Abbey schory, Erik bidinger, Joshua wolf, Leigh
positive effect of strengthening of scapular stabilizers on Murray. A systematic review of the exercises that
rounded shoulder posture in dental students. produce optimal muscle ratios of the scapular
stabilizers in normal shoulders. IJSPT,321-336.
Conclusion 9. Rabiei M. Shakiba M, Dehghan H, Talezadeh
On the basis of the results of our study, it is M. Musculoskeletal Disorders in Dentists. Int J
concluded that strengthening of scapular stabilizersis Occupat Hygin. 2012;4(1):36-40.
extremely significant effective in correcting rounded 10. Leila Vakili, FarzinHalabchi,
shoulder posture among male dental students. Mohammadalimansournia, Mohmmadrezakhami,
Shahlairandoost, Zahraalizadeh. Prevalence of
Conflicts of Interest: The authors declare that there common postural disorders among academic dental
are no conflicts of interest concerning the content of the staff. Asian journal sports medicine.
present study.
11] Peter A. leggat, Urepornkedjarune, Derek R.
Source of Funding: Self Smith. Occupational health problems in in modern
dentistry: are view, industrial health,611-621.
References 12] Ylippa V, Arnetz BB, Benko SS, Ryden H.
1. Do youn lee, Chan woo nam, Youn bum sung, Physical and psychosocial work environments
Kyoungkim, Haeyong lee Changes in rounded among swdish dental hygienists :risk indicators
shoulder posture and forward head posture for musculoskeletal complaints. Swd Dent J.
according to exercise method. The journal of 1997;21(3):111-20.
physical therapy science. 1824-1827. 13] Crawford L, Gutierrez G, Harber P. Work
2. Debra E.Peterson, Kenneth R. Blankenship,Joel environment and occupational health of dental
B. Robb, Michael J.Walker, Jean M. Bryan, hygienists :a qualitative assessment. JOccup
Deborth M. Stetts, Lynne M et al. Investigation Environ Med. 2005;47(6):623-32.
of the validity and reliability of four objective 14. Carolyn Kisner. Therapeutic exercise foundations
techniques for measuring forward shoulder posture. and techniques :sixth edition JAYPEE; pg no.601-
JOSPT,34-42. 608.
3. Raines, twomey LT: Head and shoulder posture 15. Andrews,JR, and Satter white, YE: anatomic
variations in 160 asymptomatic women and men. capsular shift. J Orthop Tech 1:151-160,1993.
ArchPhys Med Rehabil,1997,78;1215-1223. 16. Rupali Salvi, Sneha Battin. Correlation of
4. Kendall FP, McCreary EK: Muscles :Testing mobile phone addiction scale (MPAS) score with
function (3rd Ed), pp 269-301. Baltimore, MD: Craniovertebralangle, scapular index and beck’s
Williams & Wilkins, 1983. depression inventory score in young adults.
5. Kendall HO, Kendall FP, Boynton DA: Posture and IJPHY,7-12
Pain,p 15,153. Huntington, NY: Robert E. Krieger
Publishing Company, Inc,1970.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 31

Elder Abuse in Indian Setting–A Misconception or a Reality–

A Deductive Analysis

Anusha Rashmi1, Linda Sequeira2, Prianka Shashi Kumar2, Rashmi3

1Assistant Professor, 2Post Graduate, Community Medicine, AJIMS & RC, 3Professor,
Community Medicine, K.S. Hegde Medical Academy, Mangalore

Abstract
Background: Elderabuse has come to the limelight only since the past decade. WHO estimates that 15.7%
of individuals above 60 years undergo abuse in various forms and is proposed to increase in the coming
years owing to ageing population in many countries. Hence this study attempts to find out the perception of
individuals towards elder abuse.

Method: A qualitative study was done by conducting Focussed group discussions (FGDs) amongst elders
and those between 18–60 years of age. The discussion was audio taped and scribed which was then analysed
by deductive thematic analysis. The findings have been presented based on the themes that emerged along
with verbatim.

Results: The study groups were of the consensus that elder abuse is prevalent in our country. Themes that
emerged were: 1) Elders are considered a burden in the society, 2) Sons and daughter in laws abuse elders
more, 3) Elderly females are abused more than elderly males. The discussions also revealed a low level of
knowledge amongst the groups regarding helplines for elderly/schemes for the elderly in our country.

Conclusion: Elderly abuse though prevalent in our societies lay hidden mostly because complaint
registrations of such instances are very few owing to the fact that elders are dependent and are not aware of
where and how to seek help.

Keywords: Elderly, abuse, deductive analysis, FGD, Misconception, Qualitative study.

Introduction Elder abuse can be defined as “a single, or repeated

act, or lack of appropriate action, occurring within any
Though Domestic violence and Child abuse and
relationship where there is an expectation of trust which
gender-based violence have been receiving considerable
causes harm or distress to an older person”.1 Elder
attention, Elder abuse has come to the foray only since
abuse can take various forms such as financial, physical,
the past decade. Based on available evidence, WHO
psychological and sexual. It can also be the result of
estimates that 15.7% of people 60 years and older are
intentional or unintentional neglect.
subjected to abuse.1 These are likely to be underestimates
as many cases of elder abuse are not reported. Globally the number of people affected are
predicted to increase as many countries are experiencing
rapidly ageing populations. While in India, 8 percent
of its population was recorded 60 years and above in
Corresponding Author: 2011 Census, it is expected to increase its share to 12.5
Dr. Anusha Rashmi percent and 20 percent by 2026 and 2050 respectively.2
Assistant Professor, Community Medicine, AJIMS & With this kind of an ageing scenario, there is pressure on
RC, Mangalore all aspects of care for the older persons–be it financial,
e-mail: [email protected] health or shelter.
32 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Studies have also shown that the phenomenon of information from 2 groups of Elderly (> 60 years)
elder abuse has been considered a social taboo by many having 5 and 6 members each and 2 groups from general
and people struggle to discuss such a sensitive issue and population group (> or = 18 yrs - <60 years) having 4
report elder mistreatment.3 Family members have been and 5 members each. Hence a total of 4 FGD sessions
the most common perpetrators of elder abuse.4,5 were conducted. Each session lasted for 45 minutes.
It comprised of a moderator who was the principle
Survey conducted by Help Age India in 23 cities investigator of the study, a scribe to note down the verbal
in 2018 revealed that 60% of adults confirmed that discussions during the FGD as well as audio taping
elder abuse is prevalent in the society. 25% confirmed of the entire session. The recruited participants were
to being victims of the abuse as well. Elder Abuse was explained about the purpose of the study and informed
reported maximum in Mangalore, Ahmedabad, Bhopal, consent was obtained from each of them. Themes that
Amritsar, Delhi and Kanpur. It was least in Jammu, emerged from the discussions have been analysed using
Mumbai, Vizag, Kochi, Guwahati.2 deductive analysis and the same has been reproduced in
Hence this study tries to find out situation of elders the results along with the verbatims of the participants.
through perceptions and views about the same from Areas discussed were
representative populations in Mangalore.
1. Elder abuse in our country
Objective:
2. Elders are considered a burden in our society
1. To assess perception regarding elder abuse amongst
3. Elder abuse and financial status are related
the elders in selected urban field practice area in
Mangalore 4. Elder abuse is related to gender of the individual
2. To assess perception regarding elder abuse amongst 5. Elder abuse is done by people whom you know
the General population in selected urban field
6. Helplines and Schemes for the elderly
practice area in Mangalore
7. Elder abuse is a punishable offence
Methodology
8. Personal experience regarding elder abuse
Study site: Urban field practice area of A J Institute
of Medical Science and Research Centre Results

Study duration: Study was conducted over a period Elder abuse: Most of the elders concluded that
of 2 months (October–November 2018) elder abuse is a phenomenon where elders are not cared
for. “Elder abuse is something where the elders are not
Study participants: Elderly individuals (>/= 60 looked after well.” All of them agreed to the fact that
years) elder abuse is prevalent in our country. Though they
were not aware of geographical areas where elder abuse
Individuals from the general population (> 18 years is present at a high rate, they did say that Mangalore is a
and < 60 years) city where elder abuse is present. When asked regarding
Individuals consenting to participate were included the situation outside Mangalore they said that did hear
in the study. Those individuals with debilitating it through media. “These days one gets to hear of such
diseases were excluded considering that the FGDs were things on television and also in newspapers.” There were
conducted at the health centre. a few elders who also said that their children cared for
them well. The youngsters also opined that elder abuse
For assessing the perceptions regarding elder is happening in many ways “we read in newspapers
abuse focussed group discussions were carried out at that elders get beaten up at their homes. Some of these
health centre of urban field practice area of AJIMS & incidents come out in the open while some others don’t
RC. Study subjects were recruited from the said area. as the elders do not complain of the same”.“Abuse is
Discussion was based on the FGD guide prepared after happening in many ways. Especially when it concerns
a literature review,whichwas also validated. The FGDs family property matters, relatives too abuse them,
were continued till repetitive answers were obtained and since they have grown old, they feel helpless.”
from consecutive groups. With this method we collected “Some elders even get kicked out of their homes.” All
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 33
participants felt that elder abuse is a heinous act, but Elder females are abused more: Most of the elders
such instances should not happen as reciprocating the felt it is the elder females who are abused more. They
love and affection towards elders is but the duty of their said “the females stay at home mostly. And the daughters
children. 3 of the total 11 elders from the elderly group in law abuse their mother in law”. The younger group
had experienced verbal abuse and neglect. “These days similarly opined saying “the mother in law would not
they don’t even ask if we need a drop even to the hospital like the daughter in law and later the daughter in law
when we are sick.” would care less for the elderly female.” Some believed
“since the males no longer earn after a certain age, they
Elders are a burden: Many elders confirmed that undergo abuse more. The mothers are looked after while
children these days consider elders to be a burden. “At the fathers are cared less.” Some participants from both
this age we cannot earn. So, we become a burden to groups felt that “abuse is same for both, be it males or
them.” One elderly male stated “When I used to earn, females, when there is a financial burden no one sees if
I was looked after at home. Now that I have stopped it a male or a female.”
earning since the last 1 year, I must end up begging for
money even for bus charges. That is my state currently. The discussions also showed that neither the elders
Plus, ill health adds to the situation.” They were also not the youngsters knew about any helplines for the
of the opinion that in some families children prefer elderly. The youngsters however believed that the
that their parents stay in old age homes. “These days perpetrators need to be punished. However, one elderly
expenses have increased. So, when there are members stated that “whatever neglect we face we will have to
in the family who do not contribute to the finances, they continue living with them.”
become a burden.” “If the elders are financially better
off, they are looked after well. If not, then they get Discussion
treated badly.” Both the elders and the youngsters felt Our FGD revealed that elderly females are at a
that sometimes even if the elders have money or property higher risk of being abused as compared to males which
then it adds to elder abuse since children start bargaining has been similarly reported in other studies6,7 as well. In
over their property share and pressurize the elders. Some a male dominated society, females generally are more
of the younsters commented saying “Elders are not a at risk since they are more vulnerable than the rest. The
burden. Their presence gives us happiness. They give us common forms of abuse discussed were verbal abuse
blessings. They have seen much more of life and their and neglect which is also seen in other studies.6,7,8The
experience and advice can solve a lot of our problems.” elderly are often a marginalized sect who are dependent
Sons and daughters in law abuse elders: “It is the financially and emotionally on others especially their
sons who abuse their parents more.” “Previously the family for support. These factorspose them at a risk for
daughter in laws would be abused. These days it is abuse from their close family, relatives and many a times
the other way around. The daughter in law abuses the even the neighbours.
elders at home.” A participant from the younger group This study has its findings in line with other studies2,7
mentioned that “when I am not at home my wife treats where sons have been commonly implicated as main
my mother differently.” One of the elders also stated perpetrators of abuse over elder individuals. This may
that “for me the abuse is not only at home by my son be because sons continue to stay with their parents and
but also by the neighbours. Neighbours create lot of later take over the responsibility of the household. But
trouble”. Some of them also opined that son in laws the finding is ironic that in a country like India where a
tend to abuse more since they have a good hold in the male child is preferred over the female child at birth, the
household matters. One of the youngsters said, “in same male offspring is later implicated in elder abuse by
the neighbourhood there was family where the elder most elder individuals.
daughter used to hit her mother who was later ‘sent to
the sons house where, the daughter in law started hitting It has also been seen in our study that though there
her and then would close her in a bathroom and deprive are certain personal experiences of abuse there has been
the elderly lady of food.”Some also said“We cannot tell no complaint whatsoever registered against the crime
who does the abuse, most times it depends on the bread which also goes to show that the elders are irrevocably
earner and decision maker in the family.” dependent on their children and others that they either do
not want such incidents to come to the limelight fearing
34 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
retaliation or they just simply ignore the incidents as a 3. Public perceptions on elder abuse: A literature
part and parcel of growing old. review [Internet]. [cited 2018 Dec 11]. Available
fromwww.ncpop.ie/
Conclusion 4. Skirbekk V, James K. Abuse against elderly in
The study shows that though not much about the India–The role of education. BMC Public Health.
elder abuse gets reported it continues to happen behind 2014 Apr 9;14(1):336.
the closed doors of households. Financial reasons being 5. Chapter 5: Abuse of the Elderly [Internet]. [cited
the most common factor behind the abuse, it is a matter 2019 Apr 8]. Available from: http://cureviolence.
of great concern as well a matter for action in the light of org/post/resource/chapter-5-abuse-of-the-elderly/
facing an ageing population in the coming years. 6. Anand A. “Exploring the role of socioeconomic
Source of Funding: Nil factors in abuse and neglect of elderly population
in Maharashtra” India. J GeriatrMent Health
Conflict of Interest: None declared 2016;3:150-7.
7. D Sebastian, T V Sekher. “Abuse and Neglect
Ethical Clearance: Obtained from institutional
of Elderly in Indian Families: Findings of Elder
ethical committee, A J Institute of Medical Science and
Abuse Screening Test in Kerala” Journal of The
Research Centre, Mangaluru.
Indian Academy of Geriatrics, 2010; 6: 54-60
References 8. Yongjie Yon, Christopher R Mikton, Zachary
D Gassoumis, Kathleen H Wilber “Elder abuse
1. WHO | Elder abuse [Internet]. [cited 2018 Nov
prevalence in community settings: a systematic
10]. Available from: https://www.who.int/ageing/
review and meta-analysis” Lancet Glob Health
projects/elder_abuse/en/
2017; 5: e147–56
2. Elder Abuse in India–HelpAge India [Internet].
[cited 2018 Nov 15]. Available from: https://www.
helpageindia.org/
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 35

A Study on Women Entrepreneurs Dealing Through Stress

Archana R.V.1, K. Vasanthi Kumari2

1Research Scholar, VELS Institute of Science, Technology & Advanced Studies (VISTAS), Pallavaram,
2
HOD, Department of Business Administration,RV Government Arts College, Chengalpattu

Abstract
Modern living is occupied of stress. Stress is an unavoidable consequence of socio-economic intricacy and
to some extent, its stimulant as well. Even as stress is foreseeable in today’s complex life, it is essential for
individual life. When a women entrepreneur’s gains practice and self-assurance in her work, the stress is leap
to turn down. The proficient women entrepreneurs are found to suffer greatest extent of stress. Numerous
aspects contribute for the escalating stress level of these women entrepreneurs and an effort is made in this
study to analyze such contributory factors.

Keywords: Women entrepreneurs, stress, entrepreneurial constraints.

Introduction of the enterprise or job do now not in shape the

capabilities, resources, or needs of the entrepreneurs[6].
Women entrepreneurs play a very important
The stress of the women entrepreneurs will be decreased
role in generating employment to others in the well-
based on their work knowledge, experience and
organized segments and place the drift for other women
confidence in the work [7]. Every entrepreneur deal
entrepreneurs to grow[1]. The participation and progress
with some problems and the most unpleasant part is
of women entrepreneurs is now very much evident in
that women entrepreneurs were greatly encountered by
India. Entrepreneur being women have to carry out and
plentiful difficulties and obstacles than men.
keep up a sense of balance among several responsibilities
and its concern obligations. It is eminent that women Problems faced by women entrepreneurs:
entrepreneurs were suffering from role divergence i.e. Women entrepreneurs stumble upon a problem such as an
one had to concurrently be a mother, a wife and a boss inadequate training, financial strain and family errands,
and this put forth’s a lot of mental stress and strain[2]. worked time is not measured with respective wages, the
rate of struggling to go on in the market is high, and
Stress: Stress grounds a commotion in the
certain entrepreneurs have not even used the internet
emotional firmness of an individual that brings about a
in their business [8]. Women entrepreneurs endure
state of ineffectiveness in the personality and conduct[3].
various personal problems like the absence of business
It is well thought-out to be an internal state or response
contact, the lack of adequate experience and suspicious
to anything actual or imagined that an individual
attitude towards risk. They also face certain familiar
deliberately or instinctively perceives as a threat [4].
social problems like family responsibilities, unwritten
Women Entrepreneurs: The women entrepreneurs rules of society, and male supremacy, no possession of
create new jobs for themselves and also for others properties, the lack of economic power, depending on
and render a great service to the society[5]. Women male members on banking and few economic related
Entrepreneurs may be defined as the woman or group of issues[9].
women who initiate, organize and co-operate a business
Stress faced by women entrepreneurs: Compared
enterprise
to the other occupation categories women entrepreneurs
Entrepreneurs’ stress: Entrepreneurial position sense more stress in their profession [3]. The role related
stress can be described as the detrimental physical and stress experienced by the women Entrepreneurs can
emotional responses that take place when the necessities be characterized into three major magnitude, role
36 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
overload, role conflict and role ambiguity [10]. Women extended from education or experience [13].
entrepreneurs experience role stress in performing twin
responsibilities [2] Stress coping strategies: Stress arises when
perceived strain exceeds your perceived ability to cope
Constraints faced by women entrepreneurs: It is [14].Stress can be coped by emotional focus; it is finding

observed that women entrepreneurs were facing many a way to ease their reaction to emotional issues by giving
constraints in running an enterprise[11] as follows. them an emotional support. Secondly, stress coped by
problem focus, it is categorising the issue and adopting
Knowledge associated: Women entrepreneurs are a direct and constructive strategies to solve the issue[15].
in general not conscious of whom to contact when there
is a need. The sources which they have contact with Conclusion
are on the whole did not endow with full knowledge
and sometimes even exploit them. Most of the women It is necessary to involve women entrepreneurs
entrepreneurs lack knowledge in many financial activities. on an equal foothold with men and this can be done
They also lack knowledge in practice and advancement only if women are given the proper means to improve
in technology. They are not alert concerning the loans themselves, and their entrepreneurial situation. The
and the financial schemes offered for the entrepreneurs. government is enchanting numerous initiatives for
They does not seize any economic credibility too. improving the growth of women entrepreneurs so the
women who aspire to become an entrepreneur must
Man Power: The success of an endeavour is make use of the facilities provided. Women’s definitely
for the most part rely on the hands of skilled labour. play a major part in the economic progression. It is the
Many women entrepreneurs find difficulty in reaching responsibility of the society to facilitate every women
cooperation from the male employees. At times, they entrepreneur to cross the obstruction such as education
were being dominated by the male employees and they type, availability of fund, management skills and so
were not ready to accept a woman as boss and attempt to forth. Women are becoming great victims to increasing
show non co-operative approach. stress as they are taking multi-role duties from career
and home so it is the responsible of family affiliates and
Raw Material: According to the demands and society to help her out to attain a balance between work
choice of customer’s diligent selection of raw material is and life.
important. It is one of the important spot to be determined
and if it is not properly scrutinized there may be immense Ethical Clearance: Nil
interruption in production process. Selecting a trustful
supply agency is yet another intricate task. Determining Source of Funding: Self
the prices of raw material is an additional constraint. Conflict of Interest: Nil
Marketing: For any venture, competition is a great
challenge. As many of the women entrepreneurs have
Reference
not attended any training programme, lack of business 1. Akande A. Coping with entrepreneurial stress:
education and knowledge make them ignorant of the Evidence from Nigeria. Journal of Small Business
marketing strategies like market segmentation, market Management. 1994;32(1):83.
positioning and marketing mix strategy, hence the 2] Singh NP, Gupta RS. Potential Women
survival of the business against the competition is found Entrepreneurs: Their Profile, Vision, and
to be a huge constraint. Motivation. National Institute for Enterpreneurship
and Small Business Development; 1985.
Effect of stress among women entrepreneurs:
Stress among the women entrepreneurs generates a 3. Örtqvist D, Drnovsek M, Wincent J. Entrepreneurs’
interruption in the emotional stability which includes coping with challenging role expectations. Baltic
a circumstances of inefficiency in the performance, journal of management. 2007 Sep 18;2(3):288-304
personality and encompass expensive misplace for 4. Clark LA, Watson D. Tripartite model of anxiety
themselves, organizations and society[12], such situation and depression: psychometric evidence and
have been defined as ‘role novelty’, which refers to an taxonomic implications. Journal of abnormal
untutored characters for a precise role, which can be psychology. 1991 Aug;100(3):316.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 37
5. Cooper CL, O’Driscoll MP, Dewe PJ. 9. Rao JP, editor. Entrepreneurship and economic
Organizational stress: A review and critique of development. Kanishka Publishers; 2000.
theory, research, and applications. Sage; 2001 10. Boyd DP, Gumpert DE. Coping with entrepreneurial
Feb 6. stress. Harvard business review. 1983 Jan
6. Naik BA. Entrepreneurial Role Stress Among 1;61(2):44.
Women Working in Mahila Bachat Group (Women 11. Paul J, Kumar NA, Mampilly PT. Entrepreneurship
self-help group). Golden Research Thoughts. Development. New Delh: Himalaya Publishing
2012;1(7). House. 1996.
7. Shepherd DA, Douglas EJ, Shanley M. New 12. Fitzgerald Miller J. Coping with chronic illness:
venture survival: Ignorance, external shocks, overcoming powerlessness. FA Davis, Philadelphia.
and risk reduction strategies. Journal of Business 2000.
Venturing. 2000 Sep 1;15(5-6):393-410.
13. Robertson D. Stress and the entrepreneur. Bibby
8. Chhichhia V. Problems faced by Women Financial Services. 2004.
Entrepreneurs and Importance of Training in
14. Gyllensten K, Palmer S. The role of gender in
their Entrepreneurs. Research Paper Presented at
workplace stress: A critical literature review.
National seminar on Women Entrepreneurship–A
Health education journal. 2005 Sep;64(3):271-88.
Need for Training and Curriculum Development
held by Development of Home Science Extension 15. Lazarus RS, Folkman S. Stress, appraisal, and
and Communication, Faculty of Home Science, MS coping. Springer publishing company; 1984
University, Vadodara. 2004 Mar 15.
38 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Effect of Bilateral Scapular Muscles Strengthening on

Dynamic Balance in Post Stroke Individuals

Arpan Dhoka1, G. Varadharajulu2

1MPTh (Neurology), 2Dean/Professor/HOD, Krishna College of Physiotherapy,
Krishna Institute of Medical Science Deemed to be University, Karad, Maharshtra, India

Abstract
Aim: To determine the effect of bilateral strengthening of scapular muscles to improve dynamic balance in
post stroke individuals.

Objectives: To find the effect of bilateral scapular muscles strengthening in stroke and to find the upper
trunk balance in stroke after intervention.

Materials and Method: 42 patients were included according to Brunstrom’s recovery stage 2 and voluntary
control grade 2 of upper limb were randomized by chit method into two groups, group A (conventional
Physiotherapy{PT}) and group B (bilateral scapular muscle strengthening and conventional PT) - with 21
patients in each group. All the patients were assessed with Berg balance scale (BBS), voluntary control
grading of upper limb (VCG), and bilateral scapular muscle recruitment by Electromyography (EMG). The
treatment was given for 5 days a week for 4 weeks. After 4 weeks effect of interventions were assessed by
BBS, VCG and EMG.

Conclusion: Bilateral scapular muscles strengthening combined with conventional PT showed improvement
in dynamic balance and had an additional effect on muscle recruitment, control of upper limb and mobility
in stroke patients.

Keywords: Stroke, scapular muscles, berg balance scale, EMG, Dynamic balance.

Introduction are recurrent strokes. Women have a lower age–adjusted

stroke incidence then men, but this is reversed in older
The defination of stroke was issued by the WHO
ages, women with 85 years and above have high rate of
as: a rapidly developing clinical signs of focal or global
risk compared to men.3
disturbances of cerebral function, with symptoms lasting
for more than 24 hours or leading to death, with no After an immediate discharge from the hospital,
apparent cause other than of vascular origin. 1 It is the stroke patients are at a high risk of fall (1.3–6.5 falls/
most common life threatening neurological disorder. 2 person/year) while performing transfer activities on bed
and out of bed. After an insult to the brain falls it can
Cerebrovascular stroke (CVS) is a neurologic event
cause various problems in everyday life disturbing the
related to diseases of the cerebral circulation.1 CVS has
daily activities. Stroke survivors’ has more frequency of
been shown to be a major cause of death and disability
fall and injury compared to general older population.9
in all communities. According to the American Stroke
Association, about 87% of strokes are ischemic, and Approximately, one third of the stroke survivors
the remaining 13% are hemorrhagic. Stroke is the will have residual disability on the affected side, with
fourth leading cause of death and long term disability the severity of hemiparetic upper extremity, a significant
in developed countries among adults. Each year determinant of post-stroke disability and quality of
approximately 7, 95,000 individuals experience stroke; life of the patient. Therefore, impact of upper limb
approximately 6, 10,000 are the first attack and 1, 85,000 impairments on disability and health is very obvious.5
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 39
However, limited attention has been given to upper- the serratus anterior can impair scapular orientation and
extremity rehabilitation after stroke, and generally stability, thereby contributing to pathologic kinematics.
functional recovery of the upper limb and hand is Latissimusdorsi is a trunk muscle but it assists in
limited compared with that of lower extremities. Upper scapular depression with various agonist muscles like
limb hemiparesis leads to various impairments of daily serratus anterior, lower fibers of trapezius and pectoralis
living like eating, dressing, bathing, self care activities minor. Adducts, extends and internally rotates the arm at
and writing, which result in reduced functions of daily the shoulder.14
living. Therefore, stroke individuals must participate
into various rehabilitation programs to improve their As per Brunstorm’s recovery stage, stage 2 of
activities of daily living.5 Brunstorm is a stage where there is change in muscle
tone i.e from flaccidity to spasticity emerges, which
In stroke survivors’, ability of controlling balance is leads to impairment of upper limb, lower limb and trunk
reduced. Especially, the postural sway in static position control. From these impairments one of the problems
is more than twice that of the healthy individual of chosen is dynamic balance. There are various forms of
the same age group, which consequences for safety.10 exercise for stroke patients to improve balance in the
Balance is described as the co-ordination in which all individuals like manual perturbation, rhythmic rotation,
forces acting on body are balance such that the center of rhythmic stabilization and many more. Therefore
gravity (COG) is within stability limits, the boundaries by using scapular muscles strengthening to improve
of base of support (BOS).11 Balance has been implicated dynamic balance is being introduced.
in the poor recovery of activities of daily living (ADL)
and mobility and increased risk of falls. Therefore, it Stroke is a chronic condition and have to spend
is important to maintain balance in activities of daily the more time of rehabilitation, and from the early
living (ADL), posture control is essential, while motor, stage that is inpatient in the acute care hospitals
sensory and higher cognitive functions play an important physiotherapy intervention are the primary mechanisms
role in postural control. There are various factors that by which functional recovery, mobility and functional
influence selection of balance strategies and they are as independence of patient are achieved in stroke.9 There
follows 1) Speed and intensity of the displacing factors. are various therapeutic interventions which can be given
2) Characteristic of support surface 3) Magnitude of to improve balance by using electrotherapy, exercise
the displacement of the COM 4) Subject’s awareness therapy and many more.
of the disturbance 5) Subjects posture at the time of This study examined the effect of scapular muscles
perturbation 6) Subjects prior experiences.22 strengthening on dynamic balance in post stroke
The scapula provides dynamic stability with individuals. We also investigated the balance of the
controlled mobility at the glenohumeral and scapulo- patient using BBS, scapular muscles recruitment of the
thoracic joint. It plays a significant role in facilitating patient at its maximum effort by EMG, and pattern of
shoulder joint function, as anatomy and biomechanics of movement by VCG to see the postural and trunk control
the scapula allow for controlled movement of shoulder during change in position. Therefore, to improve balance
joints. Scapular stabilization exercise may be effective and postural control during the dynamic movement’s
in increasing muscle strength, balance and decreasing bilateral scapular strengthening exercise has been given
scapular dyskinesis.13 to the patients.

In stroke condition, it is observed that lattisimusdorsi, Method

teres major and serratus anterior do not take part in any Study Type: Experimental study
of the synergic patterns (flexion synergy and extension
synergy).3 Study Design: Pre test or post test

Muscles are providing stability. The serratus Sample Size: 42 (21 + 21)
anterior and rhomboid muscles, attached to the scapula,
have the crucial function of scapular stabilization. Place of Study: Krishna Hospital and Physiotherapy
The serratus anterior is to stabilize the scapula during OPD, Karad
elevation and pulls the scapular forward. Weakness in Criterion for Study:
40 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Inclusion criteria: • Any associated orthopedic and cardio respiratory
condition
• Stroke with MCA infarct
• Patients with unilateral neglect
• Both males and females
• Visual impairment
• Age ≥ 30 years
Procedure: By using random sampling method
• Brunstorm stage 2 and above
the participants had been divided into 2 groups by chit
• Voluntary control grade ≥ 2 method; Group A, Group B. subjects with stroke with
• Poor or fair balance in sitting and standing impaired balance and scapular muscle weakness had
been assessed by BBS, EMG, VCG of upper limb.
Exclusion criteria:
The intervention had been given for 4 weeks and
• Patient not willing to give consent
treatment will be given 5 times a week.
• Sensory impairment

Intervention protocol for group A and group B

Group A (Control Group) Group B (Experimental Group)

• Sustained stretching • Conventional exercise and
• Slow icing • Stabilization Exercises (Open chain,
• Tapping • Closed chain and Dynamic closed chain scapular stabilization
exercise)
• Slow brushing
• Dynamic strengthening exercises of scapula
• Continuous joint compression
• Reaching out with the arm in different direction moving the
• Trunk rotation in supine specific to shoulder joint scapula out as far as possible
• Passive movement
• Active assisted exercise
• Resisted exercise
• Sit on a chair and place the pelvis and the spine in the neutral
position
• Put the less affected arm on a support table
• Balance exercises
• Manual pertubation
• Electrical stimulation

Outcome Measure: 2. VCG of upper limb: VCG has 7 components in it

rating from 0- 6 point Ordinal Scale, which is used
1. BBS: BBS is a 14 item rating 5 point ordinal scale,
in various upper motor neuron (UMN) lesions. It
used to evaluate the balance in elderly population
is used to assess the control of the limbs in UMN
and other neurological conditions. It is easy to
lesions. It is an active movement performed by the
administer and doesn’t require specialized training
patient and depending upon the quality of movement
and takes 15-20 mins. It has moderate to excellent
performed the grading is done.
sensitivity while measuring balance in stroke
patients, maximum scoring in BBS is 56. 3. EMG: It was done by a physiologist. The EMG
machine was of the company “octopus clarity”
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 41

Results
Table No. 1: Comparison of post- post BBS between the group

Conventional V/S experimental post -

post
Conventional Post (mean± SD) 36.66± 6.981

Experimental Post (mean± SD) 50.09± 4.49

p value <0.0001

t value 6.729

Df 20

Table No. 2: Mean Comparison of post- post VCG between the groups

Table No. 3: Mean Comparison between conventional and experimental post right hemiplegic side
42 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table No. 4: Mean Comparison between conventional and experimental post left hemiplegic side

Statistics: The outcomes were assessed at the 1st In the present study, the participants were selected
day prior to treatment and at the end of 4th week post on the basis of inclusion and exclusion criteria. In the
treatment. Inter group analysis was done by paired t test study there were 11 males and females in group A
and intra group analysis was done by using unpaired whereas, 16 males and 5 females in group B. in group A
t test. The inter and intra group analysis was done by there were 13 right and 8 left hemiperatic side, in group
using Instat 3. B there were 12 right 9 left hemiperatic patients.

Discussion In this, the efficacy of the scapular stabilization and

strengthening exercises in improving dynamic balance
Dynamic balance is a very complex process which in post stroke individuals were investigated. They
requires interaction between various components like were investigated using BBS, VCG upper limb and
vestibular, visual, proprioceptive, musculoskeletal and bilateral scapular recruitment by EMG. The intervention
cognitive systems. Dynamic control to stabilize the body was given for 5 days a week for 4 weeks. In group A
when the support surface is moving or when the body is the conventional PT was given whereas, in group B
moving on a stable surface, such as sit to stand transfer scapular strengthening (stabilization) exercise along
or walking.18 with conventional PT was given. Scapular strengthening
One of the keystone structures of the body is scapula exercises were given in various positions like prone and
which plays an important role in postural control. sitting.

Muscle sling in the trunk are necessary for facilitating Post- intervention it was found that there was
reciprocal gait pattern between upper and lower extremity significant improvement in all the muscles strength when
as well as for rotational trunk stabilization. Muscle sling examined on EMG. But only Lt Serratus anterior muscle
plays an important role in maintaining and providing was found that there is no significant improvement may
dynamic movements of the body. As all the slings are be because Lt Serratus anterior muscle works more at
inter-related to each other, if one part of the muscle sling acromio- clavicular joint and is responsible for more
is activated automatically other muscles involved in the work at shoulder complex and another reason may be
sling are activated to provide the dynamic movement because of dominance of hand as dominant side muscle
while performing any activity of daily living. There are are strong as compared to non- dominant side.
three types of sling and they are anterior, posterior and During the initial stages, patient had difficulty in
spiral. Therefore, wrapping from the posterior to the moving trunk or in performing trunk activities due to
anterior the muscles are rhomboids and serratus anterior. which it happened that various upper limb and lower
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 43
limb activities of daily living. As the intervention was Conflict of Interest: It is difficult to get samples
going on for the patient, they felt more free mobility who are having Brunstorms recovery stage 2 and VCG
and enhanced the activity of daily living. Some patient at 2 simultaneously.
had impaired scapular position initially, as the scapular
muscle got strengthen, it helped in correction and better Funding: This study was funded by Krishna
mobility of the scapula and upper limb Institute of Medical science Deemed to be University,
Karad.
Relatively, small changes in the scapular muscles
affect the alignment and forces out the shoulder complex. Ethical Clearance: The study was approved by the
Because scapula plays an important role in controlling institutional etjics committee of KIMSDU.
shoulder joint position and joining it with the humeral
head. 5
References
1. Chandan Kumar etal “Effectiveness of Manual
Chiang-Song reported concluded that scapular Perturbation Exercises in Improving Balance,
stabilization exercise program did not have any Function and Mobility in Stroke Patients: A
improvement in berg balance and basic daily activities.5 Randomized Controlled Trial” Journal of Novel
Karatas M concluded that trunk muscle strength had Physiotherapies Volume 6 Issue 2 ISSN: 2165-
a significant improvement in BBS and FIMS.18 7025.
2. Dong-Sik Oh “The effect of motor imagery training
Dae-Jung Yang concluded that scapular stabilization for trunk movements on trunk muscle control and
exercises are more effective then task oriented training proprioception in stroke patients.” J. Phys. Ther.
in facilitating muscle activity and functional capacity of Sci. 29: 1224-1228,2017
upper limb.7
3. Susan B. O Sullivan et al “Physical Rehabilitation
After comparing with the previous study, scapular 6th edition” chapter no 15 pg no “647-648”
stabilization exercise is important for performing 4. AjitDabholkar “Assessment of scapular behavior in
the mobility. One of the studies had no significant stroke patients” International Journal of Health and
improvement in the balance due to limitation of the Rehabilitation Sciences Volume 4 Issue 2 95-102,
subjects and exercises given to the patients. 2015.
5. Chiang-Soon Song “Effects of Scapular
In the present study, after comparing the results
Stabilization Exercise on Function of Paretic Upper
with the previous study it suggests that to perform
Extremity of Chronic Stroke Patients” J. Phys.
dynamic balance, scapular strengthening (stabilization)
Ther. Sci. Vol. 25, No. 4, 2013.
is important and also helps in maintaining postural
stability. 6. Sang-MI Chung “Effect of shoulder reaching
exercise on the balance of patients with hemiplegia
Therefore, scapular stabilization and strengthening after stroke” J. Phys. Ther. Sci. 28: 2151–2153,
plays an important role in maintaining dynamicity of the 2016.
body. There was an additional effect on scapular muscle 7. Dae-Jung Yang et al “The Biofeedback Scapular
strength an improvement in upper extremity control. Stabilization Exercise in Stroke Patients
Effectiveness of Muscle Activity and Function
Conclusion
of the Upper Extremity” The Journal of Korean
The present study provided the evidence to support Physical Therapy 2015; 27 (5): 325-331.
that the bilateral scapular muscles strengthening along 8. JanneMarieke Veerbeek1, Erwin van Wegen1
with conventional physiotherapy and conventional et al What Is the Evidence for Physical Therapy
physiotherapy alone has shown improvement in balance, Poststroke? ASystematic Review and Meta-
voluntary control and strength in stroke patients. Analysis PLOS ONE Vol 9 Issue 2 February 2014.
However, the subjects treated with bilateral 9. Viswanathan et al “Dynamic balance status among
scapular muscles strengthening along with conventional stroke survivors-a comparative study with age,
physiotherapy showed an additional benefit on Dynamic sex matched population using berg balance scale”
Balance and Mobility of the patients. Indian Journal of Physical Therapy; Volume-3;
Issue-1.
44 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
10. Won Seob Shin et al “Effect of combined exercise Balance and Upper Extremity Function: A
training on balance of hemiplegic of stroke patients” Preliminary Randomized Controlled Study with
J. Phys. Ther. Sci. Vol. 23 No 4, 2011. Subacute Stroke”Med SciMonit, 2018; 24: 2590-
11. Chaitali Shah “Neurological Examination for 2598.”
Physiotherapist” chapter no 8 pg no 217-221. 18. Karatas M etal “Trunk muscle strength in relation to
12. Chen IC et al “Effect of balance training on balance and functional disability in unihemispheric
hemiplegic stroke patients” Chang Gung Med J 25: stroke patients” J Phys Med Rehabil 2004; 83:
583- 590. 81‑87.
13. Si-Eun Park “Immediate effects of scapular 19. Ntamo NP, MPH1; Buso D, MSc2; Longo-Mbenza
stabilizing exercise in chronic stroke patient with B, PhD, DSc3 Factors affecting poor attendance
winging and elevated scapula: a case study” J. for outpatient physiotherapy by patients discharged
Phys. Ther. Sci. 30: 190–193. from Mthatha General Hospital with a stroke SA
Journal of Physiotherapy 2013 Vol 69 No3.
14. Amina Awad et al “Effect of shoulder girdle
strengthening on trunk alignment in patients with 20. Rose Galvin, Brendan Murphy, Tara Cusack,
stroke” J. Physi. Ther, Sci. 27: 2195- 2200. and Emma Stokes, etalThe Impact of Increased
Duration of Exercise Therapy on Functional
15. Cheng PT et al “Effect of visual feedback rhythmic
Recovery Following Stroke–What Is the Evidence?
weight shift training on hemiplegic stroke patients”
Top stroke RehabilVol 15 Issue 4 July-August
ClinRehabil 18: 747- 753.
2008, 365-377.
16. Duncan PW et al “Body- weight support treadmill
21. Venkatraman S, etal, “API Textbook of Medicine”.
rehabilitation after stroke” N Engl J Med 364:
7th Ed. New Delhi. Jaypee Brothers; p 2003
2026-2036.
22. Carolyn Kisneretal “Therapeutic Exercise” Sixth
17. Myung Mo etal “Game-Based Virtual Reality
edition. Chapter no 8 p 264.
Canoe Paddling Training to Improve Postural
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 45

In Vitro Antibacterial and Anticancer Study of

Bioactive Compounds Isolated from Punica Grantum Peel

Arunava Das1, J. Bindhu, M. Bharath2, Nithin Johnson3, M. Jeevanantham3

1Associate
Professor, 2Research Associate cum Assistant Professor, Molecular Diagnostics and Bacterial
Pathogenomics Research Laboratory, Department of Biotechnology, Bannari Amman Institute Technology,
Sathyamangalam, Erode District, Tamil Nadu, India, 3III-Year Biotech Students

Abstract
Plants have been used as natural medicines since the dawn of human kind. This research was focused on
phytochemical analysis of Punica grantum peel extract consist of ethanol: chloroform (99:1) as solvent
and its constituents were molecularly characterized by GCMS analysis and its ability as an antioxidant,
anticancer against K562 cell and antibacterial against some food borne pathogens which comprises of 5
gram-positive and 3-gram-negative bacteria. The phytochemical analysis was performed biochemically and
results reveals the presence of secondary metabolites such as Flavonoids, Alkaloids, Tannins, Saponins, etc.
and absence of glycosides. The extract was tested against both gram-positive and gram-negative bacteria
by agar well diffusion method and its results have shown that the streptococcus faecalis have shown highest
susceptibility against the extract. Its antioxidant potential was quantitatively determined by DPPH assay and
results showed high range of antioxidant present in the extract with IC50 as 504.9µg/ml. The cytotoxicity
assay was performed with peel extract of different concentration against K562 cancer lines which is a
myelogenous leukemia cell line. However, the cytotoxicity is less when compared with cell viability and its
effects were mild against the cancer cells.

Keywords: Punicagranatum, DPPH, GCMS, K562 cancer cells (myelogenous leukemia).

Introduction the phytochemistry of P. granatum peels and found that

the peel extract had abundant polyphenolic compounds
Punicagranatum, whose common names are
mainly tannins and flavonoids, which are responsible for
pomegranate, grenade, granats and punica apple,
astringent and antioxidant properties.[13] The secondary
belongs to the Punicaceae family which is a deciduous
metabolites of P. granatumpeel extract such as tannis,
shrub that grows between 5 and 10m tall with multiple
flavonoids, other polyphenols and some anthocyanins
spiny branches and lives extremely long. The fruit is red
have various pharmacological activities like anticancer
purple in colour and it is cultivated in Mediterranean
activity by flavonoids and antimicrobial activity by
region since 3000 BC.[1,8] Some researchers studied
tannins and also some alkaloids are useful for treating
HIV infection.[2,4]Agrobacterium tumefaciens, which
is the causative agent of plant tumour was suppressed
Corresponding Author: by the crude extract of P. granatum peels.[4] Various
Dr. Arunava Das parts of P. granatum have been used in traditional
Associate Professor, Molecular Diagnostics and medicine for treating many diseases like diarhoea,
Bacterial Pathogenomics Research Laboratory, diabetes, ulcer and also digestive system disorders.[1,4]
Department of Biotechnology, Bannari Amman P.granatum also reported antivirus, antiproliferative,
Institute Technology, Sathyamangalam-638401, Erode antimutagenic, antidiabetic, antidiarrheal, anti-obesity,
District, Tamil Nadu, India antifungal properties and also photo-protection activity.
[12,13] Antibacterial activity against different strains of
e-mail: [email protected]
Phone: 9751882590 bacteria like E. coli, L. monocytogenes, E. aerogenes,
46 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
K. oxytoca, B. subtilis, S. agalactiae and S. aureus was together and the dark blue or green colour formation
shown by P. granatum peel extracts.[3] The components indicates the presence of tannins.[17]
in P. granatum juice that inhibits the cancer cells was
identified by scientist in December,2010.[6] The peel Test for Saponins: The peel extract of 1ml was
extract of P. granatum was tested on Human Chronic mixed with 1ml of distilled water and shook it vigorously.
Myeloid Leukemia (CML) (K562) cell lines in order Formation of foam layer of about 1cm indicates the
to test the anticancerous property.[5] The compounds presence of saponins.[17]
present in P.granatum peel extracts like gallocate Test for Quinones: 1ml of peel extract and 1ml of
chins, delphinidin, cyaniding, gallic acid and ellagic H2SO4 were mixed together and the red colour formation
acid, pelargonidin and sitosterol show therapeutic indicates the presence of quinones. [17]
properties.[7] The infections present in sexual organs of
humans and also infections like mastitis, acne, etc., were Test for Flavonoids: 1 ml of peel extract was mixed
treated by the pericarp of P.granatum.[8] The antioxidants with 1ml of 2N NaOH and the yellow colour formation
which are present in the fruits and vegetables such indicates the presence of flavonoids. [17]
as ascorbic acid, flavonoids and tannins are used to
play an vital role in the prevention of diseases. The Test for Alkaloids: The peel extract of 1ml and 2ml
biomolecules such as proteins, lipids, DNA, RNA of conc.HCl were mixed together and then few drops
are when reacted with the unstable Reactive Oxygen of Mayer’s reagent was added. Presence of alkaloids
Species (ROS), it will react rapidly and destructively. was confirmed by formation of green or white colour
Most microorganisms that colonize gingival margin or precipitate. [17]
gingival sulcus are compatible with periodontal health. Test for Glycosides: One ml of the peel extract was
[9,10] The Phytoestrogenic compounds are present in
added to 3 ml chloroform and 10% ammonium solution.
the pomegranate seed oil and also the fruit has strong Formation of pink col our indicates the presence of
antioxidant activity which is because of the high levels glycosides. [17]
of phenolic compounds. The pomegranate seed oil has
an inhibitory activity on skin and breast cancers.[11] The Test for Cardiac Glycosides: 1ml of peel extract,
incidence of collagen-induced arthritis was reduced 2ml of glacial acetic acid and few drops of 5% ferric
due to the consumption of pomegranate extract.[12] chloride was mixed together. Then it was under
The characterization of the phytochemical constituents layered with 1ml of conc. H2SO4. Presence of cardiac
present in P. granatum peel extract was done by GCMS glycosides was confirmed by brown ring formation at
analysis.[14] the interface.[17]

Identification and Handling of Sample: Fruits Test for Terpenoids: 1ml of peel extract and 2ml
were collected from local market in Sathyamangalam, of chloroform were mixed together and then few drops
which is situated in the southern part of India and of conc. H2SO4 was added. The presence of terpenoids
brought to laboratory. The fruit was thoroughly cleaned was confirmed by the formation of red brown col our at
with H2O. The leathery peel was separated from edible the interface.[17]
portions by cutting it carefully. Later the peel was
Test for Phenols: 1 ml of peel extract and 2ml of
dried in a hot air oven at 45°C for 48 hours. Later the
distilled water were mixed together and then few drops
dried peels were pulverized into fine powder by using
of 10% ferric chloride was added. The presence of
a blender and then it is stored in air tight compartment.
phenols was confirmed by formation of blue or green
Extraction: The shattered peel powder of 10g was colour.[17]
packed was packed within the filter paper. The Soxhlet’s
Test for Steroids: 1ml of the peel extract and 2ml
extraction method was carried out at 65°C for 6 cycles
and the solvent was ethanol: chloroform (99:1) of 250ml. of chloroform followed by 1ml of H2SO4 were added
and the presence of steroids was confirmed by formation
After extraction process the extract was concentrated to
of reddish-brown ring at interface.[17]
25ml through steam distillationprocess.
GC-MS:
Phytochemicalanalysis: Test for Tannins: The
peel extract of 1ml and 5%ferric chloride were mixed The sample was subjected to GC-MS analysis to
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 47
quantify the number of molecules and its structures. The done by measuring its absorbance at 517nm against the
analysis was carried out using GC–MS (Perkin Elmer blank. The IC50 value (inhibitory concentration) was
model: Clarus 680) and also it is equipped with mass calculated for both sample and standard. The percentage
spectrometer (Clarus 600 (EI) analysed using (Turbo of inhibition was calculated using the following formula:
Massver 5.4.2) software. Fused silica which is packed
with Elite-5MS. At a constant flow rate about 1ml/ % of inhibition = [A0-A1/A0] * 100
min, carrier gas such as helium was used to separate Where A0 is absorbance of control (i.e. DPPH
the components. The temperature of the injector was solution without sample) and A1is absorbance of sample
adjusted to 260oC while performing the experiment. or standard (i.e. DPPH solution with sample/standard).
The extract sample of 1µl was injected into the
Cytotoxic assay (MTT method): The results of
equipment the temperatures of the oven were 60oC (2
each test were reported as the growth percentage of
mins); followed by 300oC at the rate of 10oC min-1; and
treated cells compared to untreated control cells. A 0.1
300oC for 6mins. The conditions of the mass detector
mL aliquot of the cell suspension (5 × 106 cells/100μl)
were: the temperature of transfer line was 240oC; and
and 0.1 mL of the test solution (10-50μl) were added to
ionization mode electron impact at 70eV, the duration
the wells, with the plates kept in an incubator (5% CO2)
time of scan interval is 0.2sec and scan interval is
at 37 °C for 18 h. After 18 h, 1mg/ml of MTT was added,
0.1sec. The fragments from 40 to 600Da. The spectrum
and the plates were kept in the CO2 incubator for 4h,
of components was corresponding to the database of the
followed by the addition of propanol (100μl). The plates
spectrum of established components gathered in the GC-
were covered with aluminum foil to protect them from
MS NIST library.
light and subsequently agitated in a rotary shaker for
Antibacterialassay: The antibacterial assay was 10–20 min, afterwards the well plates were processed
performed against 5-gram positive bacteria such as on an ELISA reader to obtain absorption data at 517 nm.
Listeria. monocytogenes, Bacillussubtilis, Streptococcus
Cytotoxicity = [(Control- Treated)/Control] * 100
agalactiae, Staphylococcus aureus, Streptococcus
faecalis and 3-gram negative bacteriasuch as Escherichia Cell viability = (Treated/Control) * 100
coli, Klebsiella oxytoca, Klebsiellaaerogenes by
following Agar well diffusion method. The following Results and Discussion
bacteria were inoculated in the sterile nutrient plates
The researchers are continuously exploiting the
individually in triplicates by swabbing technique. The
plant extracts to produce potential drugs with reduced
wells in diameter of 3.5mm were made using the sterile
toxicity and increased medicinal properties. The
agar well puncher. The peel extract sample was diluted
ethanol: chloroform extract of Punica granatum peel
at different concentration (20%, 40%, 60%, 80%, 100%)
was subjected to different phytochemical tests such as
using distilled water.Then the agar plates were placed in
secondary metabolites flavonoids, tannins, saponins,
an incubator at ±37oC. After 24 hours of incubation, the
alkaloids, cardiac glycosides, glycosides, quinones,
zone of incubation was measured in mm.
terpenoids, phenols and steroids were qualitatively
Antioxidantactivity: The antioxidant activity analysed by biochemical method and the results reveals
oft he extract was determined by 2,2-Diphenyl- the absence of glycosides in the peel extract. In plants
1-picrylhydrazyl (DPPH) assay. Both Samples and glycosides are the energy source in inactive form.
Standards (Ascorbic acid) were taken in different However, another study report shows glycosides are
concentrations and the volume was adjusted to 100µl present in sample contains acetone as solvent.[17]
using methanol. The DPPH solution of 0.1mM was
The GCMS analysis revealed the compounds
prepared by using methanol as solvent. About 3ml of
present in the extract in molecular level. The molecule
0.1mM DPPH solution was mixed with samples of
4-hexen-3-one, 4,5- dimethyl which is an oxygenated
different concentrations and the negative control was
hydrocarbon showed highest peak followed by
prepared by adding 100µl of methanol to the 3ml of
4-ETHYL-2-hydroxycyclopent-2-en-1-one and
DPPH solution. The tubes with mixtures were allowed
3-heptanol, 3, 6-dimethyl showed high peaks, Figure 1.
to stand in dark at room temperature for 30mins.
The color change from violet to yellow indicates the The antibacterial assay was performed using the
presence of antioxidants and the quantification was peel extract against different bacterial strains such
48 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
as Bacillus subtilis, Escherichia coli, Streptococcus have shown a severe effect where they tested with Punica
agalactiae, Staphylococcus aureus, Listeria granatum seeds and husks.[15] Another experimental
monocytogenes, Enterobacter aerogenes, klebsiella study tested using polysaccharide (PSP001) separated
oxytoca and streptococcus faecalis. The results indicate from P.granatum fruits against the K562, MCF-7, KB
that streptococcus faecalis and Listeria monocytogenes cancer cell lines have proved its potential ability as an
have shown the highest susceptibility to the peel antitumor agent.[16] The activity of sample at different
extract. Bacteria such as Streptococcus agalactiae, concentrations against the cells are displayed in Figure 4
Staphylococcus aureus were less susceptibility to the and the cytotoxicity is represented in Figure 5.
peel extract. The gram-positive bacteria have exhibited
both high sensitivity and resistivity. The gram-negative Table 1: The phytochemical constituents of Punica
bacteria such as Escherichia coli, Klebsiella oxytoca, grantum peel extract
Klebsiellaaerogenes has exhibited moderate sensitivity. Phytochemicalconstituents Presence
The zone of inhibitions is represented in the Figure 2.
Tannins +
The DPPH results indicate the high number of Saponins +
antioxidants were present in the sample. The IC50 value Quinones +
for both standard (Ascorbic acid) and sample (peel Flavonoids +
extract) were measured from the graph reveals that Alkaloids +
standard has 482.5µg/mland the sample have 504.9µg/ Glycosides -
ml. The obtained values are represented in Figure 3. Cardiac Glycosides +
Terpenoids +
The MTT results reveals the peel extract have shown
Phenols +
mild effects over the K562 cancer cells. The cell death
Steroids +
was increased with increase in concentration on the
sample. Another experimental result tested against the (+ present, - absent)
Hepato-cellular carcinoma and Colon cancer cell lines

Figure 1: Chromatogram of compounds present in Punica granatum

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 49
Table 2: GCMS analysis result for major phytocomponents in Punica grantum peel

Molecular Molecular Peak

RT Name of compound Structure
formula weight area

2-FURANCARBOXALDEHYDE,
13.488 C6H6O3 126 6.965
5-(HYDROXYMETHYL)-

13.578 4-HEXEN-3-ONE, 4,5-DIMETHYL- C8H14O 126 3.082

13.708 2-CYCLOHEXEN-1-OL, 3-BROMO- C6H9OBr 176 5.132

14.143 4-HEPTEN-3-ONE, 2,6-DIMETHYL- C9H16O 140 3.374

4-ETHYL-2-HYDROXYCYCLOPENT-
15.654 C6H10O6 126 41.158
2-EN-1-ONE

16.284 2,3-ANHYDRO-D-MANNOSAN C6H8O4 144 7.881

17.479 3-HEPTANOL, 3,6-DIMETHYL- C9H20O 144 9.510

19.160 2,3-ANHYDRO-D-GALACTOSAN C6H8O4 144 4.156

50 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Molecular Molecular Peak

RT Name of compound Structure
formula weight area

4-ETHYL-2-HYDROXYCYCLOPENT-
19.700 C7H10O2 126 2.911
2-EN-1-ONE

2-[1,2-DIHYDROXYETHYL]-9-[.
20.486 BETA.-D-RIBOFURANOSYL] C12H16O7N4 328 3.222
HYPOXANTHINE

24.732 HEXATRIACONTANE C36H74 506 6.674

25.988 HEPTACOSANE, 1-CHLORO- C27H55Cl 414 5.934

Figure 2: Different Bacteria and its zone of inhibition

Figure 3: DPPH scavenging activity.

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 51

Figure 4: K562 cells reactions at different sample concentrations.

Figure 5: Cell death percentage of K562 cells against Punica grantum.

Acknowledgement: This research is a part of B. Source of Funding: Self

Tech Project work of the third,fourth and fifth authors.
The authors have no other relevant affiliations or Conflict of Interest: Nil
financial involvement with any organization.
References
Ethical Clearance: Ethical approval is taken from 1. Wu, S., & Tian, L. Diverse Phytochemicals and
IEC.This work is carried out by following the strict Bioactivities in the Ancient Fruit and Modern
guidelines of IEC.
52 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Functional Food Pomegranate (Punica granatum); Oliveira Fugisaki, L., … Junqueira, J.C. Punica
Molecules. 2017:22, 1606. granatum L. (Pomegranate) Extract: In Vivo Study
2. Barathikannan, K., Venkatadri, B., Khusro, A., of Antimicrobial Activity against Porphyromonas
Al-Dhabi, N. A., Agastian, P., Arasu, M. V., … gingivalis in Galleria mellonella Model; Scientific
Kim., Y. O. Chemical analysis of Punica granatum World Journal. 2016.
fruit peel and its in vitro and in vivo biological 11. Shaygannia, E., Bahmani, M., Zamanzad, B.,
properties; BMC Complementary and Alternative & Rafieian-Kopaei, M. A Review Study on
Medicine. 2016:16, 264 Punica granatum L; Journal of Evidence-Based
3. Khan, J. A., & Hanee, S. Antibacterial properties of Complementary & Alternative Medicine. 2016: 21,
Punica granatum peels; IJABPT. 2011:2, 23-27. 221-227.
4. Sajjad, W., Sohail, M., Ali, B., Haq, A., Din, G., 12. Rahmani, A.H., Alsahli, M. A., & Almatroodi,
Hayat, M., … Khan, S. Antibacterial activity of S. A. Active Constituents of Pomegranates
Punica granatum peel extract; Mycopath. 2015:13, (Punica granatum) as Potential Candidates in the
105-111. Management of Health through Modulation of
Biological Activities; A Multifaceted Journal in
5. El-Awady, M. A., Awad, N.S., & El-Tarras,
the field of Natural Products and Pharmacognosy.
A.E. Evaluation of the anticancer activities of
2017:9, 689-695.
pomegranate (Punica granatum) and harmal
(Rhazya stricta) plants grown in Saudi arabia; 13. Ashok kumar, K., & Vijayalakshmi, K. GC-MS
International journal of current microbiology and Analysis of phytochemical constituents in ethanolic
applied science. 2015:4, 1158-1167. extract of punica granatum peel and vitis vinifera
seeds; International Journal of Pharma and Bio
6. Bhowmik, D., Gopinath, H., Pragati Kumar, B.,
Sciences. 2011:2.
Duraivel, S., Aravind, G., & Sampath Kumar,
K.P. Medicinal Uses of Punica granatum and Its 14. Almiahy, F. H., & Jum’a, F. F. GC-MS Analysis
Health Benefits; Journal of Pharmacognosy and of Phytochemical Constituents in Ethanoic Extract
Phytochemistry. 2013:1, 28-34. of Pomegranate (Punica granatum L.) “Salami
variety” grown in Iraq; IOSR Journal of Agriculture
7. Sreedevi, P., Vijayalakshmi, K., & Venkateswari,
and Ve terinary Science. 2017:10, 48-53.
R. Phytochemical evaluation of punica granatum
l. leaf extract.; International Journal of Current 15. Prasad, D., Kunnaiah, R. Punica granatum: A review
Pharmaceutical Research. 2017:9, 15-18. on its potential role in treating periodontal disease;
Journal of Indian Society of Periodontology.
8. Choi, J.-G., Kang, O.-H., Lee, Y.-S., Chae, H.-
2014:18, 428–432.
S., Oh, Y.-C., Brice, O.-O., … Kwon, D.-Y. In
Vitro and In Vivo Antibacterial Activity of Punica 16. Joseph, M. M., Aravind, S. R., Varghese, S., Mini,
granatum Peel Ethanol Extract against Salmonella; & S., Sreelekha, T. T. Evaluation of antioxidant,
Evidence-Based Complementary and Alternative antitumor and immunomodulatory properties of
Medicine. 2009. polysaccharide isolated from fruit rind of Punica
granatum;Molecular medicine reports. 2012:5,
9. Shiban, M. S., Al-Otaibi, M. M., & Al-Zoreky,
489-496.
N.S. Antioxidant Activity of Pomegranate (Punica
granatum L.) Fruit Peels; Food and Nutrition 17. Jayaprakash, A., & Sangeetha, R. Phytochemical
Sciences. 2012: 3, 991-996 Screening of Punica granatum Linn. Peel Extracts;
Journal of Academia and Industrial Research.
10. Aparecida Procópio Gomes, L., Alves Figueiredo,
2015:4, 160-162.
L. M., Luiza do Rosário Palma, A., Corrêa
Geraldo, B. M., Isler Castro, K. C., Ruano de
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 53

A Study on Utilization of Primary Health Care Services among

the People Residing in a SEMI-URBAN AREA

B. Charumathi1, D. Jayashri1, S. Manisha2, Aadithya2, C. Hemanthkumar2, Timsi Jain3

1Post Graduate, 2CRRI, Professor and Head, 3Department of Community Medicine,
Saveetha Medical College Hospital, Thandalam, Kanchipuram

Abstract
Background: Primary healthcare is a vital strategy which remains the backbone of health service delivery.
As on March 31st 2017, there were a total of 25, 650 primary health centres(PHC) functioning in the country.
Though the number of PHC’s had increased, the utilization is declining over the years as people seek private
health sectors due to various reasons. Objective: To assess the awareness and utilization of primary health
care services provided by Thirumazhisai PHC. Methodology: A Community based cross-sectional study
was conducted among people residing in Thirumazhisai. The Sample size of 233 was calculated. The study
population was selected by simple random sampling technique. A pre-designed, pre-tested semi- structured
questionnaire was used to collect data. Data entered in MS excel and analyzed using proportion. Results:
Among 233 people, 183 (78.8%) people knew about PHC services. Regarding utilization of services,
165(70.8%) were availing services provided by PHC. The reasons given for non utilization of services
were long waiting time (51.4%), dissatisfaction of Doctor-Patient relationship(17.7%), non-availability of
essential medicines (14.7%), PHC not clean (8.8%), and PHC does not have all required services (7.4%).
Conclusion: In resource-constrained developing countries like India, all efforts should be undertaken to
bring about the maximum efficiency of health care delivery. Role of primary healthcare is essential in the
progress towards achieving universal health coverage (UHC).

Keywords: Primary health care, primary health centres, awareness, utilization.

Introduction PHC is the first level of contact and also direct link
between the health care provider and the community.
The Alma-Ata Conference held in 1978 set the goal
According to the National Health Plan 1983, the primary
of attaining the ‘Health for all’ by 2000 through primary
health centers were reorganized on the basis of one PHC
health care approach.1 Primary health care is defined as
for every 30,000 rural populations in the plains, and one
“Essential health care made universally accessible to
PHC for every 20,000 population in hilly, tribal and
individuals and acceptable to them, through their full
backward areas for more effective coverage.1
participation and at a cost the community and country
can afford”. In India Primary health care is delivered PHC provides OPD services, free medicines, health
through a network of Primary Health Centers (PHC).1 education, antenatal services, immunization, family
welfare services and information on basic sanitation.2
As on March 31st 2017, there were a total of 25, 650
PHCs functioning in the country. Percentage of PHCs
Corresponding Author:
functioning in government buildings has increased
Dr. B. Charumathi
significantly from 78% in 2005 to 90.9% in 2017. In
Post-Graduate, Department of Community
Tamilnadu, out of total 1835 PHCs, 473 PHCs are in
Medicine, No: 127 A Brick Kiln Road, Tvh Lumbini urban areas.3
Square, Block 9, Flat No: 9013, Purasawalkam,
Chennai-600007 Though the number of primary health centres had
e-mail: [email protected] increased, the utilization is declining over the years as
54 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
people seek private health sectors due to various reasons.4 Demographic Details Number (n = 233) Percentage
In 2015, an estimated 8% of the Indian population had Socio Economic Status
been pushed below the poverty line by high out-of- Upper Class 10 4.3%
pocket expenditure for health care.5 Upper-Middle Class 95 40.8%
Lower-Middle Class 60 25.8%
This study is conducted to assess the awareness Upper-Lower Class 50 21.4%
and utilization of primary health care services provided Lower Class 18 7.7%
by a Government PHC in urban field practice area of a
Private Medical College near Chennai. Details regarding awareness of PHC services
in study population: Among the 233 people,183
Methodology (78.5%) people were aware of PHC services and among
A community based cross sectional study was all services the awareness for OPD services was high
conducted in Thirumazhisai, a semi–urban area located (28.9%). (Table 2).
near Chennai. The study was conducted between May Table No 2: Awareness of PHC services in study
2017- July 2017. Households in Thirumazhisai were population:
selected by Simple Random Sampling. One person from
each household was selected. The sample size of 233 Number of People
PHC Services Percentage
wascalculated by using prevalence of 62% utilization Aware (n = 183)
of PHC services.6 A pre-designed, pre-tested semi- Immunization services 15 8.2%
structured questionnaire was used to collect data. Data Family welfare services 42 23%
on socio-demographic details, awareness and utilization Lab facilities 23 12.5%
of PHC services and reasons for non utilization was Antenatal services 20 11%
collected. People who were willing to participate in the Essential medicines 30 16.4%
study were included and those who were not available OPD services 53 28.9%
in households were excluded. Data was entered in MS
excel and analysed using proportions. Details regarding utilization of PHC services
in study population: Among 233 people, 165(70.8%)
Results were availing services provided by PHC. Majority of
the population utilized OPD services (29%) followed by
Details regarding demography of study family welfare services (23.6%).
population: In the present study, majority of participants
belong to the age group 25-34 years (36.5%). Male Table No 3: Utilization of PHC services in study
population was 128 (55%) and female population was population:
105 (45%).Modified Kuppuswamy scale was used to
assess the socio economic status of study population. Number of People
PHC Services Percentage
Utilize (n = 165)
Majority of the population belonged to upper middle
Immunization services 13 7.9%
class (40.8%). (Table 1)
Family welfare services 39 23.6%
Table No. 1: Demographic details of study Lab facilities 20 12.2%
population Antenatal services 19 11.5%
Essential medicines 26 15.8%
Demographic Details Number (n = 233) Percentage
OPD services 48 29%
Age
15-24 9 3.8% Details regarding non utilization of PHC services
25-34 85 36.5% in study population: In the present study one third
35-44 60 25.7% (29.1%) of the participants were not availing PHC
45-54 79 34% services. The major reason for non utilization of services
Sex was the long waiting time (51.4%). (Table 3)
Male 128 55%
Female 105 45%
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 55
Table No 4: Reasons for non utilization of services Practitioners. It is a key tool for optimal utilization of
in study population resources and improving health outcomes and client
satisfaction.10 Improving the quality of health care is
Reasons for non Number of People also essential to meet the health related targets of the
Percentage
utilization (n = 68)
Sustainable Development Goals (SDGs). 11
Longwaiting time 35 51.4%
PHC not clean 6 8.8% As a major initiative of Ministry of health and family
PHC does not have all
5 7.4%
welfare (MoHFW) under National Health Mission,
required services Kayakalp initiative was launched in 2015 to promote
Dissatisfaction of Doctor- cleanliness, hygiene and infection control practices
12 17.7%
Patient relationship
in public health facilities. Under this initiative, public
Non-availability of
10 14.7% health care facilities are appraised and those facilities
essential medicines
that meet the standard protocol receive awards and
Discussion commendations. National Quality Assurance framework
was rolled out in November 2014 to improve the quality
The present study was focused on the awareness of health care in over 31000 public facilities including
and utilization of PHC services. In the present study, PHCs.12
78.5% people were aware of PHC services in their area
and this was found to be similar (76.2%) as reported by More qualitative research had to be carried out to
Rajpurohit et al in Barabanki, a rural area of Northern determine the factors influencing utilization of services;
India.7 this will lead us to develop a public health marketing
strategy for care access.
Majority of people in the present study were aware
of OPD services followed by family welfare services. For last two years (2018 & 2019)WHO Day theme
In the present study, 70.8% study population reported is “Universal Health Coverage: Everyone, Everywhere.”
that they utilize PHC services. This was found much Universal health coverage (UHC) means that all people
greater than the study in Barabanki, Northern India7 and and communities can use the promotive, preventive,
Nepal8 which reported only 36.3% and 48% utilization curative, rehabilitative and palliative health services
respectively. Majority people in the present study they need, of sufficient quality to be effective, while also
utilized PHC for OPD services, family welfare and free ensuring that the use of these services does not expose
drug services. the user to financial hardship. UHC can only be achieved
by proper delivery and utilization of Primary health care
In the present study the major reason given by services through PHCs.13
people who were not utilizing PHC services was long
waiting time(51.4%) followed by dissatisfaction in Conclusion
doctor patient relationship (17.7%), non-availability of
Only two third of the study population was found to
essential medicine (14.7%), cleanliness issues (8.8%)
be aware and were utilizing PHC services. In resource-
and not all required services available in PHC (7.4%).
constrained developing countries like India, all efforts
Rajpurohit et al 7and Kumari R9also reported long
should be undertaken to bring about the maximum
waiting time 43.9% and 62.5% respectively as the main
efficiency of health care delivery. Role of primary
reason for non- utilization of PHC services in Barabanki
healthcare is essential in the progress towards achieving
and Lucknow.
Universal health coverage.
In present study, low utilization of health care
Limitations of the study: This study was conducted
services was reported in spite of good accessibility to the
in our field practice area covered by one Urban PHC,
PHC. Though, the facilities were existing, poor quality
therefore the findings cannot be generalised to all PHCs.
care and lack of drugs resulted in the non utilization of
PHC services. Similar findings were also reported by Conflict of Interest: Nil
YadavD K in rural Nepal.8
Source of Funding: Nil
Recently Quality of Care has emerged as a
crucial area for both Policy Makers and Public Health Ethical Clearance: Ethical approval was obtained
56 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
from the Institutional Review Board (IRB) and 7. Rajpurohit AC, Srivastava AK, Srivastava VK.
Institutional Ethics committee. Written informed consent Utilization of primary health centre services
was obtained from the parents of the study participants amongst rural population of northern India - some
and information sheet regarding the study was given to socio-demographic correlates. Ind J Comm Health.
all the participants. October 2013; 25(4); 445–450.
8. YADAV, D K. Utilization Pattern of Health Care
References Services at Village Level. J Nepal Health Res
1. K.Park. Health care of the community. Park’s Counc. 2010 Apr;8(16):10-14
textbook of preventive and social medicine 24th 9. Kumari R, Idris M, Bhushan V, Khanna A, Agarwal
edition: Banarsidas Bhanot;2017.p.904-905 M, Singh S. Study on patient satisfaction in the
2. M Chokshi, B Patil, R Khanna, SB Neogi, J Sharma, government allopathic health facilities of Lucknow
VK Paul and S Zodpey.Health systems in India. J district, India. Indian J Community Med. January
Perinatol. 2016;36(s3):S9-S12 2009; 34(1):35-42.
3. Rural health statistics -2017 Available from URL: 10. Quality Improvement. National Health System
https://data.gov.in/catalog/rural-health-statistics- Resource Center. Technical Support Institute
2017. Accessed on 24 June 2018 with National Health Mission. Available from
4. Shivani Bhardwaj, Vishal Garg, Kislaya URL: http://nhsrcindia.org/quality-improvement.
Kumar. Rural Healthcare in India: paucity Accessed on June 24 2018
between prerequisites and provisions. Journal of 11. Strategies for Ensuring Quality Health Care in
Advanced Medical and Dental Sciences Research. India: Experiences from the Field. IJCM. January-
2018July;6(7). March 2019; 44(1)Published by Wolters Kluwer
5. Kaushalendra Kumar1, Ashish Singh, Santosh Medknow
Kumar, Faujdar Ram, Abhishek Singh, Usha Ram, 12. National Health Mission. Ministry of Health
Joel Negin4, Paul R. Kowal. Socio-economic and Family Welfare. Available from URL:
differentials in impoverishment effects of out- https://mohfw.gov.in/sites/default/files/
of-pocket health expenditure in China and India: 56987532145632566578.pdf. Accessed on 24 June
evidence from WHO SAGE.PLoSOne.2015August 2018
13; 10(8):e0135051. 13. WHO, Health Financing. Available from URL:
6. Al-Doghaither AH, Abdelrhman BM, Saeed AA, https://www.who.int/health_financing/universal_
Al-Kamil AA, Majzoub MM. Patients’ satisfaction coverage_definition/en/. Accessed on 24 June 2018
with primary health care centers services in Kuwait
city, Kuwait. J Family Community Med. 2001;
8(3):59-65.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 57

An Empirical Relationship between Stress and Job

Performance: A Study with Private School Teachers

D.S. Premalatha1, S. Subramanian2

1Research Scholar, 2HOD & Research Supervisor, Department of Commerce (Ca), Vistas, Pallavaram, Chennai

Abstract
Stress reacts in the human body with physical, mental and emotional responses. It may be positive or
negative. Negative stress affects the concern person and the environment also. It is part of our body. Stress
can experience stress from our environment, body, and thoughts. The main purpose of this study is to find the
factors causing stress among the teachers working in private schools. The researcher used linear regression
analysis to find the result. The results show that the main factor causing stress are role conflicts and Pay. The
stress and job performance are negatively correlated. Stressful teachers not performed well compared with
other teachers.

Keywords: Stress, Job Performance, Role conflicts.

Introduction relationship with other people. If this is failed stress can

cause. It affects the people physically and mentally.
Stress is the important factor that affect employee’s
mood, health, behaviour and relationship with other Some people feel the stress as a motivator. This is
employees. Some Individuals suffered with their young essential to survive and to fight with the problems day
age and they are very healthy also. This is called acute to day faced by the people. It teaches people how to
stress. Nowadays, stress mostly affected on employees respond in a risky situation.
with high job pressure. There is a limit of stress i.e. it
cross more than this limit it given negative, impact on Impact of Stress:
their job otherwise the impact is positive. • Blood Pressure
The stress is affected not only because of job • Breathing problems
sometimes unhealthy behaviour causes stress. The main
• Digestive problems
thing is to the person should know how to handle the
stress without affecting their health and society. There • Reduce Immunity power
is lot of awareness programs are conducting in the • Mental problems
organisation to get rid from stress.
• Affects Job
Stress is affected to the teachers those who are
• Affects Family
working in private schools. There are lot of reasons for
causing the same such as pay, work load, long working Factors Causing Stress of Employees:
hours, culture, task etc., To overcome the stress to the
• Promotion
teachers management has to arrange some remedial
classes like yoga, Meditation etc. • Status of the Job

Stress Meaning: Stress is a feeling of people when • Discrepancies in the pay

the expectation is not fulfilled or demand is not satisfied • Conflicts between the employees
it affects the concern person. The expectation or demands
• Target
are related to work, promotions, finance, maintaining the
58 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
• Competition a simplified process model, a so-called salutogenic
approach, of coping with stress in the workplace. As
• Management problems
expected, individuals with a stronger sense of coherence
• Cultural differences and a stronger internal locus of control experienced
• No cooperation lower levels of stress and vice versa. Nevertheless,
in a regression analysis only the sense of coherence
• Work load and external locus of control variables contributed
• Environment of the work place significantly to variance in the criterion variable stress3.

• Job insecurity Moaz Garib et al(2016) The impact of job stress on

job performance: A case study on academic staff at dhofar
The main factor of causing stress is the work place of
university. The purpose of this study is to determine the
the person. The demand and pressures of the Management
levels of job stress among the academic staff at Dhofar
causing stress to the employees. Conflicting role in
University, to measure the job performance level, and
the work place also affects employees to cause stress.
determine the impact of the job stress factors (workload,
The management has to arrange or follow the cope up
role conflict and role ambiguity) on job performance.
strategies of stress to reduce and recover from the same.
Results show that the level of academic staff of job stress
In this research the researcher finds the factors was medium and sometimes low. In addition, the level
causing stress to the private school teachers and impact of Job performance was somewhat high. Moreover, it
on stress on their performance. was found that workload has a positive statistical effect
on job performance5.
Review of Literature: Ahmad Usman et al
(2011). Work Stress Experienced by the Teaching Staff Ashfaq Ahmed, Dr. Muhammad Ramzan (2013).
of University of the Punjab, Pakistan: Antecedents Effects of Job Stress on Employees Job Performance
and Consequences. This study tends to examine the A Study on Banking Sector of Pakistan. This study
relationship between role conflict, role ambiguity and examines the relationship between job stress and job
attitudinal outcomes of the job i.e. job satisfaction and performance on bank employees of banking sector
organizational commitment of teaching staff in the largest in Pakistan. The results are significant with negative
and most populated university of Pakistan i.e. University correlation between job stress and job performances
of the Punjab. The findings of the study suggests that and shows that job stress significantly reduces the
there is a positive and significant relationship between performance of an individual. The results suggest to
role stress i.e. role conflict and role ambiguity and work the organization that they have sustained a very health,
stress however work stress is negatively and significantly cooperative and friendly environment within the team
associated with job satisfaction and organizational for better performance2.
commitment of the teaching staff of the university under
Mai Ngoc Khuong and Vu Hai Yen(2016).
examination1.
Investigate the Effects of Job Stress on Employee Job
Sai Mei Ling and Muhammad Awais Bhatti (2014). Performance—A Case Study at Dong Xuyen Industrial
Work Stress and Job Performance in Malaysia Academic Zone, Vietnam. The purpose of this research was to
Sector: Role of Social Support as Moderator. The analyse the effects of five working factors including
present study aims to investigate the relationship role work overload, role ambiguity & role conflict, working
conflict, job control, social support and job performance relationship, career development, and working
among administration staff in University Utara Malaysia environment on job stress and employee job performance
(UUM), Kedah. Results indicate that a positive and in six different industries at Dong Xuyen Industrial Zone,
significant relationship found between job control, social Ba Ria–Vung Tau province, Vietnam. As a result, these
support and job performance. Besides, results indicated working factors had significant and positive influence
social support moderate between role conflict and job on job stress and in contrast, job stress had negative
performance showed significant relationship6. influence on employee job performance. In addition,
this research also found that career development did not
Janine, Oosthuizen et al (2013) Coping with directly affect employee job performance, but indirectly
stress in the workplace. The researchers investigated through job stress. It is recommended that organizations
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 59
at Dong Xuyen Industrial Zone should reduce job stress are Role conflicts, Culture variance, Competition,
by reducing conflicts in working relationship, career Completion of target, Work load and Pay. The influence
development, and working environment in order to of these variables on Job performance are presented in
improve employee job performance4. the following regression analysis.

Sharmilee Bala Murali (2017) Impact of Job Table 1: Model Summary

Stress on Employee Performance. The main Purpose
of this study is to analyses the impact of job stress on Adjusted R Std. Error of
Model R R Square
Square the Estimate
employee performance. It found that time pressure
1 .950a .902 .901 .435
and role ambiguity have significant and negative
a. Predictors: (Constant), S5, S1, S5, S3, S4, S2
influence on employee performance. The other two
factors of workload and lack of motivation do not have Source: Computed data
any significant influence on employee performance.
From the above table it is found that R=.950 R
Therefore we concluded that increasing time pressure
square = .902 and adjusted R square .901. This implies
and role ambiguity would reduce employee performance
the stress causes 90% variance over the Job performance.
in all aspects7.
The cumulative influence of six variables of stress over
Objectives of the Study: Job performance is ascertained through the following
one way analysis of variance.
1. To find the factors causing stress among the
employees working in Private schools. Table 2: ANOVAa
2. To know the impact of stress on Job Performance Sum of Mean
Model df F Sig.
Hypotheses of the Study Squares Square
Regression 860.347 6 143.391 757.758 .000b
1. There is no significant difference among the factors 1 Residual 93.291 493 .189
causing stress among the employees working in Total 953.638 499
Private schools.
a. Dependent Variable: Job Performance,
2. There is no significant impact of stress on Job b. Predictors: (Constant), S5, S1, S5, S3, S4, S2
Performance Source: Computed data

Result and Discussion Table 2 presents that F = 757.758 p=.000 are

statistically significant at 5% level. This indicates all
Influence on Stress on Job Performance: The
the six variables cumulatively responsible for Job
stress consist of eight variables and it subsequent
performance. The individual influence of all this six
influence over Job performance is measured through
variables is clearly presented in the following co-
linear multiple regression analysis. The variables
efficient table.

Table 3: Coefficientsa

Unstandardized Coefficients Standardized

Model B t Sig.
Std. Error Beta Coefficients
(Constant) .257 .073 3.506 .000
Role conflict .681 .059 .626 11.617 .000
Culture variance .282 .086 .244 3.291 .001
1 Competition .217 .082 .198 2.651 .008
Completion of Target .101 .070 .082 1.432 .153
Work load .434 .075 .385 5.797 .000
Pay .356 .059 .356 6.078 .000
a. Dependent Variable: Job Performance
Source: Computed data
60 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
From the above table it shows that Role conflict Conflict of Interest: Nil
(Beta=.626, t=11.617, p=.000), Culture variance
(Beta=.244, t=3.291, p=.001), Competition (Beta=.198, Ethical Clearance: Taken from UGC Committee
t=2.651, p=.008), Work load (Beta=.385, t=5.797, Source of Funding: Self
p=.000) and Pay(Beta=.356, t=6.078, p=.000) are
statistically significant at 5% level. Completion of References
Target (Beta=.082, t=1.432, p=.153) are not statistically
significant at 5% level.This indicates that role conflict 1. Ahmad Usman et al. Work Stress Experienced by
among the teachers working in private schools causes the Teaching Staff of University of the Punjab,
more stress followed by pay given by the management. Pakistan: Antecedents and Consequences.
It reflects in their job performance as low performance International Journal of Business and Social
level compared with other teachers. Science (2011) Vol. 2 No. 8.
2. Ashfaq Ahmed, Dr. Muhammad Ramzan. Effects
Findings and Conclusions of Job Stress on Employees Job Performance A
Study on Banking Sector of Pakistan. IOSR Journal
1. There are many factors causing stress among the
of Business and Management (IOSR-JBM) (2013)
employees working in private schools.
e-ISSN: 2278-487X, p-ISSN: 2319-7668. Volume
2. The factors are role conflicts, culture variance, 11, Issue 6 (Jul. - Aug. 2013), PP 61-68.
Competition, completion of target, work load and 3. Janine D OOSTHUIZEN et al. Coping with stress in
Pay. the workplace. SA Journal of Industrial Psychology
3. The most important factor causing stress are role (2013). Vol. 34 No. 1 pp. 64–69.
conflicts among the teachers followed by Pay 4. Mai Ngoc Khuong and Vu Hai Yen. Investigate
and the least factors are completion of target and the Effects of Job Stress on Employee Job
competition. Performance—A Case Study at Dong Xuyen
4. The impact of stress reflected in the Job performance Industrial Zone, Vietnam. International Journal
of teachers working in Private schools. of Trade, Economics and Finance, (2016). Vol. 7,
No. 2.
5. They perform very low and they could not complete
5. Moaz Garib et al.The impact of job stress on job
their target with in that period.
performance: A case study on academic staff
6. Finally, it concludes that the management should at dhofar university. International Journal of
takes steps to reduce stress by the way of arranging Economic Research (2016). 13(1):21-33.
motivational programs, given the pay based on their 6. Sai Mei Ling and Muhammad Awais Bhatti. Work
performance. Stress and Job Performance in Malaysia Academic
Testing of Hypotheses: Sector: Role of Social Support as Moderator.
British Journal of Economics, Management &
1. There is no significant difference among the factors Trade (2014).4(12).
causing stress among the employees working in
7. Sharmilee Bala Murali. IMPACT OF JOB STRESS
Private schools - Rejected
ON EMPLOYEE PERFORMANCE. International
2. There is no significant impact of stress on Job Journal of Accounting & Business Management
Performance - Rejected (2017).Vol. 5 (No.2) ISSN: 2289-4519.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 61

Decision Tree Ensemble Techniques to Predict Thyroid Disease

Dhyan Chandra Yadav1, Saurabh Pal2

1Research Fellow, Dept. of MCA, 2Associate Professor, Head Dept. of MCA, VBSPU Jaunpur, U.P.

Abstract
Background: Decision tree provides help in making decision for very complex and large dataset. Decision
tree techniques are used for gathering knowledge. Classification tree algorithms predict the experimental
values of women thyroid dataset. The objective of this research paper observation is to determine
hyperthyroidism, hypothyroidism and euthyroidism participation in hormones can be good predictor of
the final result of laboratories and to examination whether the propose ensemble approach can be similar
accuracy to other single classification algorithm.

Results: In the proposed experiment real data from 499 thyroid patients were used classifications algorithms
in predicting whether thyroid detected or not detected on the basis of T3, T4 and TSH experimental values.
The results show that the expectation of maximization classification tree algorithms in those of the best
classification algorithm especially when using only a group of selected attributes. Finally we predict batch
size, tree confidential factor, min number of observation, num folds, seed, accuracy and time build model
with different classes of thyroid sickness.

Conclusion: Different classification algorithms are analyzed using thyroid dataset. The results obtained by
individual classification algorithms like J48, Random Tree and Hoeffding gives accuracy 99.12%, 97.59%
and 92.37 respectively. Then we developed a new ensemble method and apply again on the same dataset,
which gives a better accuracy of 99.2% and sensitivity of 99.36%. This new proposed ensemble method can
be used for better classification of thyroid patients.

Keywords: J48, Random Tree, Hoeffding, Prediction, T3, T4, TSH, hypothyroidism, hyperthyroidism,
euthyroidism and ensemble model.

Introduction Thyroid disease is a different thing about all other

diagnosis system. It’s visibility and treatments are
Hormones play major role in blood stream to
different. Thyroid hormone has many symptoms in
maintain metabolism in human. The production of
initial to final stage. It is generally arises from disorder
high hormones and low hormones both are dangerous.
life style and foods after it increasing and decreasing
The general objective of thyroid gland is to produce
hormones production finally make health system [3].
thyroid hormones. The main objective of thyroid gland
is to maintain bloodstream through the regulation of The paper analysis is organized on batch size,
metabolism. If thyroid gland produces more hormones confidential factor, num decimal places, num folds, seed
then it will be hyperthyroidism and if thyroid gland and accuracy of a model in decision making through
produces less hormones then it will be hypothyroidism[1]. J48, Hoeffding and Random Tree. The discuss about
all dataset of thyroid in multiple way of classification
The three hormones tri-iodothyronine (T3),
tree algorithm and finally measure the evaluation
L-thyroxin and TSH regulate the metabolic functions
accuracy increases with time built model training set.
of human body. These hormones utilize proteins
Classification decision tree provide many types help
and manage fats in human body. In pituitary gland
in identification of thyroid disease. It provides better
thyrotrophic stimulating is released if require more
help in dataset classification as a tree model in which
hormones. The pituitary gland control and manage
attributes represents root, nodes and leaf nodes. Analyst
production of hormones in the blood stream [2].
easily analysis all the functions of related dataset [4].
62 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
By the help of proposed three algorithms easily Saiti et.al discussed about thyroid cancer by different
classify hyperthyroidism, hypothyroidism and classifier algorithms. They increase accuracy of thyroid
euthyroidism. We easily indentify as a tree path and cancer dataset. They generated an ensemble model to
finally reach on decision node to leaf nodes. collect predict thyroid cancer and provided much accuracy
Present paper discuss to all the symptoms of thyroid compare to other previous prediction [11].
patients and declare types of problem. It is very difficult
to identify hyperthyroidism and hypothyroidism Vikas et.al discussed about medical dataset by
problems in another way [5]. different machine learning algorithms. They used data
mining different algorithms for taking decision as a
Related Work: Ahmad et.al discussed about decision tree and regression tree. After all the prediction
thyroid endocrine gland in blood issue and function of find 93% classification accuracy. They suggested to
the body. They discussed by feature selection, Fuzzy boost algorithm for prediction [12].
rule, maximal absolute difference Linguistic Hedge
and total serum thyroxin. They provided classification Vikas et.al discussed about breast cancer in women
accuracy 98.604% and achieved different testing phase by some different machine learning algorithms. They
of clustering one, two, three and four clusters for each used supporting key as like: Breast, Data Mining, Naïve
class and 12 fuzzy rules. The generated 88.372%, Bayes and RBF Network. After all the prediction they
90.6977%, 91.6744%, and 97.6744% cluster size during find Naïve Bayes give the highest accuracy 97.36% [13].
training phase [6]. Bridget et al. discussed about circulation serum FT4
Tahaniet.al discussed about clustering ensemble level in pregnant women. In circulation FT4 perchlorate
model and how combines multiple clustering models. exposure is negatively associated with circulating
They analyzed adaptive clustering ensemble model. levels in third trimester pregnant women. They used
Adaptive algorithm measured and transformed initial Perchlorate, Iodine, Pregnancy, birth and Weight[14].
clusters into binary representation aggregation to Awasthiand Anil Antony discussed about
produce final clusters. They used co- association, classification and diagnosis of thyroid disease. They
k-means, similarity measurement, machine learning and used KNN, Support Vector Machine, T3, T4 and TSH
data mining[7]. for diagnosis. They find some values missing while the
Xiyu et.al discussed about new class of tissue user entering the values. They used K-Nearest Neighbor
system. They analyzed traditional tissue P systems to algorithm in thyroid diagnosis for approximating the
new class of tissue system. They used thyroid disease missing values in the user input[15].
analysis, tissue P system,membranes structure and This analysis paper analyze classification tree
clustering algorithm. They analyzed thyroid disease for algorithms: J48, Random tree and Hoeffding for
classification [8]. predicting where thyroid hormones as like T3, T4 and
Amrollahiet.al discussed about effect on thyroid TSH experimental values. The results show that the
gland of human bodies. They analyzed how thyroid expectation maximization classification tree algorithmsin
function managed and balanced the metabolism. They those of the best classification algorithm especially when
used expert systems Bio-chemistry. They used fuzzy using only a group of selected attributes. Summaries all
rules to system provided help in non expert who are the analysis paper predict batch size, tree confidential
suspicions of their thyroid function and provided help in factor, min number of observation, num folds, seed,
expert for their diagnosis [9]. accuracy and time build model withdifferent classes of
thyroid sickness.
Ahmad et.al discussed about thyroid hormones
production from thyroid gland. They analyzed Methodology
compression hard and fuzzy clustering for thyroid disease Collected thyroid dataset is from githubuci
and find optimal number of clusters. They used thyroid and pathology. The use of these data sets for only
disease K-means, K-model clustering fuzzy C-means. experimental purposes. We have used all methodology
They improved actual number of clusters present in are used in four stages:
thyroid data set and find clustering performance is much
better to compare to other[10].
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 63
• Data Description • Result and discussion
• Algorithm description • Conclusion

Data Description:

Table 1: Thyroid Dataset variables representation

Rahul thyroid diagnosis center, https://github.com/mikeizbicki/datasets/blob/

Source References
master/csv/uci/new-thyroid.names
Sample Size 499= Total: 228 =Hyperthyroidism, 237= Euthyroid State and 34= Hypothyroidism
Dependent Variables
Hyperthyroidism Too much hormone production
Hypothyroidism To little hormone production [3],[16]
Euthyroidism The state of normal thyroid function
Independent Variables
T3 (60-200)ng/dl Triiodothyronine Stimulates the metabolism
T4 (4.5-12.0)µg/dl Thyroxin produced by thyroid gland [3],[16],[17]
TSH (6.3-5.5)µl/ml Thyroid Stimulating Hormone pituitary hormone

In our experiment we select data from Rahul thyroid J48: The generate the building model of thyroid data
diagnosis center and githubuci. All the dependable set classes by J48 algorithm from a set of records that
variables have definition with his explanation as like: contain class level. The decision tree find out the way of
Hyperthyroidism: Too much hormone production, attribute direction behaves for all thyroid instances. By
Hypothyroidism: To little hormone production, the help of this algorithm we will generate the rules for
Euthyroidism: The state of normal thyroid function. prediction for all target variables. The main objective of
All the hormones (T3, T4 and TSH) define in with his this algorithm in decision generation more progressive,
evolution ranges in ng/dl, µg/dl and µl/ml. The values of decision tree and gain more accurate result by decision
T3, T4 and TSH mentioned in above table.1. tree[21].

Algorithms Description: In this analysis developed Hoeffding: Hoeffding decision tree algorithm
model provides support to doctor in treatment. Proposed support in generating stream. Now generate an
model is for consulting only doctors but final decision incremental generating stream that will not be change
follow by doctors in treatment. Three classification over time [22].
algorithms J48,Random Tree and Hoeffding. Generate
and combine model with carrying the majority by voting Propose Method: This analysis uses algorithm
algorithms. Different varieties of seeds and portioned for classification and prediction, by the help of these
into different classes which is based on many features. decision trees easily organize form of tree structure of
thyroid dataset. Nodes of the tree shows the attributes
Random Tree: Random tree provide a platform for of the dataset and edges will be use for represent the
merging the individual learners. It constructs a random value of these attributes and finally find the leaf nodes as
field of data for constructing decision tree. Every nodes of decision nodes. In propose model select women thyroid
generated tree behaves as like best split for all variables dataset from laboratories and after the preprocessing
and randomly choose best node. If we use random tree of missing values evaluate the correlation of attribute
as a group of tree then it will be tree predictors or forest and take the values of T3, T4 and TSH then apply the
but all the mechanism follows the random trees and the algorithm in many faces of tree. Classify all thyroid
outputs the class level has received the majority of votes. dataset with different iteration of attributes and compare
Random tree improve the performance of single decision with tree ensemble model and finally evaluate the
tree and conscience more way of randomization[17-20]. majority of voting for different classes of thyroid as like
hyperthyroidism, hypothyroidism and euthyroidism.
64 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Results and Discussion Some issues overcome in random split thyroid

dataset in training and testing set. The randomsplits
Thyroid dataset in which 499 cases included as
find contradiction between getting results and realistic
a record in csv file. The classification model has four
results. In this paper, discuss and compare three tree
attributes T3, T4, TSH. The target variables as a class
algorithms with an ensemble model:
level observation have three type of classes that are:
hypothyroidism, hyperthyroidism and euthyroidism.

Experiment-I:

Table 2: Computational table for thyroid dataset using J48

Iterations Batch Size Confidential Factor Min Num Obj Num Folds Seed Accuracy Time (in Second)
1 100 0.25 2 3 1 97.32 0.04
2 200 0.50 3 5 2 97.34 0.04
3 300 0.75 4 10 3 99.12 0.03

The role of J48 tree algorithm in thyroid dataset for pruning for randomize dataset. By the experiment it
different number of samples as like 100, 200 and 300, is clear that the default value of seed is 1, but select
by the help of these batch prediction easily perform different sequence of random attributes by changing the
instances process. In this analysis observe confidential seed 2 and 3. In this experiment find, if increase batch
factor (0.25, 0.50 and 0.75) pruning and find minimum size (300), MinNumObj (4), Number of fold (10) and
number of branches of instances in thyroid dataset seed (3) then find highest accuracy (99.12%) with less
experiment are 2, 3 and 4,. Analyze and discuss about time build model 0.03 seconds.
controlling the sequences by number and reduce error

Experiment-II:

Table 3: Computational table for thyroid dataset using Random tree

Iterations Batch Size Confidential Factor Min NumObj Num Folds Seed Accuracy Time (in Second)
1 100 0.25 2 3 1 93.67 0.02
2 200 0.50 3 5 2 93.67 0.02
3 300 0.75 4 10 3 97.59 0.02

The role of random tree algorithm in thyroid dataset of fold (10) and seed (3) then find highest accuracy
for different number of samples. In this experiment find, (97.59%) with less time build model 0.02 seconds.
if increase batch size (300), MinNumObj (4), Number

Experiment-III:

Table 4: Computational table for thyroid dataset using Hoeffding

Iterations Batch Size Confidential Factor Min NumObj Num Folds Seed Accuracy Time (in Second)
1 100 0.25 2 3 1 89.31 0.07
2 200 0.50 3 5 2 89.22 0.07
3 300 0.75 4 10 3 92.37 0.05
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 65
The role of hoeffding tree algorithm in thyroid dataset of fold (10) and seed (3) then find highest accuracy
for different number of samples. In this experiment find, (92.37%) hoeffding tree with less time build model 0.05
if increase batch size (300), MinNumObj (4), Number seconds.

Experiment-IV:

Table 5: Computational for thyroid dataset using Ensemble Model

Iterations Batch Size Confidential Factor Min NumObj Num Folds Seed Accuracy Time (in Second)
1 100 0.25 2 3 1 98.43 0.05
2 200 0.50 3 5 2 98.43 0.05
3 300 0.75 4 10 3 99.20 0.05

The role of ensemble model in thyroid dataset for of fold (10) and seed (3) then find highest accuracy
different number of samples. In this experiment find, (99.20%) with less time build model 0.05 seconds.
if increase batch size (300), MinNumObj (4), Number

Fig. 1. Computational figure with table of thyroid dataset for comparing

66 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
In the above all analysis of experiment I, II, III and 4. Elte JW, Bussemaker JK, Haak A. The natural history
IV, find the heighest batch size(300), confidental factor of euthyroidmultinodulargoitre. Postgraduate
(75%), mnimum number of objects (4), number of folds medical journal. 1990 Mar 1;66(773):186-90..
(10) and seed (4) claculated heighest classification 5. Zhang GP, Berardi VL. An investigation of neural
accuracy (99.2%). It is generated by Ensemble model of networks in thyroid function diagnosis. Health Care
all given tree algorithms so majority of voting find that Management Science. 1998 Sep 1;1(1):29-37.
ensemble model of these tree algorithm is best. There
6. Azar AT, Hassanien AE, Kim TH. Expert system
is not major difference between generated time build
based on neural-fuzzy rules for thyroid diseases
models.
diagnosis. InComputer Applications for Bio-
technology, Multimedia, and Ubiquitous City 2012
Conclusion
Dec 16 (pp. 94-105). Springer, Berlin, Heidelberg..
Hormones disorders in thyroid are a major problem 7. Alqurashi T, Wang W. Clustering ensemble
in human. Various researchers work continues on this method. International Journal of Machine Learning
thyroid field and they used classification based data and Cybernetics. 2018 Jan 16:1-20.
mining techniques. In this analysis used J48, Hoeffding
8. Liu X, Xue A. The thyroid disease analysis by a
and Random tree on thyroid dataset and identify more
class of tissue P system. In2012 International
accurately model of decision tree on all possible
Symposium on Information Technologies in
experiments. In experimental study collect data from the
Medicine and Education 2012 Aug 3 (Vol. 2, pp.
values of T3, T4, TSH, Thyroid gland, Hyperthyroid,
744-748). IEEE.
Hypothyroid and Euthyroidism at various levels and find
(99.2%) classification accuracy in thyroid dataset. It is 9. Biyouki SA, Turksen IB, Zarandi MF. Fuzzy
more accurate result of ensemble model compares the rule-based expert system for diagnosis of thyroid
all other used tree algorithms with (0.05 seconds) time disease. In2015 IEEE Conference on Computational
built model. Summaries all the experimental results and Intelligence in Bioinformatics and Computational
implement decision tree using more helpful data mining Biology (CIBCB) 2015 Aug 12 (pp. 1-7). IEEE.
technique. In this analysis the ensemble classification 10. Azar AT, El-Said SA, Hassanien AE. Fuzzy
technique improved evaluates accuracy and test thyroid and hard clustering analysis for thyroid disease.
dataset. In future work observe the identification of Computer method and programs in biomedicine.
different affected factors of thyroid dataset and test more 2013 Jul 1;111(1):1-6.
different and large dataset for diabetes, heart disease etc. 11. Saiti F, Naini AA, Shoorehdeli MA, Teshnehlab
M. Thyroid disease diagnosis based on genetic
Ethical Clearance: No ethical clearance is needed
algorithms using PNN and SVM. In2009 3rd
for this research paper.
International Conference on Bioinformatics and
Funding: This study was not funded by any funding Biomedical Engineering 2009 Jun 11 (pp. 1-4).
agency. IEEE.
12. Chaurasia V, Pal S, Tiwari BB. Chronic Kidney
Competing Interests: None declared
Disease: A Predictive model using Decision Tree.
International Journal of Engineering Research and
References
Technology. 2018 Dec 9.
1. Ozyilmaz L, Yildirim T. Diagnosis of thyroid 13. Chaurasia V, Pal S, Tiwari BB. Prediction of benign
disease using artificial neural network method. and malignant breast cancer using data mining
InProceedings of the 9th International Conference techniques. Journal of Algorithms & Computational
on Neural Information Processing, 2002. Technology. 2018 Jun;12(2):119‑26.
ICONIP’02. 2002 Nov 18 (Vol. 4, pp. 2033-2036).
14. Knight BA, Shields BM, He X, Pearce EN,
IEEE.
Braverman LE, Sturley R, Vaidya B. Effect of
2. http://www.emedicinehealth.com/thyroid_faqs/ar perchlorate and thiocyanate exposure on thyroid
ticle_em.htm. function of pregnant women from South-West
3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3 England: a cohort study. Thyroid research. 2018
169866/(accessed dec 2015). Dec;11(1):9.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 67
15. Aswathi AK, Antony A. An Intelligent System 19. Leo B. Random forests. Machine learning. 2001
for Thyroid Disease Classification and Diagnosis. Oct;45(1):5-32.
In2018 Second International Conference on 20. Liaw A. Documentation for R package
Inventive Communication and Computational randomForest. PDF). Retrieved. 2013 Mar;15:191.
Technologies (ICICCT) 2018 Apr 20 (pp. 1261-
21. Korting TS. C4. 5 algorithm and multivariate
1264). IEEE.
decision trees. Image Processing Division, National
16. http://archive.ics.uci.edu/ml/datasets/Thyroid+ Institute for Space Research–INPE Sao Jose dos
Disease2013. Campos–SP, Brazil. 2006.
17. http://www.irdindia.in/journal_ijaece/pdf/vol3_ 22. http://weka.sourceforge.net/doc.dev/weka/
iss4/2.pdf classifiers/trees/HoeffdingTree.html.
18. Landwehr N, Hall M, Frank E. Logistic model trees.
Machine learning. 2005 May 1;59(1-2):161‑205.
68 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

A Descriptive Study to Assess the Knowledge on Child Birth

Preparation among Primigravid Mothers in a Selected Tertiary
Care Hospital at Kelambakkam, Kanchipuram District,
Tamilnadu, India

J. Chrislin Jebisha1, R.J. Joey Persul1, D. Joaniepriya2

1IIIrdYear B.Sc. (N) Student, 2Asst. Professor, Guide, Chettinad College of Nursing,
Rajiv Gandhi Salai, Kelambakkam, Kancheepuram, District Tamil Nadu, India

Abstract
A descriptive study to assess the knowledge on child birth preparation among primigravid mothers in a
selected tertiary care hospital at Kelambakkam, Kanchipuram district, Tamil Nadu, India. The objectives
are to assess the knowledge on child birth preparation among primigravid mothers in a selected tertiary care
hospital at Kelambakkam, Kanchipuram district, Tamil Nadu, India. To find out the association between
level of knowledge with demographic variables. The convenience sampling technique was used to select
41 samples. Validity and reliability data collection tools were established. The data were collected by self-
administered questionnaires. The collected data were tabulated and analyzed. Descriptive and inferential
statistics were used. The study shows that 2.5% of the women had adequate knowledge, 61% of the women
had moderate knowledge, and 36.5% of the women had inadequate knowledge regarding child birth
preparation.

Keywords: Knowledge, Child birth preparation, Primigravid mothers.

Introduction Pregnancy and giving birth to a child are normal

physiological process, but the circumstances both
Back Ground of the Study:
internal and external, in which the child is conceived and
“Giving birth should be your greatest achievement not born, affect the life of mother and child. Every pregnancy
your greatest fear” is associated with certain amount of unpredictability of
risk of complication. Socio-cultural beliefs and lack
Birth preparedness is a strategy to promote
of awareness in mothers and family members on how
utilization of maternal healthcare services and to ensure
to recognize danger signs and symptoms, where to go
safe motherhood. Birth preparedness concept is based
when complication occurs, results in delay in seeking
on the theory that preparing for childbirth and being
care and unprepared families waste time in recognizing
ready to deal with complications reduces the delays in
problem, getting organized, getting money, finding
obtaining timely care and addressing the three delays
transport and reaching the appropriate referral facility[2].
of deciding to seek care, reaching health facility and
Ms. Supriyachinchpure (2015)
receiving care[1].
In spite of important progress towards attaining
the Millennium Development Goals (MDGs), maternal
Corresponding Author. and neonatal mortality continue to figure as major
Ms. J. Chrislin Jebisha public health problems in developing countries[3,4].
IIIrd Year B.Sc. (N) Student, Chettinad College Improvements in maternal health and reductions in
of Nursing, Rajiv Gandhisalai, Kelambakkam, maternal mortality have been slower than anticipated
Kancheepuram, District, Tamil Nadu, India and–despite isolated successes–remain far from the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 69
MDG5 target of a 75% reduction in the maternal the mother had married at the age of 21-25 years, (83%)
mortality ratio (MMR) from 1990 to 2015[5]. Maternal of the mother were living in nuclear family, (85.3%)
mortality is a global burden, about 287,000 women of the mother taking mixed diet, (83%) of the mother
died in 2010 due to pregnancy and childbirth related were living in the town, (48.8%) of the mother working
complications[6]. In India, Maternal Mortality Ratio is as a professional, (58.6%) of the mother had monthly
212 per 100,000 live births[7]. income of above Rs.15,000, (51.2%) of the mother were
in second trimester.
Morbidities related to pregnancy are related to
medical causes which goes uncounted. Most maternal The Chi-square association revealed there was no
death occurs during delivery due to unpreparedness for significant association between demographic variables
childbirth and managing complications, which results in related with the knowledge aspects of primigravid
in delivery by the mother itself or untrained attendant. mothers with aspects of knowledge on child birth
These maternal deaths are unjust and avoidable if preparation. It shows that there is no significant
preventive measures are taken on time like ensuring association between knowledge aspects with Age of the
antenatal care to all mothers, delivery by skilled birth mothers (X2=4.25), Age at marriage (X2=1.48),Types
attendant and timely referral to hospital. As in most rural of family (X2=1.61), Dietary pattern (X2=0.6), Area
and tribal areas, delivery takes place at home, far from (X2=4.63), Occupation (X2=10.32), Monthly income
emergency obstetric services or without access to skilled (X2=7.32). There is Significant Association Between
attendant, there is more risk associated with mother and Trimester (X2=14.27).
child life[8].
Ethical Clearance:
Many birth preparedness programs widely
promoted by governments and international agencies to Summary, Findings, Discussion, Implication,
reduce maternal and neonatal health risks in developing Limitataion, Recommendation And Conclusion.
countries; however, their overall impact is uncertain. The essence of any research project lies in reporting
Thus investigator felt need to assess whether pregnant in the findings. This chapter gives a brief account of
women have adequate knowledge on antenatal, Intranatal the present study including conclusion drawn from the
and postnatal preparedness. Dr. Alka Despande (2015) findings, recommendations, limitation, suggestion for
Research Methodology: A Quantitative approach future studies and nursing implication.
with descriptive design was used in the study. The study Summary: The study is to assess the knowledge
was conducted among primigravid mothers attending regarding child birth preparation among primi gravid
OPD at selected tertiary care hospital. A purposive Mothers attending antenatal OPD and ward at selected
sampling technique was used to select 45 samples with tertiary care hospital. This will enhance the primi gravid
the following inclusion criteria. Primigravid mothers mothers to improve the knowledge regarding child birth
who are willing to participate in the study and the preparation.
mothers who all are attending Antenatal OPD.
The objectives of the study were,
Tool for the Study: Self-structured questionnaire
used to elicit the demographic variables and to assess the Assess knowledge on child birth preparation among
knowledge on child birth preparation among primigravid primi gravid Mothers.
mothers.
Associate the knowledge on birth preparation
Scoring and Interpretation: among primi gravid Mothers with selected demographic
variables.
Score Level of Knowledge
Above 75% Adequate Knowledge The study attempted to examine the following
51-75% Moderate Knowledge null hypothesis that
Below 50% Inadequate Knowledge
H0: There is no significant association between
Study Findings: The majoriy (85.3%) of the demographic variables with the knowledge on child birth
mother is under the age group of 21-25 years, (78%) of preparation among primigravid mothers in a selected
70 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
tertiary care hospital at Kelambakkam, Kanchipuram of child birth preparation.
District, Tamil Nadu, India.
There is no significant association between the
The review of literature enabled the investigator to type of family and level of knowledge of child birth
develop methodology of the study literature review was preparation. X2=1.61,(P<0.05).
done and organized as studies related to knowledge on
child birth preparation among primigravid mothers. Finding-4: Dietary pattern and level of knowledge
of child birth preparation.
The research approach used was quantitative
approach with descriptive design. The main study was There is no significant association between the
done in a selected tertiary care hospital at Kelambakkam, dietary pattern and level of knowledge of child birth
Kanchipuram District, Tamil Nadu, India. 41 samples preparation. X2=0.6,(P<0.05).
were selected by convenience sampling. Finding-5: Area and level of knowledge of child
The self-administered questionnaire was used birth preparation.
to collect the data regarding demographic variables There is no significant association between the
and the knowledge on child birth preparation among area and level of knowledge of child birth preparation.
primigravid mothers. The data gathered were analyzed X2=4.63, (P<0.05).
by using descriptive and inferential statistical method.
The findings were presented on the basis of objectives Finding-6: Occupation and level of knowledge of
of the study. child birth preparation.

Findings: Findings of the study were presented There is no significant association between the
under the following headings based on the study occupation and level of knowledge of child birth
objectives preparation. X2=10.32, (P<0.05).

Objective 1: Assess the level of knowledge on child Finding-7: Monthly income and level of knowledge
birth preparation. of child birth preparation.

The finding of the present study reveals that There is no significant association between the
monthly income and level of knowledge of child birth
1 (2.5%) had adequate knowledge preparation. X2=7.32, (P<0.05).
25 (61%) had moderate knowledge Finding-8
15 (36.5%) had inadequate knowledge Trimester and level of knowledge of child birth
OBJECTIVE 2: Associate demographic variables preparation.
with the level of knowledge on child birth preparation. There is significant association between the trimester
Finding-1: Age and level of knowledge of child and level of knowledge of child birth preparation.
birth preparation. X2=14.27, (P>0.05).

There is no significant association between the Implication: The findings of the study have
age and level of knowledge of child birth preparation. implication in Nursing services and research.
X2=4.25, (P<0.05). Nursing Service: Community health nurse conduct
Finding-2: Age at marriage and level of knowledge educational programs to improve knowledge on child
of child birth preparation. birth preparation.

There is no significant association between the In hospital Nurse can provide health education to
age at marriage and level of knowledge of child birth create knowledge.
preparation. X2=1.48, (P<0.05). Limitation: Primigravid mothers only included in
Finding-3: Type of family and level of knowledge the study.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 71
Recommendation: This study can be replicated 2. S Thaddeus and D Maine. Too far to walk: Maternal
an large sample studies can be conducted in different mortality in context. Social Science and Medicine
settings to validate findings 1994; 38(1091).
3. United Nations: The Millennium Development
A similar study can be conducted on general public
Goals Report 2012. New York; 2012.
regarding child birth preparation.
4. Lozano R, Wang H etal: Progress towards
Conclusion Millennium Development Goals 4 and 5 on
maternal and child mortality: an updated systematic
Create awareness about child birth preparation.
analysis. Lancet 2011,378(9797):1139–1165. Pub
This study helps us to understand the need for child
Med View Article
birth preparation to the primigravid mothers, it becomes
necessary to involve the primigravid mothers as and 5. Hogan MC, Foreman KJ etal: Maternal mortality
when during pregnancy and it can also able to prevent for 181 countries, 1980–2008: a systematic analysis
the complications, miscarriage and fetal death during of progress towards Millennium Development Goal
pregnancy. 5. Lancet 2010,375(9726):1609–1623. Pub Med
View Article
Source of Funding: Self 6. World Health Organization. Global Health
Observatory, World Health Statistics 2013.
Conflict of Interest: Nil
7. The Registrar General and Census Commissioner,
Reference India, New Delhi. 2010. (Ministry of Home Affair,
Government of India).
1. JHPIEGO, Monitoring birth preparedness and
complication readiness, tools and indicators for 8. The state of World’s Children 2009, Maternal and
maternal and newborn health.: (Bloomberg school Newborn Health. United Nation Children’s Fund,
of Public Health, Family Care International); 2004. 2008.
72 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Lateral Periodontal Cyst Masquerading Dentigerous Cyst:

A Rare Case Report

Jagannath Patro1, Swagatika Panda2, Sreepreeti Champatyray2, Alkananda Sahoo2, Neeta Mohanty3
1Post Graduate Student, 2Associate Professor, 3Dean & Head, Department of Oral Pathology and Microbiology,
Institute of Dental Sciences, Siksha ‘O’ Anusandhan, Deemed to be University, Bhubaneswar, Odisha, India

Abstract
Dentigerous cyst is the most commonly occurring developmental odontogenic cyst. Because of the typical
clinical and radiologic attributes, the present case was clinically misdiagnosed as Dentigerous cyst which
was later confirmed histopathologically as Lateral periodontal cyst. Lateral periodontal Cyst is defined as
non-keratinized developmental cyst located lateral to the root of a vital tooth. This case report presents
a unique case of lateral periodontal cyst present in 58-year-old female patient. Atypical presentation of
lateral periodontal cyst as is presented in this case report should be considered by the histopathologist while
interpreting microscopic preparations of odontogenic cysts.

Keywords: Lateral periodontal Cyst; Dentigerous cyst; Histopathology; Orthopantomograph.

Introduction reports a classic case of Lateral periodontal cyst which

was clinically diagnosed as dentigerous cyst along
Lateral periodontal Cyst (LPC) is defined as non-
with a brief literature on the clinical, radiological and
keratinized developmental cyst located lateral to the root
histopathological features of LPC.
of a vital tooth. This cyst is most frequently associated
with mandibular premolars but has been reported to Case Report: 58-year-old female patient reported
occur at the other areas.1 Since pain or other clinical with the chief complaint of mild pain and swelling in
symptoms have seldom been reported, the lesion is the lower left back tooth region with oozing of pus for
often discovered on routine radiographic examination. 5 days (Figure 1). Patient gives a history of extraction
Radiographs of the lateral periodontal cyst show a well- of lower left second premolar one year back. Intra oral
circumscribed round or ovoid radiolucent area, usually examination reveals an intraoral sinus with respect to
with a sclerotic margin. Most of them are less than 1 36. Orthopantomograph revealed four supernumerary
cm in diameter.1-4 Owing to the common prevalence impacted teeth in the lower left pre molar region
of dentigerous cyst among developmental odontogenic with unilocular radiolucency encircling the crown of
cyst, radiological presentation of unilocular radiolucency impacted teeth and involving the root of 34 (Figure 2).A
circumscribing crown of impacted supernumeraries are provisional diagnosis of infected dentigerous cyst was
usually diagnosed as dentigerous cysts. This article given.Microscopic sections(Figure3) of the submitted
biopsy specimens showed non keratinized squamous
epithelial lining of uneven thickness supported by
Corresponding Author: delicately collagenous connective tissue wall, which
is infiltrated with minimal focal collection of chronic
Dr. Swagatika Panda
inflammatory cells. At areas focal nodular thickening
Associate Professor, Department of Oral Pathology and
of epithelial cells with many glycogen rich clear cells
Microbiology, Institute of Dental Sciences, Siksha ‘O’
is observed. Connective tissue wall shows evidence
Anusandhan, Deemed to be University, Bhubaneswar,
of daughter cysts. Histopathological diagnosis was
Odisha-751003, India
conclusive of lateral periodontal cyst.
e-mail: [email protected]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 73

Discussion
LPC is considered as developmental odontogenic
cyst which represents approximately 0.8% to 2% of all
odontogenic cysts which is most of the time identified
in routine radiographic examination.5,6 The LPC was
described for the first time by Standish and Shafer in
1958.7 In the year 1973, Wysocki et al. considered
it as a representation of intrabony counterpart of the
gingival cyst of adults. In the same year, Weather and
Waldron reported for the first time an unusual form of
the LPC called Botryoid Odontogenic Cyst owing to
its appearance as a bunch of grapes.8 Wysocki et al.
suggested that the polycystic variant of LPC formed
through cystic transformation of multiple islands of Figure 3: Microscopic features (10X) show focal
dental lamina and some authors consider it to originate nodular thickening of epithelium with many
from fusion of adjacent multiple LPCs.9Literature glycogen rich clear cells
review shows that the LPC is more prevalent in adults
in the 5th - 7th decades of life with mean age of 52 years, The pathogenesis of LPC may be related to the
without preference for race or sex. The most frequently three aetiopathological hypotheses: reduced enamel
reported location of LPC is the mandibular premolar epitheliumremnants of dental lamina and cellular
area. In most cases the LPC does not present distinctive remnants of Malassez.5,6,10 The first hypothesis is
clinical symptoms, the associated teeth are vital, unless that the cyst is lined by non-keratinized epithelium
secondarily infected. reminiscent of the reduced enamel epithelium which is
supported by PCNA immunohistochemical expression.
The second theory is related to dental lamina remnants,
because LPC histopathologically presents glycogen-
rich clear cells, which is also seen in the dental lamina.
The third hypothesis offered that the epithelial remnants
of Malassez presented in the roots surface, principal
location of the LPC, play a role.

The diagnosis of LPC should be restricted to cysts

that are in the periodontal side. Radiographically, the
orthopantomograph represents four supernumerary
impacted teeth in the left lower premolar region
with unilocular radiolucency encircling the crown of
Figure 1: Mild swelling in relation to 36 and missing 35 impacted tooth and involving the root of vital tooth
of first premolar region. The periodontal ligament
space as a rule is not enlarged and there must not be
a communication between the cyst’s cavity and the
oral environment.1,10,11 Occasionally, LPC may be
multicystic, and called as odontogenic botryoid cyst due
to macro- and microscopic features resemble to “bunch
of grapes” (from the Greek word “botrios”). 10,11

The radiographic features may be inconclusive

relative to the diagnosis. Other interradicular
Figure 2: Orthopantomograph reveals unilocular
radiolucencies must be distinguished from the LPC:
radiolucency encircling the crown of impacted
anatomic radiolucencies, such as the mental foramen,
supernumerary teeth in the lower left pre molar
maxillary sinus and the nutrient canals; cyst of pulpal
region
74 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
origin, other cysts of the jaws, odontomas and other References
tumours. It may resemble a cyst that develops laterally
1. Krier PW. Lateral periodontal cyst. Oral Surg Oral
through a side channel accessory in a non-vital tooth.11
Med Oral Pathol. 1980;49(5):475.
The histopathology revealed that LPC is a developmental
cyst characterized by a thin layer nonkeratinized 2. Ortega A, Farina V, Gallardo A, Espinoza I, Acosta
stratified squamous epithelium of with uneven thickness S. Nonendodontic periapicallesions: a retrospective
supported by delicately collagenous connective tissue study in Chile. Int Endod J. 2007;40(5):386-90.
wall, which is infiltrated with mild focal collection 3. Kelsey WPt, Kalmar JR, Tatakis DN. Gingival cyst
chronic inflammatory cell infiltration. of the adult: regenerative therapy of associated root
exposure. A case report and literature review. J
At focal areas thenodular epithelial thickening, Periodontol. 2009;80(12):2073-81.
referred to as plaques or theca, are commonly found and
4. Nikitakis NG, Brooks JK, Melakopoulos I,
composed of the clear fusiform cells rich in glycogen.
Younis RH, Scheper MA, Pitts MA, et al. Lateral
However, it is possible to observe the histopathological
periodontal cysts arising in periapical sites: a report
variant of LPC - botryoid cyst, that should receive a
of two cases. J Endod. 2010;36(10):1707-11.
greater attention considering the rate of recurrence and
unusual presentation.12-16. The botryoid cyst represents 5. Shear M. Developmental odontogenic cysts. An
a histopathological variant which presents with update. J Oral Pathol Med. 1994;23(1):1-11.
multilocular cystic “grape-like” appearance inside the 6. Altini M, Shear M. The lateral periodontal cyst: an
bone. Histopathological findings show multiple cystic update. J Oral Pathol Med. 1992;21(6):245-50.
spaces lined by nonkeratinized stratified squamous 7. Standish SM SW. The lateral periodontal cyst. J
epithelium.12,15,16 The mobility of mandibular lateral Periodontol 1958(29):27-33.
incisor and canine reported by the patient can be 8. Weathers DR, Waldron CA. Unusual multilocular
justified by the cyst growth. However, LPC does not cysts of the jaws (botryoid odontogenic cysts). Oral
reach proportions that are larger than 1 cm while cysts of Surg Oral Med Oral Pathol. 1973;36(2):235-41.
inflammatory origin tend to grow continuously.13,15,17 In
9. Wysocki GP, Brannon RB, Gardner DG, Sapp P.
cases of a vital tooth, LPC can still be clinically confused
Histogenesis of the lateral periodontal cyst and the
with cysts that develop in inflammatory processes in cases
gingival cyst of the adult. Oral Surg Oral Med Oral
of advanced periodontal disease, where the presence
Pathol. 1980;50(4):327-34.
of periodontal inflammation stimulates epithelial
proliferation. In most cases the differential diagnosis 10. Cohen DA, Neville BW, Damm DD, White DK.
must be established with radicular cysts, in a view of The lateral periodontal cyst. A report of 37 cases. J
their high frequency. These lesions are characterized by Periodontol. 1984;55(4):230-4.
necrosis of the affected tooth, as a result of which vitality 11. Rasmusson LG, Magnusson BC, Borrman H. The
testing proves negative. Follicular or dentigerous cysts lateral periodontal cyst. A histopathological and
are always associated to an impacted tooth (particularly radiographic study of 32 cases. Br J Oral Maxillofac
a lower third molar), while primordial cysts are mostly Surg. 1991;29(1):54-7.
located in the ascending mandibular ramus. Authors 12. Carter LC, Carney YL, Perez-Pudlewski D. Lateral
suggest the investigation of the possibility of LPC periodontal cyst. Multifactorial analysis of a
causing isolated bone defects.15,16 previously unreported series. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 1996;81(2):210-6.
The common treatment modality for LPC includes
enucleation of the cyst in toto.16,18 In general, LPC has 13. Mendes RA, van der Waal I. An unusual
a low rate of recurrence from 3 to 4% hence, long-term clinicoradiographic presentation of a lateral
follow-up is necessary. periodontal cyst--report of two cases. Med Oral
Patol Oral Cir Bucal. 2006;11(2):E185-7.
Funding: None 14. Santos PP, Freitas VS, Freitas Rde A, Pinto
Conflicts of Interests: No conflicts of interests. LP, Souza LB. Botryoid odontogenic cyst: a
clinicopathologic study of 10 cases. Ann Diagn
Ethical Permission: Not required. Pathol. 2011;15(4):221-4.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 75
15. Gurol M, Burkes EJ, Jr., Jacoway J. Botryoid 17. Eliasson S, Isacsson G, Kondell PA. Lateral
odontogenic cyst: analysis of 33 cases. J periodontal cysts. Clinical, radiographical and
Periodontol. 1995;66(12):1069-73. histopathological findings. Int J Oral Maxillofac
16. Hethcox JM, Mackey SA, Fowler CB, Kirkpatrick Surg. 1989;18(4):191-3.
TC, Deas DE. Case report: Diagnosis and treatment 18. Farina VH, Brandao AA, Almeida JD, Cabral
of a botryoid odontogenic cyst found in the maxillary LA. Clinical and histologic features of botryoid
anterior region. J Endod. 2010;36(4):751-4. odontogenic cyst: a case report. J Med Case Rep.
2010;4:260.
76 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Investigation of a Food Poisoning Outbreak in a

Private Hostel in Kanchipuram District, Tamilnadu

Jayashri Damodharan1, Prashanth Rajendiran1, Charumathi Boominathan1,

Muthulakshmi Muthiah2, Gomathy Parasuraman3, Ruma Dutta3, Timsi Jain4
1Postgraduate, 2Assistant
Professor, 3Associate Professor, 4Professor & Head,
Department of Community Medicine, Saveetha Medical College, Chennai, India

Abstract
Food borne disease can be defined as any disease of an infectious or toxic nature caused by the consumption
of food or water(1). The investigation was carried out after receiving information on food poisoning cases
from the RMO of SMCH among the inmates of a private women’s hostel.

Methodology: Epidemiological case sheet was prepared and details from the affected individuals were
obtained. On the same day, the kitchen and the mess were inspected and food handlers were examined.

Findings of the Outbreak: During the investigation, it was found that among the 120 inmates who
consumed the dinner, 79(65.8%) inmates developed symptoms of food poisoning and 41(34.2%) inmates
did not develop any symptoms. Diarrhea, abdominal pain, fever, headache, nausea and vomiting were the
symptoms and the incubation period ranged between 3–38 hours.

Among those who developed symptoms, 30(37.9%) inmates were hospitalised for conservative management
while 49(62.1%) inmates rested in the hostel, resorted to self medications. All of them completely recovered
within 3 days.

Conclusion: Curd rice is the food item suspected to be contaminated and probable source for food poisoning
outbreak. Based on the signs and symptoms of the inmates, incubation period ranging between 3–38 hours,
enquiry findings and clinical examination of the employees presumably the suspected causative agent of the
outbreak could be due to Salmonella.

Keywords: Food poisoning, Outbreak investigation, Attack rate, Attributable risk.

Introduction occur in closed communities where food is prepared and

served centrally for a sizable population(3). Outbreaks
Food poisoning is an acute gastroenteritis caused
of food poisoning are recognized by a large number of
by ingestion of food or drink contaminated with either
persons affected at the same time, similarity of signs and
living bacteria or their toxins or inorganic chemical
symptoms and history of ingestion of common meal(4).
substances and poisons derived from plants and
As people increasingly consume food prepared outside
animals(2). Outbreaks of food poisoning commonly
the home, growing numbers are potentially exposed to
the risks of poor hygiene in commercial food service
settings(5).
Corresponding Author: Methodology: The investigation was carried out
Dr. Gomathy Parasuraman after receiving information on food poisoning cases
Associate Professor, Department of Community from the RMO of SMCH among the inmates of a private
Medicine, Saveetha Medical College, Chennai, India women’s hostel.
e-mail: [email protected]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 77
Verification of the Diagnosis: The illness was the subjects was 22 years; ranged between 18–30 years
confirmed by the doctor at the hospital and based on their and all belonged to upper middle class. Among those
symptoms; preliminary case history the investigation who remained in the hostel, 126 inmates consumed food
was done. served in the mess while 10 inmates did not consume
food in the mess.
Confirmation of the Outbreak: The information
on symptoms and type of food consumed was gathered Among those who consumed food in the mess, 120
from the patients at the hospital. On the same afternoon, inmates consumed dinner on 15 January 2018; 79(65.8%)
the two women’s hostels were visited and details from inmates developed symptoms of food poisoning while
all individuals who had taken food in the mess were 41(34.2%) inmates did not develop any symptoms. Only
obtained. On the same day, the kitchen and the mess breakfast was consumed by 6 inmates served on 16
were inspected and clinical examination of food handlers January 2018 and did not develop any symptoms. The
was conducted. detail of population at risk is given in Figure 1.

Description of Cases in terms of Time, Place,

and Person: A case is defined as gastrointestinal illness
in any resident of the hostel who as a previously well
individual developed diarrhea or vomiting with or
without abdominal pain, fever, headache within two
days of consuming food in the hostel mess.

Epidemiological case sheet was developed; through

interview method the details on demographic information,
food items eaten, quantity of food consumed, time of
exposure, presenting symptoms, time of onset of initial
symptom and time of reporting, treatment and history of
consumption of water or food outside the mess and were
obtained from the inmates.

Survey was undertaken to assess the hygiene and

sanitation of the kitchen. Details of food processing,
food preparation and storage of prepared food were
ascertained by interviewing food handlers. Medical
examination of food handlers was conducted.
Figure 1: Detail of population at risk
Sample Handling and Processing: Stool
samples were collected from those consented for the Dinner, breakfast prepared in the common kitchen
microbiological examination. Food samples were are sent to the mess of two hostels. However symptoms
not available for analysis. Water (drinking, cooking of food poisoning were reported only by the inmates of
purposes) from the premises of both the hostels; mess Hostel–1 while the inmates from Hostel–2 did not report
and kitchen were collected and analyzed for residual any symptoms.
chlorine and bacteriological examination.
Diarrhea, abdominal pain, fever, headache, nausea
Data Analysis: Data analysis was done using SPSS and vomiting were the symptoms suffered by the subjects
16.0 version. Attack rate, Relative risk and Attributable after the consumption of food and details are given in
risk were calculated for each food item to establish an Table 1. Incubation period ranged between 3–38 hours(6)
association with the illness. and median incubation period was 16 hours.

Results and Discussion

During the investigation, it was found there were
530 inmates in the Hostel–I. As it was festival holidays,
136 of them remained in the hostel. The mean age of
78 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 1: Details of symptoms suffered by the loose stools–10 episodes, watery, not mixed with mucus,
inmates of Hostel-1 not blood stained, vomited food particles (1 episode),
high grade fever associated with chills and abdominal
Frequency Percentage pain, got admitted on 16th January at 9.30PM
S.No Symptoms
(N=126)* (%)
1 Diarrhoea 79 62.7 The index case consumed the food at 7PM and
2 Fever 59 46.8 developed symptoms at 9AM; incubation period of 14
3 Vomiting 51 40.4 hours. The subject complained of passing loose stools–4
4 Abdominal Pain 39 31 episodes, watery, not mixed with mucus, not blood
5 Nausea 19 15.1 stained, vomited food particles (3 episodes), high grade
6 Headache 17 13.5 fever associated with chills, got admitted on 16th January
at 4PM.
*Mutliple responses for each variable–hence percentage will not
sum up to 100% Epidemic curve of the outbreak investigation
The suspected primary case consumed the food at showed a “common vehicle point exposure”(7) curve
7PM and developed symptoms at 10PM; incubation typical of food poisoning is given in Figure–2.
period of 3 hours. The subject complained of passing

Figure 2: Epidemic curve of the outbreak investigation

Among those who developed the symptoms, prepared at 5PM; stored for 2 hours. Uppuma, coconut
30(37.9%) inmates were hospitalised for conservative chutney was prepared at 5AM; stored for 2 hours. Food
management while 49(62.1%) inmates rested in prepared in common kitchen was distributed in trolleys
the hostel, resorted to self medications. All of them in closed containers to the serving area. Food was not
completely recovered within 3 days. Stool examination re–heated before serving.
(only four patients consented)–there was no ova/cyst.
The main course of the dinner was served by a staff
Dinner comprising of tomato rice, curd rice, egg, employed in the mess while the other items of the platter
kuruma was served between 7PM–9PM and breakfast were self served by the inmates using a common laddle.
comprising of uppuma, coconut chutney was served However, according to the food handlers they wear
between 7AM–9AM. Tomato rice, kuruma, egg was aprons and caps while cooking or dispensing food. The
prepared at 3PM; stored for 4 hours while curd rice was details of risk estimation are given in Table 2.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 79
Table 2: Details of Estimation of Risk of the Population at Risk (N = 126)

Consumed Not Consumed

Relative Risk Attributable
Total Symptoms Attack Total not Symptoms Attack Risk
Food Item (95% CI for
consumed Present Rate consumed Present Rate
RR)
N* N* % N* N* % %
1.109
Tomato rice 112 71 63.4 14 8 57.1 9.9
0.690–1.784
2.678
Curd rice 75 63 84 51 16 31.4 62.6
1.763–4.066
1.218
Egg 64 44 68.8 62 35 56.5 17.8
0.926–1.602
1.135
Kuruma 63 42 66.7 63 37 58.7 11.9
0.866–1.488
1.227
Uppuma 67 46 68.7 59 33 55.9 18.6
0.929–1.621
1.135
Coconut chutney 35 24 68.6 91 55 60.4 11.9
0.858–1.500

*Mutliple responses for each variable

Inspection of the kitchen: Kitchen is located 100 stacked up in the stand. Drinking water (RO supply) is
metres away from both the hostels. Water–RO supply present and the maintenance is done once in a fortnight.
(cooking) is present, maintenance is done once in a
fortnight. Separate store area is present in the mess where dry
items like pickles, papads are stored Separate wash area
Separate store area is present near the kitchen where for washing hands, plates, vessels is present and it is
the vegetables, groceries are stored. Refrigerator is clean.
available to store dairy products but temperature log is
not maintained. Water (drinking and cooking purposes) collected
from the premises of both the hostels; mess and kitchen
Liquid waste disposal and solid waste disposal are were sent for microbiological analysis. There was no
indiscriminate. Flies nuisance are present. Separate wash growth after 3 days in the water samples. Food samples
area for cleaning vessels is present, which was found to were not available for analysis.
be untidy.
Clinical examination of the food handlers: Cook
Inspection of the mess of both the hostels: and the person who served the food in the mess were
Separate serving areas are present with adequate lighting employed for the past 1 year and the details of clinical
and ventilation. The floor and walls are clean. Tables, examination are given in Table 3.
chairs are adequate and clean. Plates are cleaned and

Table 3: Details of clinical examination of the food handlers

Characteristic Details of the Cook Details of the food handler

Personal Habits Satisfactory Satisfactory
Smoking, alcohol consumption, Use of Smoking, alcohol consumption, Use of
Personal history
pan present pan present
General examination Satisfactory Satisfactory
Clinical findings suggestive for infections None None
Last medical check up Not aware Not aware
80 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Possible Diagnosis: Curd rice is suspected to References
be the probable source for food poisoning outbreak.
1. Sudershan RV, Kumar RN, Kashinath L, Bhaskar V,
(Attack rate = 84%, relative risk = 2.678, 95% CI for
Polasa K. Foodborne infections and intoxications in
RR (1.763–4.066) and attributable risk = 62.6%). As the
Hyderabad India. Epidemiol Res Int 2014;2014:5.
inmates in hostel–2 were symptom free, probable source
of contamination could be at the distribution system or 2. Bhalwar R. Public Health and Preventive Medicine
where the food was served. for the Indian Armed Forces. 8th ed. Pune: Dept of
Community Medicine AFMC; 2008.
Given the signs and symptoms, incubation period 3. Kunwar R, Singh H, Mangla V, Hiremath R.
ranging between 3–38 hours, enquiry findings, clinical Outbreak investigation: Salmonella food poisoning.
examination of the employees presumably the suspected Med J Armed Forces India 2013;69:388‑91.
causative agent of the outbreak could be Salmonella(8,9)
4. Jadhav SL, Sinha AK, Banerjee A, Chawla PS.
An outbreak of food poisoning in a military
Conclusion
establishment. Med J Armed Forces India
Food poisoning outbreaks are common when 2007;63:130‑3.
adequate measures of food safety guidelines are not
5. World Health Organization 2008, Food borne
followed. Due to the lack of appropriate samples,
disease outbreaks: Guidelines for investigation and
causative organism could not be isolated. However,
control, accessed on 05 April 2019
clinico epidemiological evidence is suggestive of
6. Grewal VS, Khera A. Outbreak of food poisoning
Salmonella. This investigation revealed it is essential
in a working men’s hostel: A retrospective cohort
to lay emphasis on food hygiene, adequate and proper
study. Med J DY Patil Vidyapeeth 2017;10:517-21.
storage, education of food handlers on food handling
techniques, safe distribution system, and improved 7. Park K. Park’s Textbook of Preventive and Social
sanitary conditions with scrupulous surveillance Medicine. 24th ed. Jabalpur: M/S Banarsidas
systems. Bhanot; 2017.
8. Nagarajan Prabhu, Danialas Joseph Pushpa
Ethics Clearance: Obtained from the Institutional
Innocent, Asirvatham Alwin Robert. Prevalence of
Ethical Committee of Saveetha Medical College
Salmonella typhimurium infection related to street
Source of Funding: Self food consumption. Int.J.Curr. Microbiol.App.Sci
(2013) 2(12): 396-403
Conflict of Interest: None 9. Kumar MK, Bhaskar V, Ray S. Food poisoning
outbreak in a training establishment: A retrospective
cohort study. J Mar Med Soc 2017;19:28-33.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 81

A Review on Process of Data Mining Approaches in

Healthcare Sectors

K. Baalaji1, V. Khanaa2
1Research Scholar Dept of Computer Science, 2Dean-Information Technology,
Dept. of IT, Bharath University, Chennai

Abstract
Data Mining is one of the foremost motivating areas of research that is become additional and more wide
unfolds in health organization. Processing plays an awfully vital role for uncovering new trends in health
care organization that in turn helpful for all the parties associated with this field. This survey explores
the utility of various processing techniques like classification, clustering, association, regression in health
domain. Throughout this paper, we have a tendency to tend to gift a brief introduction of these techniques
and their blessings and drawbacks. This survey together highlights applications, challenges and future
issues with processing in health care. Recommendation with reference to the suitable choice of accessible
processing technique is in addition mentioned throughout this paper. A Clinical information Repository will
be used within the hospital setting to trace prescribing trends in addition as for the looking of infectious
diseases. One area CDR’s would possibly likely be used is looking the prescribing of antibiotics in hospitals
significantly as a result ofthe range of antibiotic- resistant microorganism is ever increasing. In 1995, a study
at the letter Israel deacon centre conducted by the Harvard graduate school used a CDR to observe antibiotic
use and prescribing trends since vancomycin-resistant enterococci is also a growing draw back. They used
the CDR to trace the prescribing by linking the individual patient, medication, and thus the biology science
laboratory results that were all contained at intervals the CDR.

Keywords: Data Mining, Classification, Clustering, Association, Healthcare.

Introduction many advantages like detection of the fraud in

insurance,accessibility of medical answer to the
Data Mining is one in all the foremost very
patients at lower value, detection of causes of diseases
important and motivating space of analysis with the
and identification of medical treatment strategies. It
target of finding purposeful data from Brobdingnagian
additionally helps the attention researchers for
knowledge sets. In gift era, data processing is changing
creating economical attention policies, constructing drug
into fashionable in attention field as a result of there’s
recommendation systems, developing health profiles
a requirement of economical analytical methodology
of people etc. the information generated by the health
for detective work unknown and valuable data in health
organizations is incredibly large and sophisticated owing
knowledge.
to that it’s troublesome to investigate the information so
According to DiviyaTomar and Sonaliagarwalet, as to createvital call relating to patient health1.
al., 2013, in health business, data processing provides
Data processing techniques {are also accustomed
analyze the varied factors that are liable for diseases as
an example kind of food, completely different operating
Corresponding Author:
atmosphere, education level, living conditions,
K. Baalaji
accessibility of pure water, health care services, cultural,
Research Scholar Dept. of Computer Science, Bharath
environmental and agricultural factors.
University, Chennai, Tamilnadu, India
e-mail: [email protected] Data Mining: Data Mining came into existence
82 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
within the middle of 1990’s and appeared as a strong tool data processing is one in every of the foremost necessary
that’s appropriate for attractive antecedently unknown stages of the KDD process In line with Fayyad et al.,
pat larid and helpful data from Brobdingnagian data the information discovery method area unit structured
set2. Numerous studies highlighted that data processing in numerous stages wherever as the primary stage is
techniques facilitate information holder to investigate information choice where information is collected from
and find out unexpected relationship among their data numerous sources, the second stage is pre - process
that successively useful for creating call3. of the chosen information, the third stage is that the
transformation of the info into applicable format for
In general, data and information Discovery in additional process, the fourth stage is data processing
Databases (KDD) area unit connected terms and area wherever appropriate data processing technique is
unit used interchangeably however several researchers applied data for extracting valuable information and
assume that each terms area unit completely different as analysis is that the last stage as shown in Figure 14.

Figure 1: Stages of Knowledge Discovery Process

Skills and data are essential demand for performing up clinical care through group action the temporal and
arts the info Mining task as a result of the success and flat aspects 8.
failure of knowledge Mining comes is greatly addicted
to the one who ar managing the method as a result of In gift era varied public and personal tending
inconvenience of normal framework5. CRISP-DM institutes square measure manufacturing hugeamounts
(CRoss trade normal method for data processing) of information that square measure troublesome to
provides a framework for concluding information Mining handle. So, there’s a desire of powerful machine-driven
activities. CRISP-DM divides the info mining task into data processing tools for analysis and deciphering the
six phases6. The primary part is that the understanding helpful info from this knowledge9.
of the business activities whereas the info for concluding Classification: Classification divides information
business activities are collected and analyzed within the samples into target categories. The category technique
second part7. Information pre-processing and modelling predicts the target class for every information points.
is completed within the third and fourth part severally. for instance, patient are often classified as “high risk”
Fifth part evaluates the model and last part is to blame or “low risk” patient on the idea of their sickness pattern
for preparation of the construed model. McGregor et al., exploitation information classification approach10.
projected associate extended CRISP-DM framework for
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 83
It’s a supervised learning approach having best- multiclass issues . The support vector machine classifier
known category classes. Binary and construction area creates a hyper plane or multiple hyper planes in high
unit the 2 ways of classification. In binary classification, dimensional house that’s helpful for classification,
solely 2 potential categories like, “high” or “low” risk regression and different economical tasks13.
patient is also thought-about whereas the multiclass
approach has over 2 targets for instance, “high”, SVM have several engaging options owing
“medium” and “low” risk patient. information set is to this it’s gaining quality and have promising empirical
divided as coaching and testing dataset. performance used SVM classification approach for
classification of assorted diseases and SVM along side
K-Nearest Neighbour (K-NN): K-Nearest k-meansbunch was applied on microarray information
Neighbour (K-NN) classifier is one in all the only for distinctive the diseases. SVM is one amongst the
classifier that discovers the unidentifiedin formation foremost widespread approaches that area unit utilized
exploitation the antecedently best-known information by scientist in attention field for classification. Fei
points (nearest neighbour) and classified information planned Particle Swarm improvement SVM (PSO-
points in keeping with the legal system . K-NN classifies SVM) approach for analyzing heart disease and build a
the information points exploitation over one nearest prophetical model for carcinoma designation exploitation
neighbour11. K-NN contains a range of applications in hybrid SVM primarily based strategy.
numerous areas like health datasets, image field, cluster
analysis, pattern recognition, on-line selling etc. Jen et E.Avci planned a system exploitation genetic SVM
al., used K-NN and Linear Discriminate Analysis (LDA) classifier for analyzing the center valve malady. this
for classification of chronic sickness so as to come up technique extracts the vital feature and classifies the
with early warning system. signal obatined from the ultrasound of heart valve.

Decision Tree (DT): DT associate degree alogous An ensemble neural network methodology is
to the flow chart within which each non-leaf nodes planned by Das et al., for diagnosing of cardiovascular
denotes a check on a specific attribute and each branch disease so as to develop effective call network used ANN
denotes an outcome of that check and each leaf node for locating the respiratory organ diseases. This analysis
have a category label. The node at the highest most work analyze the chest computed axial tomography (CT)
labels within the tree is named root node. For instance and extract important respiratory organ tissue feature to
we’ve a financial organization call tree that is employed cut back the information size from the Chest CT and so
to choose that someone should grant the loan or not. extracted matter attributes got to neural network as input
Building a call for any drawback does not would like any to get the assorted diseases relating to respiratory organ .
variety of domain data. call Trees could be a classifier Clustering: Clustering is associate unattended
that use tree-like graph. The foremost common use of learning methodology that’s completely different
call Tree is in research analysis for shrewd conditional from classification. Clump is not like to classification
chances12. since it’s no predefined categories. In clump massive
The additional improvement of the prevailing call info square measure separated into the shape of tiny
tree model to classify totally different activities of completely different subgroups or clusters14. Clump
patients in additional correct manner. Within the similar divided the information points supported the similarity
domain, Moon et al. exemplify the patterns of smoking live. Clump approach is employed to spot similarities
in adults victimization call tree for higher understanding between information points. Every information points
the health condition, distress, demographic and alcohol at intervals an equivalent cluster square measure having
. Chang et al., additionally used associate integrated call bigger similarity as compare to the information points
tree model for characterize the skin diseases in adults belongs to alternative cluster.
and kids. Partitioned clump: In this clump methodology
Support Vector Machine (SVM): The thought of the information sets having ‘n’ data points divided into
SVM that is predicated on applied math learning theory . ‘k’ teams or clusters. Every cluster has a minimum of
SVMs were at the start developed for binary classification one datum and every datum should belong to only 1
however it may well be with efficiency extended for cluster. During this clump approach there’s a necessity
to outline the quantity of cluster before partitioning the
84 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
datasets into teams. supported the selection of cluster these rules, this analysis discovered the factors that cause
centre of mass and similarity live, partition clump heart downside in men and girls. when analyzing the
methodology is split into 2 categories-K-means and principles authors conclude that girls have less chance
K-Mediods. K-Means clump approach is one among the of getting coronary heart condition as compare to men .
foremost wide used approach that partition the given ‘n’
information points into ‘k’ cluster supported similarity Data Mining Challenges in Healthcare: One of the
live in such the simplest way that information points foremost important challenges of the information mining
belong to an equivalent cluster have high similarity as in health care is to get the standard and relevant medical
compare to the information points of alternative cluster data. It’s troublesome to accumulate the precise and
. It initial selects the k-centroid willy-nilly so assign the complete health care information. Health information
information points to those ‘k’ centre of mass supported is advanced and heterogeneous in nature as a result of
some similarity live. for each iteration, a knowledge it’s collected from varied sources like from the medical
purpose is handed over to the cluster supported similarity reports of laboratory, from the discussion with patient
of cluster mean (the distance between the information or from the review of doctor. For health care supplier,
points) . The most recent mean is calculated and this it’s essential to keep up the standard of information
step is recurred to accommodate each freshly arrived as a result of this data is beneficial to supply value
information points. effective health care treatments to the patients. Health
Care finance Administration maintains the minimum
Density primarily-based agglomeration: The information set (MDS) that is recorded by all hospitals.
problem with partition and hierarchical agglomeration In MDS there square measure three hundred queries
technique is that they’ll handle solely spherical formed that square measure answered by the patients at arrival
cluster and don’t seem to be appropriate for locating time. However this method is advanced and patients face
cluster of whimsical shapes. downside to retort the complete queries. So, it’s essential
to keep upthe standard and accuracy information for data
Density agglomeration ways take away this downside processing to creating effective call.
and expeditiously handle outliers and whimsical formed
cluster15. DBSCAN and OPTICS area unit 2 approach Conclusion and Future Issues
of Density primarily based agglomeration that discover
cluster on the idea of density property analysis. The purpose of this section is to produce AN
DENCLUE is another approach of density primarily insight towards needs of health domain and regarding
based agglomeration ways that kind the grouping of appropriate selection of obtainable technique. Following
knowledge points on the idea of distribution price ar the rule for exploitation totally different data
analysis of density operate . processing techniques:

Association Association is one in every of the • Before applying classification technique there’s
foremost very important approach of information a necessity to acknowledge the redundant and
mining that’s accustomed establish the frequent patterns, inappropriate attributes as a result of these attributes
fascinating relationships among a of information things act as a noise and outlier that successively hamper
within the data repository. it’s additionally referred to the process task.
as market basket analysis as a result of its capability of • These attributes conjointly had AN adverse have
discovering the association among purchased item or an effect on the performance of classifier. Applied
unknown patterns of sales of consumers in an exceedingly mathematics ways are used for recognizing these
group action info. for instance if a client is shopping for attributes. On the opposite hand the foremost
a pc then the prospect of shopping for antivirus software relevant and helpful attributes is recognized by
system is high. This info helps the merchandiser to more feature choice ways that successively enhance the
enhance their sales16. Association additionally hasnice performance and accuracy of classification model.
impact within the aid field to observe the relationships
• We have a tendency to conjointly analyzed that
among diseases, health state and symptomsused Apriori,
there’s no single classifier that turn out best result
prophetical apriori for generating the principles for heart
for each dataset. So as to examine the performance
condition patients. during this analysis work rules square
of classifier, a dataset is split into 2 parts-coaching
measure created for healthy and sick folks. supported
and testing. So, a classifier is chosen only if it turn
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 85
out higher performance among all classifiers. The 7. C. McGregor, C. Christina and J. Andrew, “A
performance of a classifier is evaluated exploitation process mining driven framework for clinical
testing knowledge set. guideline improvement in critical care”, Learning
from Medical Data Streams 13th Conference on
• However there is drawback with testing knowledge
Artificial Intelligence in Medicine (LEMEDS).
set. It slow it’s complicated and a few time it
2012; 765 (1) : 13-14.
becomes simple to classify the testing knowledge
set. The performance of classifier depends on testing 8. M. Silver, T. Sakara, H. C. Su, C. Herman, S. B.
knowledge set. Dolins and M. J. O’shea, “Case study: how to
apply data mining techniques in a healthcare data
• To avoid these issues we are able to use cross warehouse”, Healthc. Inf. Manage. 2001; 15 (2):
validation technique so each record o f 155-164.
information set is employed for each coaching and
9. P. R. Harper, “A review and comparison of
testing.
classification algorithms for medical decision
Ethical Clearance: Since the article is based on making”, Health Policy. 2005; 7 (1) : 315-331.
review studies there is no need of clearance. 10. V. S. Stel, S. M. Pluijm, D. J. Deeg, J. H. Smit,
Source of Funding: Self. L. M. Bouter and P. Lips, “A classification tree for
predicting recurrent falling in community-dwelling
Conflict of Interest: Nil. older persons”, J. Am. Geriatr. Soc., 2003; 51 (1) :
1356-1364.
References 11. R. Bellazzi and B. Zupan, “Predictive data mining
1. H. C. Koh and G. Tan, “Data Mining Application in clinical medicine: current issues and guidelines”,
in Healthcare”, Journal of Healthcare Information Int. J. Med. Inform., 2008; 77 (1) : 81-97.
Management. 2005; 19 (2) : 51- 56. 12. R. D. Canlas Jr., “Data Mining in Healthcare:Current
2. R. Kandwal, P. K. Garg and R. D. Garg, “Health Applications and Issues” Healthc. Inf. Manage.
GIS and HIV/AIDS studies: Perspective and 2009; 1 (1) : 56.
retrospective”, Journal of Biomedical Informatics. 13. F. Hosseinkhah, H. Ashktorab, R. Veen, M. M.
2009; 4 (2) : 748-755. Owrang O., “Challenges in Data Mining on Medical
3. D. Hand, H. Mannila and P. Smyth, “Principles of Databases”, IGI Global. 2009; 1 (1) : 502-511.
data mining”, MIT. 2001; 1(1); 10-16. 14. M. Kumari and S. Godara, “Comparative
4. U. Fayyad, G. Piatetsky-Shapiro and P. Smyth, Study of Data Mining Classification Method in
“The KDD process of extracting useful knowledge Cardiovascular Disease Prediction”, Int.J. Comp.
form volumes of data.commun.”, ACM. 1996; 39 Science & Tech .2011; 2 (2) : 72-76 .
(11) : 27-34. 15. J. Soni, U. Ansari, D. Sharma and S. Soni,
5. J. Han and M. Kamber, “Data mining: concepts “Predictive Data Mining for Medical Diagnosis:
and techniques”, 2nd ed. The Morgan Kaufmann An Overview of Heart Disease Prediction” Int. J.
Series. 2006; 1 (2) : 21-23. Med. Inform. 2011; 1 (1) : 113-115.
6. U. Fayyad, G. Piatetsky-Shapiro and P. Smyth, 16. C. S. Dangare and S. S. Apte, “Improved Study
“From data mining to knowledge discovery in of Heart Disease Prediction System Using Data
databases”, Commun. ACM. 1996; 39 (11) : 24-26. Mining Classification Techniques”, Int. J. Med.
Inform. 2012; 1 (2) : 87-90.
86 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Prevalence of Musculoskeletal Pain among

Manual Drummers and Electric Pad Drummers

K. Jothi Prasanna1, S. Rahul Prabhu2

1Assistant Professor, SRM College of Phsiotherapy, 2Student, SRM College of Physiotherapy

Abstract
Background: Work-related musculoskeletal problems exists almost in every areas that cause pain, disability
and loss of employment . Although performing arts medicine is a growing field, the health problems of
musicians remain under-recognized and under-researched. In order to play their instrument, musicians need
to frequently repeat physically strenuous movements which has a dramatic impact on physical mobility
and function. Musculoskeletal problems among instrumental musicians are common which occurs in both
men and women. This study examines professionals who play musical instruments especially drums who
are potentially at risk of developing problems, including pain and injuries related to their playing activities.

Objective: To find out the prevalence of musculoskeletal discomfort among manual drummers and electric
pad drummers.

Study Design: Observational study design, comparative type.

Procedure: 60 subjects were selected based on inclusion and exclusion criteria and among them 30 manual
drummers and 30 electric pad drummers were seggregated into two groups, aged between 15-35 years of both
men and women were given a format of Musculoskeletal Pain Intensity And Pain Interference Questionnaire
for Musicians (MPIPIQM) which depicts the prevalence of both pain intensity and interference of drummers.

Results: Results were analysed the IBM SPSS version 20 software. The statistical tool used in the study was
the WILLCOXON SIGNED RANKS TEST to compare both the group data which gives the mean value
of 5.45 for manual drummers and the mean value of 1.97 for the electric pad drummers pain intensity and
interference score.

Conclusion: The study concludes that the manual drummers have more pronounced musculoskeletal pain
intensity and interference when compared to that of the electric pad drummers.

Keywords: Musicians, Musculoskeletal problems, Pain intensity and Pain Interference Questionnaire,
Drummers.

Introduction Like other occupations, musicians also suffer from

work related musculoskeletal disorders which are
Music is the most essential ingredient of any
often disabling 1,2 Since the occupation of instrumental
entertainment. In order to create successful entertaining
musicians involves playing musical instruments,
event musicians plays an imperative role. Musicians are
therefore, work related musculoskeletal disorders are
enchanters who spread the fragrance of joy by absorbing
called as Playing Related Musculoskeletal Disorders
woes, in the form of Playing Related Musculoskeletal
(PRMDs)3.
Disorders (PRMDs), for themselves. Most professional
classical musicians will suffer at some time during their Playing musical instrument requires technical
career from a musculoskeletal disorder (MSD). As many precision, repetitive and striking movements and is
as 12% of them have been reported to give up their often performed in constrained posture for longer period
profession permanently. of time1,5. All types of instrumental musicians (string,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 87
drums, woodwind, brass and percussionists) are prone the instruments by sitting as well as standing also,but
to Playing Related Musculoskeletal Disorders .6A high in manual drummers the musicians should have a sitting
prevalence of work-related musculoskeletal disorders posture so that the rhythm comes fine. The manual drums
has been found in musicians, ranging from 73.4% to also consists of double bass were both the limbs are used
87.7%.7 to play the instrument.

The term “Musculoskeletal disorders“includes The frequently used body parts in playing these
wide range of inflammatory and degenerative condition instruments are the upper and lower limb, wrist, elbow
affecting the muscles,tendons,ligaments,joints,periphe and fingers. Comparing these two drummers, manual
ral nerves and supporting blood vessel. These include drummers turn their whole body to play the instruments
clinical syndromes such as tendon inflammation and so the beats are clear and perfect, while the electric pad
related conditions and standardized conditions such as drummers don’t rotate their body and they can adjust
myalgia, low back pain, and neck pain. their instrument according to their comfort.

Musculoskeletal disorders are put into different There are very few studies in India done on
categories according to pain location. One category musicians’ especially on drummers and also there are
is upper limb disorders which includes any injury or no specific studies focussing on the different types of
disorder located from fingers to shoulder or the neck. drummers. In today’s world, as music has evolved,
Another category is lower limb disorders which include the pressure on drummers has increased. A drummer
injury and disorders from hip to toe. must have increasingly more speed, control, power
and endurance in order to be exceptional, but very few
Drummers represent one of the largest and fastest studies have been done to address the injuries faced
growing among professional musicians. The drum by them. Thus the study aimed to find the prevalence
is the member of the percussion group of musical of playing related musculoskeletal discomfort among
instruments. Playing drums requires effort, speed and manual and electric pad drummers.
highly repetitive movements. Drumming is a very
demanding and dynamic activity requires a tremendous Procedure: Thisstudy commenced after getting
amount of muscle conditioning, endurance, strength and clearance from the Institutional Ethical Committee and
coordination. was conducted in various music academies and schools.
Thestudy design is Non Experimental Design, study
Learning to play a musical instrument is one of the type is observational type, sample size is 60, sampling
most complex tasks that the human body can perform method was convenient sampling and the study setting
with muscles, joints and nerves often operating above its isMusic academy. The participants who fulfilled the
normal capacity. inclusion criteria (Age: 15-35 years, Experience of 1 year
To become a professionalist in drumming it needs and above, both men and women) and exclusion criteria
long hours of practice and should perform the same (History of pain in both upper limb and lower limbs,
repetitive activity over and over again to develop the History of recent fracture. Musculoskeletal pathologies,
necessary muscle memory to perform night after night. recent injury Peripheral nerve lesions) were included in
the study, written consent form was obtained from the
Risk factors for drumming-related musculoskeletal Professional drummers after explaining the procedure,
disorders include high repetition, high force, and other the benefits of the study was said to the drummers.
factors, such as vibration.Drums is usually played by
striking with the hand or with one or two sticks. Drums A sample size of 60 subjects with age group of 15-
are of two types’ manual drums and electric pad drums. 35 years, both male and female was taken, in which 30
subjectswere manual drummers and 30 subjects were
The manual drums consist of snare, high-hat, side electric pad drummers and they were asked to complete
tom, double tom and two symbols. The electric pad the questionnaire .A format of MUSCULOSKELETAL
drum consists of six small pads. PAIN INTENSITY AND PAIN INTERFERENCE
QUESTIONNAIRE FOR MUSICIANS (MPIPIQM)
These two drums have the same posture for the depicting the prevalence of pain intensity and interference
musicians,but the way of playing these instruments vary which consists of four parts that is musicians profile and
sometimes,that isthe electric pad drummers can play hours of playing, there are four questions about pain and
88 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
rest five question about the interference. The data was
recorded and tabulated.

Figure 1: Electric Pad Drum Standing Posture Figure 2: Electric Pad Drum Sitting Posture

Figure 3: Manual drum posture

Outcome Measures: Data Analysis: The collected data were tabulated

and analysed using IBM SPSS version 20 software. The
Musculoskeletal Pain Intensity and Interfrence statistical tool used in the study was the WILLCOXON
Questionnaire for Musicians: There was a substantial SIGNED RANKS TEST. The WILLCOXON SIGNED
test-retest reliability for pain intensity items (range 0.78- RANKS TEST was used to analyse and compare both
0.82) and moderate to substantial test-related reliability the groups.
for the pain interference items (range 0.56-0.76)

Table 1: Pain intensity and pain interface among manual drummers using musculoskeletal pain intensity
and interference questionnaire for musicians.

Wilcoxon Signed
Variable N Mean STD.Deviation SIG (2-Tailed)
Ranks Test
Manual drummers pain intensity 31 5.4 6.460 0.112
-1.588
Manual drummers pain interference 31 5.45 6.612
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 89
This table infers 30 samples which were taken in which the mean value of manual drummers pain intensity score
is 5.24 and the mean value of manual drummers pain interference score is 6

Table 2: Pain intensity and pain interface among electric drummers using musculoskeletal pain intensity
and interference questionnaire for musicians.

Wilcoxon Signed
Variable N Mean STD. Deviation SIG (2-Tailed)
Ranks Test
Electric pad drummers pain intensity 31 1.87 5.365 0.705
-0.378
Electric pad drummers pain interference 31 1.97 5.282

This table infers 30 samples which were taken in which the mean value of electric pad drummers pain intensity
score is 1.87 and the mean value of electric pad drummers pain interference score is 1.97 .

Table 3: Comparison of pain intensity and pain interface between manual drummers and electric drummers
using musculoskeletal pain intensity and interference questionnaire for musicians.

Wilcoxon Signed
Variable N Mean STD. Deviation SIG (2-Tailed)
Ranks Test
Manual drummers & Electric pad
31 5.45 6.612 0.007
drummers pain intensity interference
-2.716
Electric pad drummers pain intensity
31 1.97 5.282
interference

This table shows that the mean value of manual while playing the instruments. Hence this study is done
drummers pain intensity & interference score is 5.45 and to find out the prevalence of musculoskeletal problems
the mean value of electric pad drummers pain intensity among manual drummers and electric pad drummers.
& interference score is 1.97 . Drumming is characterized by involvement of several
muscle groups because it has different types of genres
Discussion which are required to play different types of beats e.g:
Work related musculoskeletal disorders have been a heavy rock song needs continuous use of double bass
widely studied over the past several decades. Several and varieties of rolls so the risk of musculoskeletal
factors such as sustained repetition, excessive force, problems is high.
static load and awkward position which paves the way Normally, the musicians suffer pain in both the
for the development of the above said disorder. limbs, mainly it takes place in both drummers, mostly
Musculoskeletal disorders are also often associated the musicians will have pain in shoulder, arm and wrist,
with psychological stress due to work environment. As and due to these problems they will have some restricted
of knowledge various researches which were done on functional activities. The health effects of vibration
musculoskeletal problems mainly focus on industry and exposure in drummers can result from extended periods
office work areas. To our knowledge there are only very of contact between a drummer and the vibrating surface
few studies done among musicians and also studies that they are exposed too.
specifically describes the playing related musculoskeletal Drummers particularly are at risk since they can be
problems among various types of drummers were found exposed to vibration through multiple body parts such as
lacking. the hands-stick-drum head, feet-pedals-bass drum head
The musicians have to perform rapid, repetitive and or hi hat or from the buttocks-seat-floor interfaces.
movements especially drummers for prolonged period Drummers can develop symptoms including back pain,
of time. Drummers have musculoskeletal pain while diminished sensation and dexterity in the hands or
playing or at rest because both the drummers have to feet, decreased grip strength, vascular injury resulting
adopt different postures during standing as well as sitting in finger blanching or “white fingers”, tendonitis or a
variety of nerve entrapment neuropathies such as carpal
90 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
tunnel syndrome. Vibration levels depend on numerous well as frequent rotation of their body, and they cannot
properties including size and weight of the drumstick, change their posture easily during the manoeuvre but
types of drums, hand grip and handle location on the stick. electric pad drummers usually can change their posture
While playing instruments, almost every musician have according to their comfort. As judged by the above
pain and discomfort but usually they have a tendency findings of the study both manual drummers and electric
of ignoring their daily complaints which results in the pad drummers have reported their pain intensity and
development of overuse injuries. interference.

This goes in hand with Steinmetz et. al. (2010) who Hence, this study concluded that the musculoskeletal
stated that insufficiencies of the postural stabilization discomfort is more pronounced in manual drummers
systems play an important role in the manifestation when compared to electric pad drummers.
of musculoskeletal pain and playing-related
musculoskeletal disorder in musicians. Conclusion
Krupagohil et al, (2016) concluded that 80% This study concludes that the musculoskeletal pain
of musicians were found to have playing related intensity and interference problems among manual
musculoskeletal disorders. Among manual drummers drummers were more when compared to electric pad
the professional players had musculoskeletal complaints drummers. Most of the musicians were aware about the
than the practicing students. This study was done among importance of warm-up and cool down exercises but
drummers from various academy and music school. only very few were found to follow it regularly.
60 professional drummers were taken which includes Also, drummers need to be made more aware
30 manual and 30 electric drummers of both male regarding Physiotherapy and its role in injury prevention
and female and the participants were asked to fill the as well as post injury rehabilitation. Simply taking a
MUSCULOSKELETAL PAIN INTENSITY AND PAIN break from an activity that has caused physical problems
INTERFRENCE QESTIONNAIRE FOR MUSICIANS, does not help to find out the underlying cause of the
which consists of four parts that is musicians profile and problem. Physiotherapy camps and seminars could be
hours of playing, then four questions about pain and rest implemented at various music schools and Institutes to
five question about the interference. help them understand the importance of Physiotherapy
In manual drum the drummers obtain sitting posture in injury prevention. Thus care should be taken and all
while playing when compared to electric drummers the musicians should be made aware of these problems
who adopts both sitting and standing posture .While and should learn to recognise such injuries at the earliest
playing the manual drums, as we observe carefully the to prevent further problems.
manual drummers have to rotate their whole body to Conflict of Interest: Authors do not have any
play the instruments so that the beats come appropriate conflicts of interest.
according to the rhythm and they also use both the
lower limbs frequently. While playing, the electric pad Source of Funding: Self
drummer does not rotate their body when compared to
manual drummers and they can adjust the height of the Ethical Clearance: Got clearance from the
instrument according to their comfortable levels. Institutional Ethical Committee.

Blanca Del Carmen florers-olivares et al, (2015) References

stated that the manual drummers adjust the height of 1. Zara C. Playing related musculoskeletal disorders
some elements of drums such symbols and snare this is in musicians: a systematic review of incidence and
done according to the dimension Most of these drummers prevalence, CMAJ. 1998 Apr 21; 158(8): 1019–
have upper and lower back pain and also complaints of 1025.
pain in shoulder, elbow, lower limbs and numbness in
2. Da Costa BR, Vieira ER. Risk factors for work-
metacarpals.
related musculoskeletal disorders: a systematic
In this study musculoskeletal pain intensity and review of recent longitudinal studies. Am J Ind
interference is more in manual drummers as reported by Med. 2010; 53: 285-323.
them that they spend more playing sessions in sitting as
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 91
3. Bragge P, Bialocerkowski A, McMeeken J. A 13. Heinan M. A review of the unique injuries sustained
systematic review of prevalence and risk factors by musicians. JAAPA. 2008; 21(48, 50):45–46
associated with playing related musculoskeletal 14. Lederman RJ. Neuromuscular and musculoskeletal
disorders in pianists. Occup Med (Lond).2006; 56: problems in instrumental musicians. Muscle Nerve.
28-38. 2003;27:549–561. doi: 10.1002/mus.10380
4. Storm SA. Assessing the instrumentalist interface: 15. Middlestadt SE, Fishbein M. The prevalence of
modifications, ergonomics and maintenance of severe musculoskeletal problems among male and
play.Phys Med RehabilClin N Am. 2006; 17: 893- female symphony orchestra string players. MPPA.
903. 1989;4:41–48.
5. Caldron PH, Calabrese LH, Clough JD, Lederman 16. Hoppmann RA, Reid RR. Musculoskeletal problems
RJ, Williams G, Leatherman J. A survey of of performing artists. Curr Opin Rheumatol.
musculoskeletal problems encountered in high- 1995;7:147–150. doi: 10.1097/00002281-
level musicians. MPPA.1986; 1: 136-139. 199503000-00014.
6. Jabusch HC, Altenmuller E. Focal dystonia in 17. Zaza C. Playing-related musculoskeletal disorders
musicians: From phenomenology to therapy. in musicians: a systematic review of incidence and
Advances in Cognitive Psychology.2006; 2: 207- prevalence. CMAJ. 1998;158:1019–1025.
220.
18. Caldron PH, Calabrese LH, Clough JD, Lederman
7. Lee HS, Park HY, Yoon JO, Kim JS, Chun JM, RJ, Williams G, Leatherman J. A survey of
Aminata IW, Cho WJ, Jeon IH. Musicians’ musculoskeletal problems encountered in high-
Medicine: Musculoskeletal problems in string level musicians. MPPA. 1986;1:136–139.
players. Clinics in orthopedic Surgery. 2013 Sep;
19. Zaza C, Charles C, Muszynski A. The meaning
5(3): 155–160
of playing-related musculoskeletal disorders to
8. Berque P. Musculoskeletal disorders affecting classical musicians. SocSci Med. 1998;47:2013–
musicians and considerations for prevention. 2023. doi: 10.1016/S0277-9536(98)00307-4
Available from: http://www.musicianshealth.
20. Roach KE, Martinez MA, Anderson N.
co.uk/musiciansmusculoskeletaldisorders.pdf
Musculoskeletal pain in student instrumentalists:
9. The Pain Disability Questionnaire: a reliability and a comparison with the general student population.
validity study.Patrícia Cantu Moreira Giordano, MPPA. 1994;9:125–130.
Neusa Maria Costa Alexandre •Roberta Cunha
22. Fry HJH, Ross P, Rutherford M. Music-related
Matheus Rodrigues • Marina ZambonOrpin.
overuse. MPPA. 1988;3:133–134.
10. A Prevalence Study Using a Validated Instrument,
23. Middlestadt SE, Fishbein M. The Prevalence of
the Musculoskeletal Pain Intensity and Interference
Severe Musculoskeletal Problems Among Male
Questionnaire for Musicians. Angus Mc Fayden,
and Female Symphony-Orchestra String Players.
Heather Graycoauth, Patrice Berque, 2016 Vol. 31
Med Probl Perform Ar. 1989;4:41–48.
No. 2
24. Zaza C, Farewell VT. Musicians’ playing-
11. Blanca del Carmen Flores-Olivares, Amalia Yoguez-
related musculoskeletal disorders: An
Seoane, Orlando Susarrey-Huerta, & Claudia del
examination of risk factors. Am J Ind
Carmen Gutiérrez-Torres. (2015). Preliminary
Med. 1997;32:292–300. doi: 10.1002/
Study on the Evaluation of Musculoskeletal Risks
(SICI)1097-0274(199709)32:3<292::AID-
through Infrared Thermography for Drummers.
AJIM16>3.0.CO;2-Q
6th International Conference on Applied Human
Factors and Ergonomics (AHFE 2015) and 25. Keijsers E, Feleus A, Miedema HS, Koes BW,
the Affiliated Conferences, AHFE 2015.3, pp. Bierma-Zeinstra SM. Psychosocial factors
4415- 4420. ELSEVIER. Retrieved from http:// predicted nonrecovery in both specific and
www.sciencedirect.com/science/article/pii/ nonspecific diagnoses at arm, neck, and shoulder.
S2351978915004436. J ClinEpidemiol. 2010;63(12):1370–1379. doi:
10.1016/j.jclinepi.2010.01.015.
12. Guptill C, Golem MB. Case study: musicians’
playing-related injuries. Work. 2008;30:307–310
92 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
26. Zetterberg C, Backlund H, Krlsson J, Werner HOL. 27. Enders L, Spector JT, Altenmuller E, Schmidt
Musculoskeletal problems among male and female A, Klein C, Jabusch HC. Musician’s dystonia
music students. MPPA. 1998; 13:160–166. and comorbid anxiety: two sides of one coin.
MovDisord. 2011;26(3):539–542. doi: 10.1002/
mds.23607.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 93

Effectiveness of Low Level Laser Therapy Versus Ultrasound

Therapy with Plantar Fascia Streching in Subjects with
Plantar Fasciitis

K. Koteeswaran1, Ramya K.2, Rajeshwari2, Manikumar Muthiah1, Sankara Kumaran Pandian3

1AssociateProfessor, 2Research Associate Saveetha College of Physiotherapy, Saveetha University,
Chennai, 3Lecturer, School of Physiotherapy, AIMST University, Bedong, Malaysia

Abstract
Aim: To find the effectiveness of low level laser therapy versus ultrasound therapy with plantar fascia
stretching in subjects with plantar fasciitis.

Materials and Method: Non equivalent quasi experimental study design was used in this study. Total of
30 subjects with plantar fasciitis were selected using non probability convenience sampling technique. 30
Subjects was divided into two groups by lot system. Group A received low level laser therapy and Group
B received ultrasound therapy and for both the group plantar fascia stretching was given. The outcome
measures are FAAM (foot ankle ability measure) and NPRS (numerical pain rating scale). Data collected
and tabulated was statistically analysed.

Result: Statistical analysis of post-test, foot and ankle ability measure questionnaire (FAAM) and NPRS
(numerical pain rating scale) revealed that there is statistically significant difference seen between Group A
and Group B.

Conclusion: From the result, it has been concluded that low level laser therapy with plantar fascia stretching
(Group A) is more effective than ultrasound therapy with plantar fascia stretching (Group B) in decreasing
pain and improving the quality of life in subjects with plantar fasciitis.

Keywords: Plantar fasciitis, low level laser therapy, ultrasound therapy.

Introduction Plantar fasciitis is a degenerative condition resulting

from compressive forces due to repeated trauma to
The human foot is a strong and complex mechanical
plantar fascia making the foot’s longitudinal arch of flat.
structure and terminal portion of the limb which bears
Traction forces during the gait on support phase leading
weight and allows locomotion.1 The plantar fascia is a
to inflammation results in fibrosis and degeneration.
dense, fibrous, connective tissue structure originating
Plantar fasciitis is the common reason for heel pain for
from the medial tuberosity of the calcaneus. It has three-
80 percentage of cases. It affects most commonly people
medial, lateral and central portions.2
who are between 40–60 years of age.3

The exact etiology of plantar fasciitis still remains

unclear but the risk factors which results in plantar
Corresponding Author: fasciitis includes overuse of plantar fascia, exercises like
Dr. Mani Kumar Muthiah ballet jumping activities, long distance running, long
Associate Professor, Svaeetha College of period of standing, obesity, pregnancy, military recruits,
Physiotherapy, Saveetha University,Chennai athletes. The patient usually complaints of pain over the
e-mail: [email protected] medial side of plantar heel, usually when taking first few
Phone: 8939164922 steps after waking up.4
94 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
The common site of pain in plantar fasciitis is near For group A Probe method (continuous) of low
to the origin of the central band of plantar Apo neurosis level laser therapy was used to treat the subjects. Safety
at the medial plantar tubercle of the calcaneus.5 precautions was taken to reduce the risk of exposure of
laser light to the eyes. Low level laser therapy was given
The windlass mechanism explains these in painful area for 3 days/week for 2 weeks. The wave
biomechanical stresses and factors. Plantar fasciitis length used in the treatment is 830nm for 9 minutes. The
forms the tie-rod that attaches from calcaneus to irradiation area include 3 point over 3cm2.
phalanges. Vertical forces from the weight of the body
travel to medial longitudinal arch in downward direction For group B Ultrasound therapy was given to the
through tibia and flattens the arch. Further, the ground subjects in the frequency of 3 MHZ in the pulsed mode
reaction forces that travel in upward direction on the (1;4) for 8 minutes with the intensity of 0.5W/cm2 for 2
calcaneus and metatarsal heads, even more leads to weeks (3days/week).
flatten of arch as these forces fall anterior and posterior
to the tibia. Plantar fascia prevent the collapse of arch by For both the group plantar fascia stretching was
its tensile force and orientation.6 given with the hold time for 20-30 seconds with the
repetaion of 10 times in the alternative days.
Plantar fasciitis tends to improve in most cases
regardless of the treatment selected. As a result Results
conservative management is effective for nearly 90% The collected data was tabulated and analyzed using
of the patient. The conservative treatments used in descriptive & inferential statistics. To all parameters
management of plantar fasciitis vary widely and are mean and standard deviation (SD) was used. Paired
dependent on physician specialty.[ t-test was used to analyse significant changes between
pre and posttest measurements. Unpaired t test was used
Methodology to analyse significant difference between the groups. P
The subjects were selected from the Saveetha value <0.05 was considered as statistically significant.
physiotherapy, outpatient department of Saveetha
medical college and hospital. 30 subjects with plantar Table 1 represents the FAAM Scale score for group
fasciitis were selected based on the inclusion and A and B. The group A pre-test mean value is 39.93%
exclusion criteria. Detailed procedure was explained (SD 7.93%) and post-test mean value is 66.87% (SD
to the subjects in the colloquial terms about the safety 7.30%).The group B pre-test mean value is 48.20%
and simplicity of the procedure. Informed concern were (SD 13.09%) and post-test mean value is 56.27% (SD
given to those who were interested to participate in this 11.81%) .This shows that FAAM Scale score values are
study. Selected subjects were randomly assigned in to gradually increasing in the group A than group B, which
two groups 15 in each group by using lottery system. is statistically significant.
The outcome measure used in this study for pain is Table 2 represents the NPRS score for group
numerical pain rating scale(NPRS) and for the quality A and B. The group A pre-test mean value is 7.47cm
of life is foot and ankle ability measure questionnaire (SD 1.19cm) and post-test mean value is 3.93cm (SD
(FAAM) respectively. For all subjects’ pre and posttest 0.80cm).The group B pre-test mean value is 6.27cm
values were calculated. (SD 0.80cm) and post-test mean value is 5.53cm (SD
Procedure: Group A Were the subjects who 0.83) .This shows that NPRS score values are gradually
received low level laser therapy along with plantar decreasing in the group A than group B, which is
fascia stretch. Group B were the subjects who received statistically significant.
ultrasound therapy along with plantar fascia stretch.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 95
Table 1: Comparison of pre and post test values of FAAM scale for group A and B

FAAM Scale Mean SD t value p value

PRE 39.93% 7.93%
Group A 38.8492 0.0001
POST 66.87% 7.30%
PRE 48.20% 13.09%
Group B 9.9896 0.0001
POST 56.27% 11.83%

Group 1: Comparison of pre and post test values of FAAM scale for group A and B

Table 2: Comparison of pre and post test values of NPRS scale for group A and B

NPRS Scale Mean SD t value p value

PRE 7.47cm 1.19cm
Group A 14.9480 0.0001
POST 3.93cm 0.80cm
PRE 6.27cm 0.80cm
Group B 4.7845 0.0003
POST 5.53cm 0.83cm

Discussion WOLGIN M, et al stated that low level laser effects

causes the stimulation of bodies own processes in
Plantar fascia is commonly a repetitive micro trauma
healing tissue by light [12]. Phototherapy increases the
overloaded injury of the attachment of plantar fascia at
both local and systemic micro circulation of the body
the inferior aspect of calcaneus.
thus it relieves pain and swelling [22]. The 2 major areas
The clinical presentation of plantar fasciitis include for which low level laser therapy is used is tissue healing
gradual insidious onset of heel pain. Pain and stiffness and pain control. Laser therapy is used for pain relief in
are worse in the morning(during first few steps) or after many conditions in both acute and long term (England
prolonged walking and increased by climbing stairs or 1998). [23] The laser therapy is found to be very effective
doing raising up activity thus impairing the activity of in various overuse tendinitis conditions. Laser has its
daily life. effect on prostaglandin synthesis and thus it relieves
inflammation. [24]. DR.ZANG said that 3 to 4 treatment
Conservative treatment for plantar fasciitis include are necessary for acute plantar fasciitis if treatment
ultrasound therapy, cryotherapy, low level laser therapy, begins 6 to 8 weeks after the onset of symptoms.
medication (steroids), stretching, foot wear modification,
manual therapy, splint, tapping and strapping. Ultrasound has been utilized for pain through
the ability of sound waves to introduce molecules of
This study compares the effectiveness of low level chemical substances through the skin by a process called
laser therapy and ultrasound therapy with plantar fascia phonophoresis [25]. Improvements in plantar fasciitis by
stretching in subjects with plantar fasciitis in terms of the application of ultrasound therapy has been reported
pain and quality of life. by Clarke and stenner (1976) [26]. The application of
ultrasound therapy for pain relief, along with plantar
The subjects with age group of 30-60 years of both
fascia stretch is commonly indicated alternative therapy
gender with plantar fasciitis were selected. 15 subjects in
for plantar fasciitis [27]. The pulsed ultrasound is believed
Group A were treated with low level laser therapy with
to have therapeutic benefits and can be applied to acute
plantar fascia stretching while 15 subjects in Group B
injuries [28]. The effects of ultrasound therapy are tissue
were treated with ultrasound therapy with plantar fascia
relaxation, increase in local blood flow, scar tissue
stretching.
breakdown. By increasing the local blood flow level it
The pre-test and post-test values of this study, reduces local swelling and inflammation. WATSON
revealed that there was a statistical difference (p<0.0005) (2006) suggested that application of ultrasound to
in both the groups in terms of pain and quality of life, but injured tissues, speed the rate of healing and enhance the
there was more improvement in Group A than Group B. quality of repair.
96 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Plantar fascia stretching reduces the tightness in 5. Thomas G. MCpoil et al. heel pain- plantar fasciitis.
the plantar fascia. Plantar fascia stretching recreates the Ortho sports phys ther. 2008:38(4): Al-A18.
windlass mechanism by decreasing the micro trauma 6. Lori A. Bolgla: Terry R. Malone- plantar fasciitis
and inflammation. Plantar fascia stretching helps in and the windlass mechanism: a biomechanical
reducing pain, improving function and gives overall link to clinical practice. Journal of athletic training
satisfaction compared to standard Achilles tendon 2004:39(1):77-82.
stretching exercises [13].
7. Nelson fong SooHOO, MD and caleb behrend,
The post mean value in this study of quality of MD. Chapter 67- what is the best treatment for
life [foot and ankle ability measure(FAAM)] and pain plantar fasciitis? 2009, pages 435-440
[numerical pain rating scale (NPRS)] score of Group A 8. Yin MC, Ye J, Yao M, Cui XJ, Xia Y, Shen QX,
treated with low level laser therapy with plantar fascia Tong ZY, Wu XQ, Ma JM, Mo W (March2014).
stretching was 66.87 and 3.93 and Group B treated with “Is Extracorporeal Shock Wave Therapy Clinical
ultrasound therapy with plantar fascia stretching was Efficacy for Relief of Chronic, Recalcitrant Plantar
56.27 and 5.33 at the end of 2 weeks. Fasciitis? A Systematic Review and Meta-Analysis
of Randomized Placebo or Active-Treatment
Hence is has been proven that the recovery is earlier Controlled Trials”. Arch Phys Med Rehabil. 95:
and faster in relieving pain and improving quality of life 1585–1593. doi:10.1016/j. apmr. 2014.01.033.
in Group A than Group B. Thus these statistical findings PMID 24662810 .
could be attributed to the fact that low level laser therapy
9. Tahririan MA, Motififard M, Tahmasebi MN,
with plantar fascia stretching works more statistically
Siavashi B (August 2012). “Plantar fasciitis” .
over ultrasound therapy with plantar fascia stretching
J Res Med Sci. 17 (8): 799–804.PMC 3687890 .
Conclusion PMID 23798950
10. Lareau CR, Sawyer GA, Wang JH, DiGiovanni
From the result, it has been concluded that low level
CW (June 2014). “Plantar and Medial Heel Pain:
laser therapy with plantar fascia stretching (Group A) is
Diagnosis and Management”. The Journal of the
more effective than ultrasound therapy with plantar fascia
American Academy of Orthopaedic Surgeons.
stretching (Group B) in reducing pain and improving
22 (6): 372–80. doi:10.5435/JAAOS-22-06-372.
quality of life in subjects with plantar fasciitis.
PMID 24860133
Ethical Clearance: Taken from Institutional 11. Brian Mccurdy. Study assesses laser treatment for
Sceintific Review Board plantar fasciitis. Journal of foot and ankle surgery.
volume 28- issues 10- October 2015. Pages 14-17.
Conflict of Interest: Nil
12. Dhia AK Jaddue M.B.Ch.B F.R.C.S (ED)
Source of Funding: Self Consultant Orthopedics Surgeon ** Ali. Sulaiman.
M. Said Al-dulaimi M.B.Ch.B FICMS (ORTHO)
Reference Orthopedics Surgeon. Using of Laser Therapy in
the Treatment of Patients With Plantar Fasciitis.
1. Neufle,s., et al plantar fasciitis; evaluation and
Al- Kindy Col Med J 2008; Vol .4 (1): p72-76
treatment . journal of the American academy of the
orthopaedic surgery, 2008,16, 338-345. 13. Benedict f. digiovanni, plantar fascia-specific
stretching exercise improves outcomes in patients
2. Sbbrotzman, clinical orthopaedic rehabilitation: A
with chronic plantar fasciitis, the journal of bone
team…., book.google.com[2017]
& joint surgery • jbjs.org volume 88-a • number 8 •
3. Renata gracile zanon, Adriana kundrat brasil, august 2006
Marta Imamura- continuous ultrasound for chronic
14. Jan magnus bjordal, P.T., ph.D, “low level laser
plantar fasciitis treatment (2006).
therapy in acute pain: a systematic review of
4. Ang Tee Lim, Choon How How, benedict Tan- possible mechanisms of action and clinical effects
management of plantar fasciitis in outpatient setting in randomized placebo–controlled trials”. Photo
(2016). medicine and laser surgery, volume 24, number 2,
2006, pg no:158-168.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 97
15. Thomas G. MCpoil et al. heel pain- plantar fasciitis. with chronic plantar fasciitis, international journal
Ortho sports phys ther. 2008:38(4): Al-A18. of clinical science, (2018).
16. alan “ultrasound treatment may be option for 22. Samoilova KA, Zhevago NA, Petrishchev NN, et
plantar fasciitis”, health day, mar 1 2018. al. Role of nitric oxide in the visible light-induced
17. Michael, H. slayton, “randomized controlled trail rapid increase of human skin microcirculation at
of intense therapeutic ultrasound for the treatment the local and systemic levels: II. Health volunteers.
of chronic plantar fasciitis, journal of foot and ankle Photomed. Laser surg 26(5), 443-449(2008)
orthopaedics, oct 6 2016. 23. John low and Ann reed “electrotherapy explained
18. Hancock, C. l., Baker, R. T., & Sorenson, E. A. principles and practice” 3rd edition 14th chapter,
(2016).treatment of plantar fascia pain with joint laser therapy pg no:356-375.
mobilizations and positional release therapy: A 24. Jagmohan singh, ph.D “textbook of electrotherapy”
case study. International journal of athletic therapy 2nd edition pg no:226-236.
& training, 21(4), 23-29. 25. Joseph khan “principles and practice of
19. Aslihan ulusoy MD. Magnetic resonance imaging electrotherapy” 4th edition, 4th chapter, ultrasound
and clinical outcomes of laser therapy, ultrasound pg no :49-68
therapy, and extracorporeal shockwave therapy 26. John low and Ann reed “electrotherapy explained
for treatment of plantar fasciitis: a randomized principles and practice” 2nd edition 6th chapter,
controlled trail. Volume 56, issues 4, july-august therapeutic ultrasound, pg no:148-178.
2017, pages 762-767.
27. Markus vinicius grecco, “1 year treatment follow
20. Cinar E, saxena S, uygur F. low level laser therapy in up of plantar fasciitis: radial shockwaves vs.
the management of plantar fasciitis: A randomized conventional physiotherapy”, clinics, 2013. pg
controlled trail. 2017 Dec 23. doi: 10.1007/s10103- no:1089-1095.
017-2423-3.
28. Paul higgins “common clinical treatment of plantar
21. Jothi prasana K, A comparison of effect of low level fasciitis. A survey of physical therapists practising
laser therapy versus ultrasound therapy in patients in the north east region”, 2012.
98 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Evaluation of Temporomandibular Disk Position In

Symptomatic Temporomandibular Disorder Patients With
Gnathological Splint Therapy Using Mri

K. Sridhar1, M.S. Kannan2, Faisaltajir3, Gnanashanmugam3

1Post Grduate, 2HOD & Professor, 3Professor, Department of Orthodontics and Dentofacial Orthopaedics, Sree
Balaji Dental College and Hospital, Bharath University, Velachery Main Road, Chennai, Tamil Nadu, India

Abstract
Objective: The aim of this study was to Evaluation of altered temporomandibular disc position in
symptomatic TMD patients with pre and post gnathological splint therapy.

Materials and Method: This study included ten patients with a mean age of 21.5 years with maxillary
transverse deficiency treated with the skeletal expander. The study consisted of 15 patients with a mean age
of 25 years with clinically symptomatic and orthodontically untreated TMD patients with splint therapy.
Statistical analysis was performed using paired t‑test.

Results: The mean AS, SS, and PS values for right TMJ that was 0.2mm (SD ±0.6mm), 0.5mm(SD±
0.3mm), 0.4mm(SD±0.1mm), respectively and the mean difference between AS, SS, and PS values for left
TMJ was 0.2mm (SD±0.1mm), 0.5mm (SD± 0.05mm), and 0.2mm (SD± 0.2mm). The ratio of AS to SS to
PS was 0.2to 0.5to 0.4, No significant sex difference was noted in joint space distances. The results showed
less variability of condylar position in the fossa than in normal subjects.

Conclusion: Gnathological splints can be used as effectiveness mean for treatment of such patients. This can
be easy made good comfort to the patients.

Keywords: TMJ, Splint, MRI, Joint space.

Introduction a much higher maximal Incisal opening than would be

possible with rotation alone. The joint is thus referred to
The temporomandibular joint (TMJ) is a compound
as “Ginglymodiarthrodial.”2 a combination of the terms
articulation of the articular surfaces of the temporal
Ginglymoid (rotation) and Arthroidal (translation).
bone and the mandibular condyle1. The TMJ functions
TMD is a prevalent disorder most commonly observed
uniquely in that the condyle both rotates within the fossa
in individuals between the ages of 20 years to 40 years.
and translates anteriorly along the articular eminence.
Approximately 33% of the population has at least one
The condyle’s ability to translate the mandible can have
TMD symptom and 3.6-7% of the population has TMD
with sufficient severity to cause them to seek treatment3.
The etiology of TMJ disorders remains unclear, but it is
likely multifactorial. Capsule inflammation or damage
Corresponding Author: and muscle pain or spasm may be caused by abnormal
Dr. K. Sridhar occlusion, parafunctional habits (e.g., bruxism, teeth
Post Grduate, Department of Orthodontics and clenching, lip biting), stress, anxiety, or abnormalities
Dentofacial Orthopaedics, Sree Balaji Dental College of the intra-articular disk. Treatment of TMJ disorders
and Hospital, Bharath University, Velachery Main are varied. But dental occlusal splinting and permanent
Road, Chennai-600100, Tamil Nadu, India occlusal adjustment have been the mainstays of TMJ
e-mail: [email protected] disorder treatment. Occlusal splint therapy may be defined
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 99
as “the art and science of establishing neuromuscular
harmony in the masticatory system by creating a
mechanical disadvantage for parafunctional forces with
removable appliances.”Conventional tomographic x rays
are commonly used to view the temporomandibular joint
area. However because of poor quality of images and
variability in interpretation of anatomic areas, it failed
to provide necessary information for diagnosing optimal
condylar position. Magnetic resonance imaging (MRI)
is a non invasive, non ionizing procedure that produces
highly sensitive and specific tomographic images in any a
plane with excellent soft tissue contrast and reduced
biologic hazards. Magnetic resonance imaging (MRI)
has become the gold standard for examination of soft
tissues of the TMJ.The purpose of the study was to
evaluation of joint spaces before and after splint therapy
by MRI5,6.

Materials and Method

The sample for the study was recruited from the
patients who reported to the Department of Orthodontics
at sreebalaji dental Dental College and Hospital. Ethical
approval was obtained from the Institutional Review
b
Board and informed written consent was obtained
from all the participants. The sample consists of fifteen Figure 1: Face bow transfer (a) frontal view (b)
patients within the age group of 22–30. profile view

Inclusion Criteria: Clicking sound in TMJ The wax bite recorded in patient’s initial CR, which
area,Tenderness of muscles of mastication, Deviation should not be mistaken for terminal CR. It is difficult to
of the lower jaw on opening, Unilateral or bilateral capture one’s true CR at chair-side during initial visit
headaches, shoulder pain and/or neck pain, Generalised a true CR can be registered only after the stabilization
attrition/mobility of teeth. Exclusion Criteria: of condylar position. Centric relation bite (Roth power
Developmental anomalies, Degenerative disc conditions, centric) [Figure 2] was taken with Delar bite registration
Orthodontically treated patients. wax in two sections, one in the anterior region and the
other in the posterior region. The patient was seated in
Splint Fabrication: The study was initiated with
the dental chair reclined at an angle of 45° to the floor. To
Maxillary and mandibular impression which were
take the anterior section, the wax (2–3 layer thickness)
taken using an irreversible hydrocolloid in sterilized
was cut in a shape and appropriate size to register from
metal rim-lock trays and poured with Type 4 Gypsum,
canine to canine. The wax was then heated until soft in a
facebow transfer, Roth’s power centric bite registration,
water bath at 138°F. The wax bite was then placed in the
centric occlusion bite registration, articulation, CO-CR
patient’s mouth extending from canine to canine. The
discrepancy. After assessing the CO-CR discrepancy
patient’s mandible was then manipulated (to CR) to make
splint was fabricated and delivered12. Face-bow transfer
an interocclusal registration in the anterior section. The
records were taken using the Axioquick Expansion Kit
patient was then instructed to close until the posterior
AX, (SAM Prazisionstechnik GmbH, Fussbergstr 1,
teeth were discluded approximately 3 mm in the area
Germany). It records the relationship of the maxilla to
of the second molars. While in the closed position, an
the cranial base [Figure 1].
air syringe was used to begin the cooling process. The
anterior record was then removed, and stored in chilled
water. The posterior section was trimmed wide enough
to include the last molar extended across the arch. The
100 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
wax was then softened and placed on the maxillary The splint was fabricated on an articulator. Upon
posterior teeth. With the posterior section in place, the closure of the arches, there were simultaneous centric
chilled anterior portion was placed back in position stops with mandibular buccal cusp. Clearance of
again. The patient was then guided in the same manner 0.0005”8 was provided for the anterior teeth. Splint was
to close into the hardened anterior segment and asked to fabricated with cold cure acrylic resin at a position with
bite as firmly as possible and hold it. This allowed the 3 mm clearance from the fulcrum. The splint was then
patient’s musculature to aid in seating the condyle in CR allowed to set for sufficient time. With the splint still
position. Both the bites were then removed and stored in not removed from the articulator, initial trimming was
chilled water. done to establish centric stops and mutually protected
functional occlusal pattern. The splint later was adjusted
in the patient’s mouth to do further trimming to establish
the same [Figure 4]. The patient was advised to wear the
splint full time9.

Figure 2: Roth power centric bite

With the help of face-bow transfer record, the

maxillary model is mounted to the articulator with
the mounting plate and mounting plaster [Figure 3].
Figure 4: Splint with centric stops
Sufficient time is allowed for the plaster to set. The
incisal guide pin is raised by 3 mm. To mount the lower Patient was recalled every month, and the splint
model, the articulator is inverted, the centric wax bites was checked for centric stops and mutually protected
are placed on the maxillary model, and the mandibular occlusal pattern each time. The mandible was checked
model is placed into the wax. A mounting plate is and guided to centric, and it was noted that each time,
fastened to the lower member of the articulator, and the the mandible exhibited lesser resistance indicating the
mandibular model is mounted, using mounting plaster reduction in muscle stiffness due to deprogramming..
or dental stone.
Measurements: The condylar joint spaces before
and after 6 months of gnathological splint therapy was
assessed by MRI

MRI:

Figure 5: Shows an measurement in MRI IMAGE

Figure 3: Mounted models of the TMJ
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 101

  
Figure 6: Pre -treatment left and Right

  
Figure 7: Post treatment left and Right

Table No.: 1: Right joint space values

Right Joint
Pre–Anterior Post–Anterior Pre- Superior Post- Superior Pre-Posterior Post-Posterior
Patient No.
Space Space Space Space Space Space
1 1.23 1.27 2.56 2.4 2.49 2.39
2 3.24 2.8 5.38 3.5 3.75 2.1
3 1.79 1.01 2.36 2.18 2.48 2.1
4 3.01 2.8 4.97 4.4 2.8 2.69
5 1.23 1.17 2.56 2.39 2.48 2.4
6 1.78 1.66 3.31 3.13 2.68 2.14
7 1.5 1.21 2.01 2.01 2.83 1.98
8 2.01 1.61 3.37 2.2 3.89 2.85
9 1.63 1.81 3.45 3.03 2.26 1.18
10 2.89 2.5 4.97 4.41 2.8 3.83
11 3.39 2.96 4.48 2.84 2.45 2.11
12 1.23 1.17 2.56 2.4 2.49 2.41
13 1.79 1.1 2.4 2.18 2.48 2.38
14 1.96 1.63 2.71 2.2 3.81 2.65
15 1.47 1.29 3.32 2.8 2.49 2.25
102 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 2: Left joint space values

Left Joint
Pre–Anterior Post–Anterior Pre- Superior Post- Superior Pre-Posterior Post-Posterior
Patient No.
Space Space Space Space Space Space
1 1.64 1.31 3.24 2.84 2.26 2.74
2 3.5 3.49 3.6 2.89 2.15 1.76
3 1.64 1.4 3.24 2.84 2.26 2.74
4 5.5 3.98 6.02 5.27 3.75 2.95
5 1.62 1.39 3.25 2.81 2.24 2.73
6 3.4 3.29 3.5 2.39 2.15 1.76
7 1.94 1.7 4.6 3.92 3.43 3.21
8 2.78 2.1 4.12 3.82 2.9 2.82
9 2.03 1.87 3.25 2.87 3.92 2.87
10 2.78 2.58 3.25 3.1 2.89 2.79
11 4.05 3.92 6.02 5.27 3.75 2.95
12 1.54 1.58 2.03 2.01 2.58 1.9
13 1.68 1.52 2.2 1.58 2.48 2.23
14 1.96 1.7 4.6 3.92 3.43 3.2
15 1.75 1.5 2.27 1.3 2.6 2.23

Table 3: Right joint space mean values compare the mean PAIRED SAMPLE t-test were
used for each measurement to evaluate the average
Mean Significant differences between the right and left side of the each
Pre vs Post Treatment (Right)
Difference P value
sample. To analyse the data SPSS (IBM SPSS Statistics
Pre treatment (AS)
0.2773 0.002 for Windows, Version 22.0, Armonk, NY: IBM Corp.
Post treatment (AS)
Released 2013) is used. Significance level is fixed as 5%
Pre treatment (SS)
0.556 0.001 (p= 0.05).
Post treatment (SS)
Pre treatment (PS)
0.448 0.005 Result
Post treatment (PS)
• Table 1 and 2 shows the pre and post treatment
Table 4: Left joint space mean values outcomes of mean value of 15 patients in terms of
change in the Anterior. Superior, Posterior joint
Mean Significant space (AS, SS and PS) (Measured in mm) in the
Pre vs Post Treatment (Left)
Difference P value
right and left side joint respectively.
Pre treatment (A)
0.2987 0.001 • Table 3 and 4 shows the mean difference between
Post treatment (AS)
Pre treatment (SS) AS, SS, and PS values of pre and post-treatment for
0.5573 0.001 right TMJ that was 0.2mm (SD ±0.6mm; p-value
Post treatment (SS)
Pre treatment (PS)
0.002), 0.5mm(SD± 0.3mm; p-value 0.001),
0.2607 0.004 0.4mm(SD±0.1mm; p- value 0.005), respectively
Post treatment (PS)
and the mean difference between AS, SS, and PS
If P-Value is <0.05 then statistically significant values of pre and post-treatment for left TMJ was
Statistical Analysis: The Normality tests 0.2mm (SD±0.1mm; p- value 0.001), 0.5mm (SD±
Kolmogorov-Smirnov and Shapiro-Wilks tests results 0.05mm; p- value 0.001), and 0.2mm (SD± 0.2mm;
reveal that the variables (Vertical and Horizontal p- value 0.004), respectively.
distances) follow Normal distribution. Therefore to • The result of this study hence showed that there was
analyse the data parametric method are applied. To statistical significant difference in the all anterior,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 103
superior, and posterior space both in the right and pain located around the TMJ, pain that was referred
left side joint pre and post treatment and the values to the neck, head and ear and pain that was located
of post treatment approached the mean values immediately in front of the tragus of the ear, projecting
reported by Kazumi et al. to the ear, cheek, and along the mandible. The restricted
jaw motion was also resolved in all of the study patients
Discussion but joint noise such as clicks and crepitus resolved only
Some TMD patients awake with TMD pain that for a little more than 60% of the patients in the span of
only last m minutes to hours, suggesting that nocturnal just four weeks of total six months.
factors are the primary contributors to these symptoms.
In this third patient group, patients generally report that Conclusion and Summary
either their awaking or daytime symptoms are worse, TMD should be treated like any other musculoskeletal
suggesting that the nocturnal or diurnal factors are complaints. If TMD is left untreated, symptoms can be
more significantly contributing to their symptoms10. worsen and extend far beyond the jaw and the mouth
Therefore it’s best that the splint is worn 24 hours a area. Gnathological splints can be used as effectiveness
day for best effective treatment and so full time wear of mean for treatment of such patients. This can be easy
gnathological splint was advocated in this study. Roth made good comfort to the patients.
power centric bite registrations anatomically seat the
condyles in anterior superior position within the fossa.14 Amount of change in the right side TMJ

It has been reported that clinical examination for the • AS – 0.2773

diagnosis of anterior disc displacement with reduction • SS – 0.556
has an accuracy of 43–75%.This suggests that a clinical
• PS – 0.448
examination should be done together with other imaging
method in order to determine the relationship between Amount of change in the left side of TMJ
the articular disc and condyle. In recent years, magnetic
• AS – 0.2987
resonance imaging (MRI) has been used because it is
an effective, noninvasive method that does not appear to • SS – 0.5573
cause any biological hazard. • PS – 0.2607
The goal of our study was to check the condylar disc • Relief of pain and other symptoms
position, joint space in pre and post gnathological splint
• MRI supported our clinical results with great
therapy for six months using MRI in patient with TMD
specificity.
problems .Subject were patients who had an anterior disc
displacement with reduction before treatment. Our study Conflict of Interest: No relavent conflict of interest
was designed to identify the condylar disc position, joint among authors.
space13.
Some of Funding: Self-funding
Kazumi et al (2009) in his study on optimal
condylar position in the fossa on sagittal CBCT images Reference
in functionally optimal joints without displacement 1. JB costen; A syndrome of ear and sinus symptoms
reported that mean AS, SS, & PS values are 1.3mm dependent upon disturbed function of the
(SD±0.2mm), 2.5mm (SD±0.5mm) and 2.1mm temporomandibular joint March 1934,Ann Otol
(SD±0.3mm), respectively. The ratio of AS to SS to PS Laryngol VOl 43,No 1,pages 1-15
was 1.0 to 1.9 to 1.6.In our present short term study the
2. Herb K choS, Stiles MA .Temporomandibular joint
patients are symptomatic of TMD and post treatment
pain and dysfunction;Cure pain headache Rep.
results were taken after six months. In my study using
2006;10:408-14
MRI, the post treatment values approximate the results
provided by Kazumi et al. 3. Moffet B.C., Johnson, LC., McCabe, J.B., &
Askew, H.C (1964) Articular Remodeling in the
All the symptomatic patients who were selected Adult Human Temporomandibular Joint. American
in this study exhibited resolution of symptoms such as journal of Anatomy,115(1),119-141.
104 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
4. Mongini, F(1972)Remodelling of the mandibular 10. Ikeda K, Kawamura A, Ikeda R. Assessment of
condyle in the adult and its relationship to the Optimal Condylar Position in the Coronal and
condition of the dental arches. cell tissues and Axial Planes with Limited Cone‐Beam Computed
organs 82(3),437-45 Tomography. Journal of Prosthodontics: Implant,
5. BENJAMIN H. WILLIAMS (1983) Oriented Esthetic and Reconstructive Dentistry. 2011
Lateral Temporomandibular Joint Laminagraphs. Aug;20(6):432-8.
The Angle Orthodontist: July 1983, Vol. 53, No. 3, 11. Ikeda K. A reference line on temporomandibular
pp. 228-233 joint MRI. Journal of Prosthodontics. 2013 Dec;
6. Lubsen, Charlotte C., et al. “Histomorphometry 22(8):603-7
of age and sex changes in mandibular condyles 12. Ikeda K, Kawamura A, Ikeda R. Prevalence of disc
of young human adults.” Archives of oral biology displacement of various severities among young
32.10 (1987): 729-733. preorthodontic population: a magnetic resonance
7. McNamara, James A., and David S. Carlson. imaging study. Journal of Prosthodontics. 2014
“Quantitative analysis of temporomandibular joint Jul;23(5):397-401
adaptations to protrusive function.” American 13. Ikeda R, Ikeda K. Directional characteristics
journal of orthodontics 76.6 (1979): 593-611. of incipient temporomandibular joint disc
8. Solberg, William K., Mae W. Woo, and John B. displacements: A magnetic resonance imaging
Houston. “Prevalence of mandibular dysfunction in study. American Journal of Orthodontics and
young adults.” The Journal of the American Dental Dentofacial Orthopedics. 2016 Jan 1;149(1):39-45.
Association 98.1 (1979): 25-34. 14. Ikeda M, Miyamoto JJ, Takada JI, Moriyama K.
9. Kazumi Ikeda and Akira Kawamura, Assessment Association between 3-dimensional mandibular
of optimal condylar position with limited cone- morphology and condylar movement in subjects
beam computed tomography, American Journal with mandibular asymmetry. American Journal of
of Orthodontics & Dentofacial Orthopedics 2009 Orthodontics and Dentofacial Orthopedics. 2017
April Volume 135, Issue 4, 495-501 Feb 1;151(2):324-34.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 105

Antimicrobial Efficacy of Triphala as Root Canal Irrigating

Solution in Infected Primary Teeth: An Ex Vivo Study

Kiran N.K.1, Nagalakshmi Chowdhary2, Y. Sharada Devi Mannur3,

Neethu Elsa Varghese4, Arvind Sridhara5, Pavana M.P.5
1Professor,
Department of Pedodontics and Preventive Dentistry, 2Professor and Head, Department of Pedodontics
and Preventive Dentistry, 3Professor, Department of Microbiology, 4Post Graduate, Department of Pedodontics
and Preventive Dentistry, 5Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Sri Siddhartha
Dental College and Hospital, Sri Siddhartha Academy of Higher Education (SSAHE), Tumkur

Abstract
Background and Objectives: Dental caries is a common problem encountered in children. Deciduous teeth
with deep dental caries can be treated with pulp therapies to allow normal exfoliation process. The process of
pulpectomy involves access cavity preparation, cleaning and shaping of the root canal and obturation. Even
though all these procedures are essential, irrigation of the root canal during cleaning and shaping is vital
in ensuring complete microbial decontamination, which guarantees the success of pulpectomy. Although
NaOCl is considered as gold standard among root canal irrigants, the quest for a better irrigant with superior
antimicrobial efficacy and biocompatibility was under consideration.

Hence, the present ex vivo study was done to evaluate and compare the antimicrobial efficacy of 0.5%
Sodium hypochlorite (Dakin’s solution) with 10% Triphala, a herbal root canal irrigant.

Results: The study showed a statistically significant difference in the anti-microbial efficacy of 10% Triphala
and 0.5% Sodium hypochlorite (Dakin’s solution).

Conclusion: The antimicrobial efficacy of 10% Triphala was better than that of 0.5% Sodium hypochlorite
(Dakin’s solution) when used as root canal irrigants in infected primary teeth.

Keywords: Triphala, Sodium hypochlorite, Root canal irrigant, Antimicrobial efficacy.

Introduction Staphylococcus, Lactobacilli, Enterococcus, Klebsiella,

Pseudomonas, Actinomyces etc. A clinician ensures a
The dental root canal is not a single microbial
patent and clean root canal system by eliminating these
environment but is one of the most heavily bacterially
microbial floras via endodontic treatment.1
contaminated sites in the body. Some of the microbial
species reported in the root canal system are Streptococcus, Though all the steps of endodontic therapy are vital
and should be carried in a systematic manner, irrigation
forms the backbone of pulp therapy. Copious irrigation
helps in the debridement of the root canal, destruction of
Corresponding Author:
microbes, removal of tissue remnants and dentin debris
Dr. Neethu Elsa Varghese
during instrumentation.2
Post Graduate, Department of Pedodontics and
Preventive Dentistry, Sri Siddhartha Dental College and Many irrigating solutions such as halogenated
Hospital, Sri Siddhartha Academy of Higher Education compounds (sodium hypochlorite), chlorhexidine,
(SSAHE), Tumkur, Karnataka, India-572107 chelating agents (EDTA, citric acid), MTAD, hydrogen
Phone: +91 8197626508 peroxide, maleic acid and chlorine dioxide have been
e-mail: [email protected] used to disinfect the root canal. Among these enumerable
106 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
irrigants sodium hypochlorite is considered as the gold (Haritaki), and Emblicaofficinalis (Amalaki) in 1:1:1
standard for endodontic irrigation.2,3 ratio. Triphala showed strong antimicrobial activity
against different microorganisms. The beneficial effects
Despite being the gold standard, sodium hypochlorite of Triphala are that, it can be used as a root canal irrigant,
has an unpleasant taste andwhen it comes in contact it has anti-caries effect, anti-periodontal disease effect,
with the tissue, causes hemolysis and ulceration. It also anti-collagenase effect, anti-microbial effect, anti-fungal
inhibits neutrophil migration and damages vascular, effect, analgesics and anti-pyretic effect, anti-oxidant
endothelial and fibroblast cells. Handling this solution effect and anti-cancer effect.5,7
also requires utmost care since it can also causes damage
to the permanent tooth follicles and periapical tissues if Hence the present study compared the antimicrobial
gone beyond the working length and resorbing apex.2,4 efficacy of 10% Triphala as a root canal irrigant, with
0.5% sodium hypochlorite (Dakin’s solution).
Due to the constant increase in antibiotic resistant
strains and also due to the side effects caused by Materials and Method
sodium hypochlorite and other synthetic drugs herbal
alternatives are more preferred as root canal irrigant. 30 patients who reported to the Department of
Various herbal alternatives for endodontic applications Pedodontics and Preventive Dentistry with deep dental
are Triphala, Morindacitrifolia (Indian mulberry), caries involving pulp were selected for the study. After
Curcuma longa (Turmeric), Green tea polyphenols, access cavity preparation a barbed broach was inserted
Liquorice, Propolis, Melaleucaalternifolia (Tea tree oil) into the canal and along with the infected pulp it was
and Azadirachtaindica (Neem).5,6 transferred to sterile container having 2ml normal saline
(Figure 1). The saline container was then taken for
Triphala is a herbal formulation consisting of fruits microbiological procedures.
of Terminaliabelerica (Bibhitaki), Terminaliachebula

Fig. 1: Collected Sample Stored in a Saline Fig. 2: Microbial growth on MacConkey Agar
Container

The sample was subcultured onto Blood agar and From the incubated plates bacterial colonies were
MacConkey agar (Figure 2 and 3). Mac Conkey agar taken and bacterial suspension was made in 1ml of
was incubated at 37oC for 24hours and Blood agar plates normal saline. A sterile swab was dipped in bacterial
was kept in 5-10% CO2 in a candle jar and incubated at suspension and transferred to Muller Hinton agar based
37oC for 24hours. After incubation period, the colonies Blood agar for Streptococci and Enterococci species
were identified by its colony morphology, gram staining, and lawn culture was made using cotton swab. For
coagulase and catalase test. Staphylococci species Muller Hinton agar was used and
lawn culture was made.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 107
6mm wells were dug in the plates and in each well
300μl of 10% Triphala, 0.5% Sodium hypochlorite
(Dakin’s solution) and Normal saline were poured
using micropipette. This plate was kept in 5-10%
carbon dioxide in a candle jar and incubated at 37oC
for 24 hours. After incubation period, diameter of zone
of inhibition was measured for 10% Triphala, 0.5%
Sodium hypochlorite (Dakin’s solution) and Normal
saline, which acted as a negative control and the values
were compared with each other to determine the anti-
microbial efficacy of root canal irrigants (Figure 4).

All the clinical procedures were carried out

following the protocols approved by the Ethics and Fig. 4: Agar Plate Showing Zones of Inhibition
Review Committee of Sri Siddhartha Dental College
and Hospital, Tumkur (IEC 12/2016). Findings: Table 1 shows the mean and standard
deviations of zone of inhibition produced by 10%
Triphala and 0.5% Sodium hypochlorite (Dakin’s
solution). It has been calculated from the zone of
inhibition values collected from 30 samples. The mean
zone of inhibition produced by 10% Triphala was 23.83
mm and that by 0.5% Sodium hypochlorite (Dakin’s
solution) was 20.97 mm with a p-value of 0.0047. This
shows that 10% Triphala has a statistically significant
antimicrobial efficacy than 0.5% Sodium hypochlorite
(Dakin’s solution).

Fig. 3: Microbial growth on Blood Agar

Table 1: Mean Zone of Inhibition produced by 10% Triphala and 0.5% Sodium Hypochlorite (Dakin’s
Solution)

Irrigant Minimum (mm) Maximum (mm) Mean (mm) Standard Deviation P Value Significant
10% Triphala 16.00 32 23.83 3.141
0.0047** Significant
0.5% Sodium hypochlorite 14 30 20.97 4.319

*p value ≤ 0.05, ** p value ≤ 0.01, *** p value ≤ 0.001

The present study was done to assess the anti- Sodium hypochlorite (Dakin’s solution). The result of
microbial effectiveness of 10% Triphala and 0.5% this study was in close accordance to the study done
Sodium hypochlorite (Dakin’s solution) as intracanal byShukla et al.8 who compared the antimicrobial efficacy
irrigants in infected primary teeth. The anti-microbial of Triphala and 5% Sodium hypochlorite and found
properties of the test solutions were evaluated by mean zone of inhibition for Triphala as 32mm and 22mm
measuring its mean zones of inhibition. for 5% Sodium hypochlorite against Staphylococcus
aureus. In the same study Triphala showed mean zone
In the present study the mean zone of inhibition for of inhibition of 27mm and 5% Sodium hypochlorite
10% Triphala was 23.83mm and 20.97mm for 0.5% showed 24mm against Enterococcus faecalis.Shakouie
108 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
et al.9
in a study found the mean zone of inhibition for 2. Kaur R et al. Irrigating solutions in pediatric
Triphala as 7.3 +/- 1.3mm and 4.6 +/- 1.6mm for 0.5% dentistry-literature review and update. J Adv Med
Sodium hypochlorite.On comparing the mean zone of Dent Sci Res. 2014;2(2):104-15.
inhibition of Triphala and 5.25% Sodium hypochlorite, 3. Esterala C et al. Charaterization of successful root
Karwa et al.10 found 18mm for Triphala and 24.6mm canal treatment. Braz Dent J. 2014;25(1):3-11.
for 5.25% Sodium hypochlorite against Enterococcus
4. Chaugule VB, Panse AM, Gawali PN. Adverse
faecalis.
reaction of sodium hypochlorite during endodontic
The increased zone of inhibition of Triphala can treatment of primary teeth. Int J ClinPediatr Dent.
be attributed to its antimicrobial effect. Antimicrobial 2015;8(2):153-56.
activity of Triphala is accredited for its formulation 5. Nair V, Das S, Kar M, Das KP. Triphala in
which contains three different medicinal plants in equal dentistry–a herbal wonder. J Dis Global Health.
proportions namely, Terminalia bellerica, Terminalia 2016;7(4):164-68.
chebula and Emblica officinalis. All these components 6. Neelakantan P, Jagannathan N, Nazar N.
have an additive orpositive synergistic effect. Emblica Ethanopharmacological approach in endodontic
officinalis assists in lipid peroxidation and plasmid treatment–a focused review. Int J Drug Dev Res.
DNA assay, while Terminalia chebula has noticeable 2011;3(4):68-77.
radical scavenging activity. The anti-bacterial property
7. Singh RL, Gupta R, Dwivedi N. A review
of Triphala includes either inhibition of cell division or
on antimicrobial activities of triphala and its
damage to the cell walls of the bacterium.11,12
constituents. W J of Pharm and Pharm Sci.
The differences in the mean zone of inhibition 2016;5(4):535-58.
among the present and other studies can be attributed to 8. Shukla N, Gupta V, Bhatt A, Bhasin A, Kankane
the concentration and volume of the solutions used and D. A comparative study of antimicrobial efficiency
the microorganisms on which the solutions were tested. of triphala, Carica papaya, Salvadorapersica and
green tea as root canal irrigants on root canal flora.
Conclusion an in vitro study. IJCPHR. 2016;1(1):22-24.
The study concludes that 10% Triphala has a 9. Shakouie S, Eskandarinezhad M, Gasemi N, Salem
statistically significant antimicrobial action compared Milani A, Golizadeh S. An in vitro comparison of
to that of 0.5% Sodium hypochlorite (Dakin’s the antibacterial efficacy of triphala with different
solution). However, further in vivo research is needed concentrations of sodium hypochlorite. Iran Endod
to conclusively recommend Triphala as a root canal J. 2014;9(4):287-89.
irrigant. 10. Karwa B, Ikhar A, Chandak M, Sande S, Agrawal,
Sawant S. Microbiological evaluation of herbal and
Conflict of Interest: There is no conflict of interest
non herbal irrigating solutions on Enterococcus
in the research.
faecalis–an in vitro study. J Adv Med Dent Sci Res.
Funding: This study has not been funded by any 2017;5(6):50-53.
organization. 11. Jyothi KN, Gopal A. Comparison of antimicrobial
efficacy of 0.3% propolis, 10% neem, 10% triphala
Ethical Clearance: All the clinical procedures were and 5% sodium hypochlorite on Candida albicans
carried out following the protocols approved by the and E.faecalis biofilm formed on root dentin–an in
Ethics and Review Committee of Sri Siddhartha Dental vitro study. J Dent Sci. 2016;4(3):90-94.
College and Hospital, Tumkur (IEC 12/2016).
12. Bhavikatti SK, Dhamija R, MLV Prabhuji.
References Triphala–envisioning its role in dentistry. Int Res J
Pharm. 2015;6(6):309-313.
1. Drucker DB, Natsiou I. Microbial ecology of the
dental root canal. Microb Ecology Health Dis.
2000;12:160-69.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 109

Association between Urinary Cotinine Levels and Buccal

Mucosal Micronuclei Cells of Smokeless Tobacco Chewers
Attending a Tertiary Care District Hospital

Kiran S. Nikam1, Kanchan C. Wingkar2, Rajesh K. Joshi3, Rajashekar K. Kallur4

1Assistant
Professor, Belagavi Institute of Medical Sciences, Belagavi, Dept of Physiology, Dr. B. R. Ambedkar
Road, Belagavi, Karnataka, 2Professor and Head, Krishna Institute of Medical Sciences Deemed University, Dept
of Physiology, Karad, Maharashtra, 3Scientist D. and Head, ICMR-National Institute of Traditional Medicine,
Dept of Phytochemistry, Nehru Nagar, Belagavi, Karnataka, 4Professor and Head, Gujarat Adani Institute of
Medical Sciences, Dept of Physiology, Bhuj, Gujarat, India

Abstract
Introduction: Oral squamous cell carcinoma encompasses at least 90% of all oral malignancies. It is sixth
most common malignancy and the major cause of cancer morbidity and mortality worldwide. Early detection
of a premalignant oral lesion would improve the survival to a greater extent. Tobacco lays an enormous
effect of disease for health, economic, social and environment issues. Cross sectional study was done at
tertiary care hospital to find association between urinary cotinine levels and buccal mucosal micronuclei
cells of smokeless tobacco chewers.

Method: Study comprised of 300 Smokeless Tobacco chewers (STC) and 300 Non tobacco chewers (NTC).
Physical examination and Anthropometric parameters were recorded. Fasting urine samples collected for
extraction of cotinine. Buccal smears were prepared for exfoliated cells. Slides were stained by Papanicolaou
stain and micronuclei (MN) cells was examined by using 100X, 400X magnification as per the Tolbert et al
criteria.

Results: Mean Urinary Cotinine in STC was enhanced as compared to NTC. The MN cells were also
increased in STC as compared to NTC & statistically highly significant (Mean SD of STC 21.30±10.55,
95% CI; 20.11 to 22.49, NTC Mean SD 3.74±3.43, 95% CI; 3.35 to 4.12). The MN cells of STC showed
strong positive association & statistically highly significant correlation with urinary cotinine levels (r=
0.692, p=<0.0001).

Conclusions: The present study establishes link between rise in exfoliated buccal MN and determination of
urinary cotinine levels which is a biomarker of genotoxicity and epithelial carcinogenic progression.

Keywords: Smokeless tobacco chewers, Non tobacco chewers, Micronuclei, Cotinine.

Introduction smokeless tobacco chewing and smoking have cancerous

causing behavior that contributes to increasing global
Oral cancer is one of the commonest causes of disease
burden of oral cancer. The World Health Organization
and death rate nowadays. In developing countries, both
figured out that proportion of deaths that result due to
tobacco-related diseases would rise in India from 1.4%
Corresponding Author:
of all in 1990 to 13.3% of all deaths in 20201,2.
Kiran S. Nikam
Assistant Professor, Belagavi Institute of Medical Tobacco lays an enormous effect of disease for
Sciences, Belagavi, Dept. of Physiology, Dr. B.R. contrary health, economic, social and environment
Ambedkar Road, Belagavi-590001, Karnataka, India issues. The tobacco epidemic is among the largest
e-mail: [email protected] public health threat at present situation which almost
110 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
kills six million peoples per year. Among mortality of chewing tobacco is approximately 50 times higher than
ten adults in every six seconds, one death is reported that of non-tobacco users. Nearly 90% of oral neoplasms
due to habitual tobacco. Use of tobacco is an indicatory are caused by smokeless chewing tobacco. Chewing
public health problem on earth and the only cause for tobacco also results in lesions like leukoplakia caused
preventable hazard for human health3. due to chronic irritation. Many tumorsare likely to be
known to arise from these lesions.
As per latest report intimated by Global Adult
Tobacco Survey 2, (GATS-2) 2016-17 in India affirm Globally, about 5, 00,000 new oral and pharyngeal
that 28.6% of adults aged >15 (26.7 crore) use tobacco cancers are diagnosed annually and three-quarters of
in various forms. Smokeless tobacco usage is marked these are seen in the developing countries, including
in every 5th adult (19.9 crore) and (10.0 crore) in every about 65, 000 cases being reported from India11. The
10th adult in smokers4.The frequency of tobacco usage micronuclei (MN) assay in exfoliated buccal epithelial
is around 37.97% in men 12.5% in female in Belgaum cells is potentially an excellent candidate to serve as a
region and the commonest form of tobacco use is biomarker. If not precise, but an arbitrary prediction
smokeless tobacco (ST)5. about the molecular changes that take place in the buccal
mucosal cells of tobacco users in individuals without any
Biological consequences of Nicotine are widespread lesion can hint towards the occurrence of any lesion in
and lengthened to all systems of the body including those individuals in future12.The biomarkers most widely
cardiovascular, respiratory, renal and reproductive used to quantify exposure to tobacco include nicotine,
systems6. Smokeless tobacco is thought to be highly and their metabolites are cotinine, carbon monoxide, and
addictive due to their high nicotine content. The ST also thiocyanate. Recent investigation has focused on various
contain carcinogenic substances like tobacco-specific hemoglobin and DNA (deoxyribonucleic acid) adducts
N-nitrosamines (TSNAs) leading to an increased risk and excretion of nitrosamines in the urine samples13.
of cancers of oral cavity, pharynx and esophagus.
Depending on the type of ST products, nicotine content The literature review revealed that there is a paucity
may vary, and therefore, measurement of nicotine and its of literature regarding the association among smokeless
metabolites among ST users is important to understand tobacco chewers in Belagavi region. Therefore, the
the addictive potential of ST products. The half life study aimed to study the cytomorphological changes in
of nicotine is very less and its metabolites especially the buccal mucosa of smokeless tobacco chewers and
cotinine has a long half life, which is good biomarker of normal subjects.
nicotine in urine (urinary cotinine level)7,8.
Material and Method
Estimation of cotinine concentration levels from
urine sample of Smokeless tobacco chewers (STC) This Cross sectional study was conducted in
and Non tobacco chewers (NTC) by High performance Belagavi region of Karnataka state in India,. The study
liquid chromatography- Diode array (HPLC-DA) groups were divided as Smokeless tobacco chewers
and conformation of cotinine metabolite by Gas (STC) and Non tobacco chewers (NTC). Ethical
Chromatography-Mass spectrometry (GC-MS) serves clearance was obtained from the Ethical Committee of
as useful marker to determine the effects of different the Institution and University. A total of 600 participants
forms of tobacco consumption.Studies on nicotine and were studied in this study. The study population
Cotinine levels in smokers and passive smoking in comprised fromBelagavi Institute of Medical Sciences
other ethnic groups are well documented but very few (BIMS), Belagavi, Karnataka, India. Written informed
studies are found in STC. This may be fact because of consent was explained and taken from the participants
the cultivation of the tobacco crops in specific parts of in English and local languages (Kannada and Marathi).
that region only9. Study was done in the month of April 2013 to December
2016.
Multiple studies have reported that all forms of
tobacco use are highly prevalent in both men and women Inclusion criteria for age were300 smokelesstobacco
in India. The prevalence of ST use is estimated 33%and chewers and 300 Non tobacco chewers between 18 to
18% for men and women respectively in India10. The 65 years.Subjects with pre-existing oral cavity lesions,
risk of oral cancer associated with those who use alcoholics and having recent viral infections and who
had received radiotherapy or chemotherapy in last month
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 111
were excluded from the study. The study included 183 Mass Index in Kg/m2 (BMI), were 24.01±3.13 in NTC
cases based on the prevalence of 13.9% in Karnataka14. and 20.66±2.41 in STC group. Body Surface Area
(BSA) m2 the mean ± SD were 1.59±0.09 in NTC and
Physical examinations of the subjects were done to 1.51±0.08 in STC group. The difference between mean
record Respiratory rate (cycles/minute) Heart rate (Beats/ values was statistically highly significant (<0.001).
minute).Anthropometric parameters was recorded for Heart rate in Beats/minute (HR) and Respiratory rate in
(Height (in cms), Weight (in kgs), Body Surface Area cycles/minute (RR) on comparison with NTC and STC
(Square meters), Body Mass Index (Kilogram/meter2), groups was statistically highly significant. Mean Urinary
Collection and chromatographic analysis of the cotinine value in STC was enhanced as compared to NTC
urine samples for cotinine has been already reported by group (NTC, Mean SD, 23.48±11.08 & STC, Mean SD,
the same group9. 1563.68±1198.97) & were statistically highly significant
statistically highly significant (<0.001)(Table/Fig 1).
Each individual was asked to rinse his mouth neatly The comparison of buccal mucosal micronuclei cells
by tap water. The exfoliated cells were taken by scrapping by using Mann-Whitney U test was increased in case of
the buccal mucosa by using wooden/steel spatula and the STC (Mean SD of STC 21.30±10.55, 95% CI; 20.11 to
scraped cells were taken on lean grease free glass slide 22.49 as compared to NTC Mean SD 3.74±3.43, 95%
and smears were prepared. All smears were stained by CI; 3.35 to 4.12) & was statistically highly significant
Papanicolaou technique using commercially available (<0.001) (Table/Fig 2).The buccal mucosal micronuclei
staining kit Rapid Pap. From each slide, minimum 100 cells in case of STC showed strong positive association
cells were examined in high power magnification (400X) & statistically highly significant correlation with urinary
and location of micronuclei (MN) cells was examined by cotinine levels (r= 0.692, p=<0.0001) by using spearman
using 100X, 400X magnification. As per the Tolbert et non parametric correlation analysis (Table/Fig 3).
al criteria identifying of micronucleus cells were done.
Table 1: Mean urinary cotinine level in smokeless
The completed questionnaires were entered into a tobacco chewers and non tobacco chewers group9.
database using MS Excel 2000. Frequency distributions
and percentages were examined for each answer. Urinary cotinine levels
Mean SD P value
(ng/mL)
Descriptive statistics,comparison among NTC and STC
NTC 23.48±11.08
groups using Mann-Whitney U testand Spearman non <0.001**
STC 1563.68±1198.97
parametric correlation analysis was used to indicate
a measure of the correlation and the strength of the *Significant, ** Highly significant.
relationship. The statistical significance level was set at
P < 0.05. The statistical analysis was conducted using
SPSS version 26.

Results
The mean age of participants for NTC was
(37.00±16.05) whereas for STC was (37.10±15.99).
Distribution of sex for male and female for NTC was
222 (74%) and 78 (26%) respectively, and for STC
male and female it was 214 (71.33%) and 86 (28.66%)
respectively. The anthropometric data for height (cm)
†STC-smokeless tobacco chewers, † NTC-Non tobacco chewers
and weight (kg) mean ± SD in case of NTC and STC
was 157.85±5.19 and 158.93±6.42 for height (cm) Fig. 2: Comparison of mean value for micronuclei
and 59.49±7.24 and 52.00±4.96 for weight (kg). The cells of buccal mucosa in smokeless tobacco chewers
difference between mean values was statistically highly and non tobacco chewers group.
significant (<0.001).The mean ± SD values of Body
112 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Fig. 3: Buccal mucosal micronuclei cells of STC showing strong positive correlation with urinary cotinine
levels.

Discussion
The present study was aimed to assess and compare
micronuclei cells of buccal mucosa in STC and NTC
and to establish the correlation between urinary
cotinine levels of STC with above findings. Previous
researchers8,13,15,16 found a wide range of urinary
cotinine levels which is also seen in the present study
in STC and NTC 100.84 -5810 and 10.01- 59.02 ng/
mL respectively. Several studies showed that urinary
cotinine levels innonsmokers are always less than 100
ng/ml17, 18. The variation in range of cotinine depends on
the tobacco chewer’s dietary intake of nicotine, cotinine
excretion, metabolic activity, passive smoking and
environmental smoke8.

From the present study highly statistically

significant difference was found between STC and
NTC group. Similar findings were also found among
previous reports19, 20, 21.The potential of carcinogenic
and genotoxicants effect is very high among tobacco
chewers. Habituated chewing tobacco users are the
likely odds estimated for oral cancer development19.
Micronuclei in oral exfoliated cells are the biomarkers
of chromosomal damage caused by genotoxic agents
Fig 4: Photomicrograph showing exfoliated cells from the tobacco and tobacco related substances20.
with micronuclei cells (Arrow) in STC stained by Tobacco-specific nitrosamines present in the smokeless
Papanicolaou stain, x 400.(Labomed Bionocular tobacco forms also play a significant role in causing the
microscope Model LX 400) damage19.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 113
Urinary cotinine levels of STC statistically correlates 2. Jandoo T, Mehrotra R. Tobacco control in India:
with micronuclei of buccal mucosa cells (STC MN cells, Present scenario and challenges ahead. Asian Pac J
r = 0.692, p <0.0001) in present study. This was similar Cancer Prev. 2008; 9:805-10.
to the findings of Poppel GV22who studied the serum 3. World Health Organization. Tobacco Fact Sheet
cotinine levels in tobacco users. Oral carcinogenesis No. 339. Available from: http://www.who.int/
is a multistep process of accumulated genetic damage mediacentre/factsheets/fs339/ en.
leading to cell dysregulation with disruption in cell-
4. GATS 2 India Report 2016‑2017. Available from:
signaling,DNA repair & cell cycle events, which are
https://www. mohfw.gov.in/sites/default/files/
fundamental to hemostasis. MN in oral exfoliated cells
GATS‑2%20FactSheet. Pdf.
is a biomarker of chromosomal damage caused by
genotoxic agents from tobacco related substances20. 5. Patil AP, Khona PP, Patil M. Prevalence of tobacco
consumption in an urban area Belgaum, Karnataka,
Conclusion India. Int J Community Med Public Health 2016;
3:3059‑62.
Early detection of a premalignant or cancerous oral
6. Mishra A, Chaturvedi P, Datta S,Sinukumar S,
lesion would improve the survival to a greater extent
Joshi P, Garg A. Harmful effects of nicotine. Indian
and also will reduce the morbidity associated with
J Med Paediatr Oncol 2015; 36:24-31.
the treatment to a considerable extent. There is strong
correlation between urinary cotinine levels of smokeless 7. Huque R, Shah S, Mushtaq N, Siddiqi K.
tobacco chewers and exfoliated buccal mucosal Determinants of Salivary Cotinine among
micronuclei cells. Thus the present study elucidates Smokeless Tobacco Users: A Cross-Sectional
the link between rise in exfoliated buccal micronuclei Survey in Bangladesh. Journal Pone. 2016; 9:1-9.
and determination of urinary cotinine levels, which is 8. Behera D, Uppal R, Majumdar S. Urinary levels
an importantbiomarker and is valuable measure for of nicotine and cotinine in tobacco users. Indian J
diagnosis of health risk. Med Res 2003; 118:129-3.
9. Nikam KS, Wingkar KC, Kallur RK, Joshi RK, Pai
For definitive and sound results, still larger samples
SR. Trends in Cotinine Level from Urine Samples
should be studied for longer duration. The buccal
of Smokeless Tobacco Chewers. Medica Innovatica
exfoliated cells should also be collected after cessation
2016; 5:15-21.
of habit to confirm the prognostic value of MN cells
and level of genotoxicity. The cause of micronuclei 10. Itagi AFH, Arora D, Patil NA, Bailwad SA, Yunus
formation due to tobacco use, different forms tobacco GY, Goel A. Short-term acute effects of gutkha
products, difference in the degree and mechanism of chewing on heart rate variability among young
action of smokeless variants of tobacco and also the adults: A cross-sectionalstudy.Int J Appl Basic
effects of cotinine levels in relation to occurrence of Med Res. 2016; 1: 45-49.
MN should be studied in detailed for strategic tobacco 11. Tolbert PE, Shy CM, Allen JW. Micronuclei
control program. and other anomalies in buccal smears: method
development. Mutation Research 1992; 271: 69-77.
Acknowledgement: Authors are indebted to the
12. Casatelli G, Bonatti S, De Ferrari M, Scala
Head of Department Physiology, Principal and Director,
M, Mereu P, Margarino G et al. Micronucleus
BIMS, Belagavi, KIMS, Karad, and NITM (ICMR),
frequency in exfoliated buccal cells in normal
Belagavi for their kind support.
mucosa, precancerous lesions and squamous cell
Financial Support and Sponsorship: Nil carcinoma. Anal Quant. Cytol Histol 2000; 22:
486-92.
Conflicts of Interest: No
13. Benowitz N, Goniewicz ML, Eisner MD, Ponce
EL, Danch WZ, Koszowski B et al., Urine Cotinine
References
Underestimates Exposure to the Tobacco-Derived
1. Global cancer facts and figures;2nd ed. Atlanta: Lung Carcinogen 4-(Methylnitrosamino)-1-(3-
American Cancer Society; 2011. Pyridyl)-1-Butanone in Passive Compared with
International Agency for Research on Cancer. 1-57. Active Smokers. Cancer Epidemiol Biomarkers
Prev 2010; 19:2795-2800.
114 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
14. Gupta PC, Ray CS. Smokeless tobacco and health in Using Papanicolaou And May Grunwald Giemsa
India and South Asia. Respirology 2003;(8):419‑43. Stain In Individuals With Different Tobacco
15. Thompson SG, Stone R, Nanchahal K, Wald NJ. Habits–A Comparative Study. Journal of Clinical
Relation of urinary cotinine concentrations to And Diagnostic Research 2010; 4:3607-3613.
cigarette smoking and to exposure to other people’s 20. Bansal H, Sandhu VS, Bhandari R, Sharma D.
smoke. Thorax 1990; 45:356-61. Evaluation of micronuclei in tobacco users: A
16. Vlasceanu AM, Petraru C, Baconi D, Ghica M, study in Punjabi population. Contemp Clin Dent
Arsene A, Popa Let al. Quantitative relationships of 2012; 3:184-7.
urinary cotinine levels in smoking diabetic patients. 21. Hilada N C, Musanovic J, Kurteshi K, Prutina E,
Farmacia 2015; 63(3):349-56. Turcalo E. The effects of sex, age and cigarette
17. Biber A, Scherer G, Hoepfner I, Adlkofer F, Heller smoking on micronucleus and degenerative nuclear
WD, Haddow JE, et al. Determination of nicotine alteration frequencies in human buccal cells
and cotinine in human serum and urine: An of healthy Bosnian subjects. Journal of Health
interlaboratory study. Toxicol Lett 1987; 35:45-52. Sciences. 2013; 3(3):196-204.
18. Kolonen SA, Puhakainen EV. Assessment of the 22. Poppel GV. Cancer epidemiology, biomarkers and
automated colorimetric and the high-performance prevention. Cancer epidemiol Biomarkers Prev.
liquid chromatographic method for nicotine intake 1993; 2: 441-447.
by urine samples of smokers’ smoking low- and
medium-yield cigarettes. Clin Chim Acta 1991;
196:159-66.
19. Palaskar S, Jindal C. Evaluation Of Micronuclei
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 115

Balanced Diet: Knowledge and Practice of Adolescents

Krupa Reji1, Leema Jacob1, Liby Kuriakose1, Linsha K.1,

Maria Augustine1, Maria George1, Priya Reshma Aranha1
1IV Year B.Sc. Students, Yenepoya Nursing College, Yenepoya (Deemed to be University), Derlakatte, Mangaluru

Abstract
Background: Adolescence is a stage of transition and psychological development. This period needs a well
balanced diet for their better growth and development. Adequate knowledge regarding balanced diet may
enhance the practice of adolescents regarding balanced diet.

Aim: The aim of the study was to determine the knowledge and practice regarding balanced diet among
adolescents, to find the correlation between knowledge and practice and to find the association between
knowledge, practice scores and the selected demographic variables.

Material and Method: Quantitative research approach and descriptive survey design was used for the
study. The study was conducted in selected urban schools. Using non probability purposive sampling
technique, 100 adolescents between the age group of 10- 17 years were selected as study sample. The
structured knowledge and practice questionnaire on balanced diet was used to assess the knowledge and
practice regarding balanced diet. Data was analysed using descriptive and inferential statistics.

Result: Study findings revealed that 4% of study samples had inadequate knowledge, 64% of study samples
had adequate knowledge and other 32% of study samples had good knowledge on balanced diet. 2% of study
samples had poor practice and other 98% of study samples had good practice regarding balanced diet. There
found a significant positive correlation (r=0.52) between knowledge and practice scores. Also it showed a
significant association between knowledge scores and selected demographic variables (p<0.05).

Conclusion: It was concluded that the adolescents have good knowledge and practice on balanced diet.

Keywords: Knowledge, practice, adolescents, balanced diet.

Introduction mental process1 but in this period, a high levels of stress

and anxiety develops in each adolescents. Adolescence
According to WHO, adolescence is a period between
is also a time of busy schedule. The high stress in some
the age of 10 to 19 years. Adolescents constitute 18 to
adolescents, may be related to eating disorders as well2.
25% of the population in member countries of South
It is estimated that during adolescence period, they gain
East Asia Region. Adolescent is a period of accelerated
25% of adult height, 50% of adult weight and 40% of
physical growth, social and psychological maturity,
adult bone mass3.
sexual maturity, experimentation, development of adult
During adolescence the rate of physical growth
actually increases. This sudden growth is associated
with hormonal, cognitive and emotional changes that
Corresponding Author: make adolescence an especially vulnerable period of
Dr. Priya Reshma Aranha life. There is a greater demand for calories and nutrients.
Assistant Professor, Department of Child Health At the same time, adolescence is a time of changing
Nursing, Yenepoya Nursing College, Yenepoya lifestyles and food habits which can affect the intake and
(Deemed to be University), Derlakatte, Mangaluru nutrition of adolescents. It is also seen that adolescents
e-mail: [email protected] strive for individuation, that means more opportunity
116 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
to assert food choices and expand or narrow healthy balanced diet. Hence the researchers were interested to
options. Studies have revealed that despite possessing assess the knowledge and practice regarding balanced
considerable food knowledge, many adolescents find diet among adolescents.
it difficult to follow healthy eating recommendations
and often consume food that they think is healthy.4 Materials and Method
Adolescence is a nutritionally vulnerable time period. Quantitative research approach with descriptive
Poor eating habits formed during adolescence period survey design was used for the study. The study was
can lead to obesity and diet-related disease in later years. conducted in selected schools at Mangaluru. The sample
In addition, the high incidence of dieting behaviours comprised of 100 adolescents between the age group of 10-
can contribute to nutritional inadequacies and to the 17 years. Non probability purposive sampling technique
development of eating disorders.5 Food choice patterns was used to select the sample. Ethical principles followed
established during youth may likely influence long- during data collection as in the guidelines of institutional
term behaviour6 Nutrition issues may also arise due to ethics committee. The tool used for data collection were
the intake fast food, snack choices, sport nutrition and structured knowledge questionnaire (reliability was 0.8)
overweight. Adolescents are not aware of the potential and practice questionnaire (reliability was 0.7). The
health risks associated with poor habits7. baseline characteristics of adolescents including dietary
It is reported that 49% of adolescent girls (15 years behaviours were collected. There were 25 questions for
of age) are under height and 67% are underweight.8 The knowledge on balanced diet, 20 questions on balanced
prevalence of overweight in girls was 24%, obesity 13% diet practice which was a five point rating scale. The
and underweight was 14%. The prevalence of anaemia data was analyzed by using descriptive and inferential
[Hb<12gm/dl] was 29%.9In a study it was observed statistics.
that majority of subjects, i.e., 83.3% were in the habit Findings: The study results showed that majority
of skipping at least one meal daily.10 In another study (30%) of the sample belonged to the age group of 10-
it was also seen that majority of the study participants 11 years, majority (56%) were females, majority (44%)
had regular meals (72%) and breakfast (80.8%). 46.8% were studying in 5- 7 standard,majority, 87% are living
consumed fruits less than 3 times per week, 58% had in nuclear family, majority (84%) of adolescents were
fried food twice or more per week and 40.5% consumed Muslim by religion, majority (20%) had family income
less than 2 litre of water a day.11 greater than Rs. 40,000/ per month, Majority (79%)
Balanced diet helps adolescents to maintain of adolescents were day scholar, majority(86%) were
good health and to promote growth and development. residing in urban area, majority (63%) were receiving
Adequate knowledge on balanced diet would improve pocket money, majority (82%) received information
the practices of adolescents regarding consumption of regarding balanced diet, 40% of adolescents received
information from school teachers.

Fig 1: Bar diagram showing the lunch arrangement for adolescents

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 117

Fig 2: Bar diagram showing the eating out pattern with family

Fig 3: Bar diagram showing the eating out pattern with friends

Fig 4: Bar diagram showing the pocket money amount of adolescents per month
118 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 1: Frequency and percentage distribution of the habit of eating food while seeing TV/mobile phone/
adolescents according to the arbitrary grading of computer every day.
their knowledge scores n=100
The study showed that there is a significant positive
Sl. Knowledge correlation between knowledge and practice scores
Arbitrary Grading Percentage
No. score of adolescents regarding balanced diet,(r = 0.52).
1 ≤8 Inadequate knowledge 4 It was also seen that there is a significant association
2 9-16 Adequate knowledge 64 between knowledge score and grade studying in (c2
3 17-25 Good knowledge 32 =51.64, p<0.05), knowledge score and area of residence
(c2 =117.473, p<0.05), knowledge score and lunch
The data in table 1 shows that 4% of study samples arrangement (c2 =65.716, p<0.05). It was seen that there
had inadequate knowledge, 64% of study samples had is no significant association between practice score and
adequate knowledge and other 32% of study samples the selected demographic variables (p>0.05) .
had good knowledge on balanced diet.

Table 2: Frequency and percentage distribution of

Discussion
adolescents according to the arbitrary grading of The current study was conducted among the
their practice scores n=100 adolescents studying in urban area. It showed that
majority (64%) of study samples had adequate
Sl. Practice
Arbitrary Grading Percentage knowledge on balanced diet. These findings are in line
No. score
with a study11 which showed that 59%of adolescents had
1 ≤ 40 Poor practice 2
quite good knowledge about balanced diet. It was also
2 >40 Good practice 98
supported by a study which was conducted on nutrition
The data in table 2 shows that 2% of study samples knowledge, attitude and practice of college students
had poor practice and other 98% of study samples had which showed that there was significant difference
good practice regarding balanced diet. in nutrition knowledge, attitude and practice score
(p<0.05).9 But another study contradicted the present
Regarding the practice of balanced diet, it was seen study findings where 41% of the subjects had low
that majority (74%) of the adolescents agreed that they knowledge regarding balanced diet.1
consume breakfast every day. Majority (35%) argued
that they never skip meals. Majority (37%) consumed In the present study 98% of sample had good practice
vitamin supplements 4 days a week and 37% consumed regarding balanced diet. This finding is in line with a
mineral supplements every day. Majority (56%) of the study11 finding where most of adolescent girls had a well-
adolescents verbalized that they eat three base meals balanced diet practices (53.5%) .Another study also has
every day. Majority (61%) verbalized that they drink at confirmed this result that the eating behaviour of women
least 8 glasses of water daily. Majority (52%) argued that is positively correlated with nutrition knowledge12.
they take carbonated beverages 1–2 days a week. 50% However, in contrary another study13 showed that nearly
said that they do not record what they eat. Adolescents 85.6% of students aware of the concept of a balanced
also reported that their daily diet contains breads / nutritious diet (nutritionally balanced food), but only a
cereals / pasta / potatoes / rice daily (74%), fruits such few (7%) applying this concept when choosing food.
as apples, bananas, oranges etc (82%), vegetable of any
Regarding the practice of balanced diet, majority
kind (64%), dairy products (75%). It was also seen that
(74%) of the study participants verbalized that they
majority (32%) consume jams, cookies, candies or other
consume breakfast every day, majority (35%) said that
sweets daily, majority (34%)snack on foods like potato
they never skip meals. Other two studies showed a
chips, cakes, etc 3–4 days a week,majority (36%) snack
different result where more than a half of respondents
on fruit salads 3–4 days per week, majority (44%) eat
rarely eat breakfast, only a third of the subjects have their
fast foods like pizza, sandwich etc. 1–2 days a week,
breakfast every day, and skip breakfast was 15.5%.11 Yet
majority (27%) seek out nutrition information every
another study14 found that 14.9% of students skipping
day in the newspaper, TV, school etc. Majority (36%)
their breakfast.
of adolescents verbalized that they get knowledge on
food habits from parents/teachers, majority (29%) have In the present study majority (56%) of the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 119
adolescents verbalized that they eat three base meals 6. Sonia GM et al.,Eating habits and total and
every day. Majority (64%) consume vegetable of any abdominal fat in Spanish adolescents: Influence
kind every day and majority (82%) adolescents consume of physical activity. Journal of adolescent Health,
fruits every day. These findings are in line with a study11 2012; 50(4):403-409.
where more than half of the subjects were eating three 7. Birch LL, Fisher JO. Development of eating
times a day (54.5%), consumption of vegetables 2 times behavior among children and adolescents.
per day (48.8%) and most of the female adolescent eat Pediatrics, 1998;101(2):539-49.
fruit once a day (47.8%). Another study15 also found that
8. Raheena MB. Prevalence of malnutrition among
56% of female adolescent (14-16 years) in secondary
adolescent girls: A case study [document on the
school had their meals 3 times a day and one more
internet]. Thiruvanthapuram: The Institute; 2001
study16 found that 80% of students consumed vegetables
[cited 2017 Oct 26]. Available from: http://www.
2 times per day.
krpcds.org/
Conclusion 9. Rafia B, Eyad ALS, Fathima BS, Ayed AL.. A
comparative study of knowledge, attitude, practice
The present study concluded that the adolescents of nutrition and non nutrition student towards a
have good knowledge and practice on balanced diet balanced diet in Hail University. IOSR Journal of
.The school, parents and peer influence the nutritional nursing and health science. 2013;2(3): 29-36.
knowledge and practice of balanced diet among
10. Abdul Majid H, Ramli L, Ving SP, Jalaludin MY,
adolescents. As told by the sample, the current study
Abdul Mohasein NA –S. Dietary intake among
setting provides nutrition education to the children. Where
adolescents in a middle income country: an
as in the other studies it was proven that adolescents lack
outcome from the Malaysian Health and Adolescent
knowledge and practice of balanced diet. Therefore it is
Longitudinal Research team study.2016;11(5) :
essential to create an awareness among the adolescents
0155447.
regarding the sound knowledge and practice to balanced
diet and to promote their growth and development. 11. Sitti P, Ida R, Ansar M, Abdul R T. Knowledge,
attitude and practice of balanced diet and
Acknowledgement: The authors wish to thank the correlation with hypochromic microcytic anemia
authorities for permitting to conduct the study and the among adolescent school girls in maros district,
study participants for their whole hearted support. South Sulawesi, Indonesia. Biomedical research.
2016; 27(1): 165-171.
Conflict of Interest: No conflict of interest.
12. Choi ES, Shin NR, Jung EI, Park HR, Lee HM
Source of Funding: Nil and Song KH. A study on nutrition knowledge and
dietary behavior of elementary school children in
References Seoul. Nutrition Research and Practice 2008; 2:
1. World Health Organization, Adolescent health and 308-316. 16.
development. [online] 2012 [cited 2017 October]; 13. Sakamaki R, Toyama K, Amamoto R, Liu CJ and
Available from: http://www.searo.who.int/en/ Shinfuku N. Nutritional knowledge, food habits
section 13. and health attitude of Chinese university students–a
2. Srilakshmi B. Human nutrition for BSc Nursing cross sectional study. Nutrition Journal 2005; 4:
students. 1sted. New age international publication: 1-5.
New Delhi; 2005.1. 14. Abalkhail B and Shawky S. Prevalence of daily
3. Giskesh K, Patterson C, Turrell G. Health and breakfast intake, iron deficiency anaemia and
nutrition beliefs and perceptions of Brisbane awareness of being anaemic among Saudi school
adolescents.Nutr and diet.2005;62[2/3]:67-75. students. Int J Food SciNutr 2002; 53: 519-528.

4. Datta P. Test book of Pediatric Nursing.2nded. New 15. Pareek P and Hafiz A. A study on anemia related
Delhi. Jaypeebrothers medical publishers private knowledge among adolescent girls. International
Ltd;2009. Journal of Nutrition and Food Sciences 2015; 4:
273-276.
5. Marian L. Farhell. Nutrition. 2nded. Jones and
Bartlett publishers; 2004.
120 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Influence of Self-Efficacy on Student Engagement of

Senior Secondary School Students

Kundan1, Bilkees Abdullah2

1Assistant Professor, 2Research Scholar, School of Education, Lovely Professional University, Phagwara Punjab

Abstract
The present study examined to investigate the influence of self-efficacy on student engagement of Senior
Secondary School students. The respondents were students from senior secondary school of Jammu and
Kashmir. A Sample of 400 senior Secondary School Students (200 boys and 200 girls) were selected from
Jammu and Kashmir by employing simple random sampling. T-test, correlations and regression were
employed to analyze the data. The study indicated that (a) there exists significant difference between senior
Secondary School boys and girls with their self-efficacy (b) there exists Significant Difference Between
Private and Government senior Secondary school Students with their self-efficacy (c) there exists Significant
Difference Between senior Secondary School Boys And Girls with their student engagement (d) there
exists significant difference between private and government senior Secondary school Students with their
student engagement. It revealed that significant relationship was found between self-efficacy and student
engagement of senior secondary school students. It also found the self-efficacy had significant influence on
student engagement of senior Secondary School Students.

Keywords: Self-efficacy, Student Engagement, Senior Secondary School students.

Introduction capacity to compose and execute a given strategy to take

care of an issue or achieve an assignment”. As indicated
Self-efficacy refers to a man’s conviction that they
by2 self- efficacy alludes to people’s feelings that they
can proficiently completed at an allocated levels in a
can effectively perform given errands at assigned levels.
specific academic part of information. A man’s trust
Self-efficacy is the conviction about person’s assessed
in their ability to make, executes, and guides execution
capacity to play out a given task. Self- Efficacy contains
with the ultimate objective to deal with an issue or
convictions individuals have about their capacity to
accomplish an endeavor at an appointed level of capacity
achieve specific results.3 It is noticed that self-efficacy
and aptitude. Students who are sure about their capacity
is the certainty a man has in realizing a particular result.
to execute, to sort out and manage with their basic
Self-efficacy as persons’ confidence about their abilities
reasoning or activity execution at an allocated levels
to make appointed levels of execution that actions
of fitness is showing high self-efficacy. Self-efficacy
affect over events that impact their lives. As shown by
is by and large viewed as a multidimensional develops
him, it chooses how people feel, think, and conscious
separated over different spaces of working. Self-efficacy
themselves and carry on.4 Self- efficacy suggested
is grounded in principle by1. As per Self-Efficacy
proposes that Academic Self- efficacy can change in
assumption, Self-Efficacy is a “person’s trust in their
quality as a component of undertaking trouble. Two
general classes of academic hope convictions have
been assumed. Understanding the distinction between
Corresponding Author: these two types of hope convictions is very important
Bilkees Abdullah as people can trust that a specific conduct will deliver a
Research Scholar, School of Education, Lovely specific (result desire), yet may not trust they can play
Professional University, Phagwara Punjab, India out that conduct (efficacy desire)”. Found that there
e-mail: [email protected] exists a positive correlation between Mental Health of
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 121
senior secondary school Boys and girls with their Life cooperation and communication with companions.
Skills and Self-Efficacy.5 Results demonstrated that Moreover, it covers students’ investment in various
self-efficacy mediated the correlation between academic elements of school life, e.g., school community activity
performance and performance accomplishments.6 found and extracurricular actions.
that higher level of academic self-efficacy is positively
correlated with scholastic performance.7 The present study is intended to find out how Student
Engagement is related to Self-efficacy. Movements like
Student Engagement: The idea of student universlization of elementary education as a fundamental
engagement has progressively increased the right have improved the quality and quantity of school
consideration throughout the most recent decade.6 It education in India. Kashmir, being a role model, has
comprehensively alludes to Students’ Engagement in better education system as compared to other states.
actions that gave up to their knowledge accomplishments Self-efficacy has a significant task in influencing
and their sense of belongings with their educational students’ academic Success and Student engagement.
network. It additionally included actions other than Many teachers complain that student’s are giving less
those straightforwardly identified with course work, for important to their academic activities, because they were
example, non necessary companion learning exercises not able to cope up effectively with academic success.
and administration exercises, for example, positions of Improved Self-efficacy may help to increases Student
authority in student tutoring or study group assistance. engagement. In this study investigators try to find out
Also, engagement is how much students are engage whether Self-efficacy had any significant influence on
in their learning actions and their commitment is Student engagement.
emphatically connected to a large group of preferred
results, include student satisfaction and determinations. Objectives:
This definition infers the utilization of three interrelated 1. To compare the difference of self-efficacy of senior
criteria to evaluate Student engagement levels namely: secondary school students on the based on gender.

Emotional Engagement: Refers to the connections 2. To compare the difference of student engagement
among students and their teachers, schoolmates and of senior secondary school students on based on
school. This has likewise been called ‘recognizable gender.
proof’ with school and learning rehearses. Students are 3. To find out the relationship between self-efficacy
engaged in when they feel incorporated into the school and student engagement of senior secondary school
and feel a passionate security with the school, its teachers students.
and their companions.
4. To find out the influence of self-efficacy on student
Cognitive Engagement: It can be understand engagement of senior secondary school students.
as a student’s psychological importance in their own
Hypotheses:
knowledge. At the point when a student is cognitively
engage in, student believe, spotlight on accomplishing 1. There exists no significant difference of self-efficacy
objectives, are stretchy in their endeavor and familiarize of senior secondary school students on the basis of
you to dissatisfaction. This is unique in relation to high Gender.
achievement a student who is performing great may at
2. There exists no significant difference of Student
present be disengaged whether they are wandering and
engagement of senior secondary school students on
not inspired to endeavor themselves more than is vital
the basis of Gender.
to obtain by.
3. There exists no significant relationship between
Behavioral Engagement: Refers to students’ Self-efficacy and Student engagement of senior
involvement in classroom activities and in learning. secondary school students.
This includes holding fast to behavior rules, leaving
to exercises as necessary and reaching at classes on 4. There exists no significant influence of self-efficacy
time. Essentially, Behavioral Engagement refers to on Student engagement of senior Secondary School
the educational performances that are critical for Students.
high students’ implementation, which may include
122 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Methodology items and 3 sub-dimensions (cognitive, emotional,

and behavioral engagement). The final set of
Descriptive Survey Method was used. Data was
statements was check for internal consistency using
collected from Senior Secondary School students of
SPSS-22 version. The Cronbach’s alpha for the final
Jammu & Kashmir, by employing simple Random
set of statements was found out to be .765
Sampling technique. The sample consists of 400 senior
secondary school Students. Procedure: Initially the investigators randomly
identified various secondary schools and contacted the
Instruments: authorities of the secondary school personally. The
1. Self-Efficacy Scale: this scale was developed purpose, objectives and relevance of the study were
by Bhatnagar and Mathure. Self-Efficacy is the explained to the head of the institution. Then, the tools
confidence that one can successfully complete in were directed to the participant after giving necessary
a given circumstance. Self-Efficacy Scale plans to instructions to them. Reassurance was given to each
study the dimension of self-efficacy in any age group that the information collected from them would be used
over 14 years. It comprises of 22 items, managing only for research identity and purpose would not to be
eight factors. Reliability co-efficient of the scale was disclosed. The scoring was done as per the manual and
estimated by test-retest and found 0.79 to 0.86. entered the data in to a spread sheet for further Statistical
Analysis by using t-test, correlation and Regression to
2. Student Engagement Scale: This scale was developed
analyze the data.
by Dogan (2014) and was adopted in Indian context.
The scale is a 5-point Likert Scale consisting of 22

Results and Discussions

Table 1: There exists no significant difference of self-efficacy of senior secondary school students on the basis
of Gender.

Gender N Mean S.D t-value Levels of significance

Self-efficacy Boys 200 88.03 4.40
6.33 Significant
Girls 200 84.91 4.96

According to the above table reflects that the mean (88.03) of boys’ Senior Secondary School Students was
scores of boys and girls of senior secondary school greater than (84.91) of girls Senior Secondary School
students is 88.03 and 84.91 respectively. The S.D for Students. So, it can be interpreted that boys’ Senior
boys and girls Senior Secondary School Students is 4.40 Secondary School Students had higher self-efficacy than
and 4.96 respectively. Further, the t-value is 6.33 which girls’ senior secondary school students.
is significant at 0.05 level. So, that there exist significant
difference between Senior Secondary school girls and According to the above results, it confirmed that the
boys in their self-efficacy. hypothesis no. 1, “there exists no significant difference
of Self-efficacy of Senior Secondary School Students on
Further it is evident from the table that mean score the basis of gender” is thus rejected.

Table 2: There exists no significant difference of Student engagement of senior secondary school students on
the basis of Gender.

Gender N Mean S.D t-value Levels of significance

Student
Boys 200 90.98 4.18
engagement 7.51 Significant
Girls 200 88.06 3.49
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 123
According to the above table reflects that the mean was greater than (88.06) of Girls Senior Secondary
scores girls and boys of Senior Secondary School School Students. So, it can be interpreted that Boys
Students are 90.98 and 88.06 respectively. The S.D Senior Secondary School Students had higher Student
for girls and boys Senior Secondary School Students engagement than Girls Senior Secondary School
is 4.18 and 3.49 respectively. Further, the t-value is Students.
7.51 which are significant at 0.05 levels.. So, that there
exist Significant Difference Between Senior Secondary According to the above results, it can be confirmed
School Girls and Boys in their Student engagement. that hypotheses no 2 i.e. “there exists no significant
difference of Student engagement of Senior Secondary
Further it is obvious from the table that Mean score School Students on the basis of gender” is thus rejected.
(90.98) of Boys Senior Secondary School Students

Table 3: There exists no significant relationship between self-efficacy and student engagement.

Student Engagement Self-efficacy

Pearson’s Correlation 1 .316**
Student engagement (sig.2 tailed) .000
N 400 400
Pearson’s Correlation .316** 1
Self-efficacy (sig. 2 tailed) .000
N 400 400

**correlation is significant at 0.01 levels of significance (2-tailed).

According to the above table it can be seen that and that those who have high self-efficacy show more
Self-efficacy significantly correlated with Student Cognitive, Behavioral and Emotional engagement.
engagement. It is observed that there exists a significant Manikandan and Neethu (2018) supported our study and
relationship between Self-efficacy and Student found that Student engagement is significantly related to
engagement of Senior Secondary School Students. From academic Stress and Self-efficacy.
the above table it reflects that coefficient of correlation
between Self-efficacy and Student engagement of senior There exists No Significant Influence of Self-
secondary school students is .316 that is significant Efficacy on Student Engagement.
at 0.01level of significance. This indicated that there Table 4: Model Summary for Regression Analysis
exists a significant relationship between Self-efficacy
and Student engagement of Senior Secondary School R Adjusted Std. Error of the
Model R
Students. It also shows that Self-efficacy had significant Square R Square Estimate
Influence on Student engagement of Senior Secondary 1 .316* .100 .098 3.899
School Students.
According to Above table shows the correlation
Therefore hypothesis 3, namely “there exists no coefficient of Self-efficacy and Student engagement of
significant relationship between Self-efficacy and adolescents. The coefficient of correlation is .316* and
Student engagement” stands rejected. its square is 0.100 Regression suggests that predictive
variables i.e. Self-efficacy can explain 1.0% variance of
Thus self-efficacy increased student engagement. the criterion variable (Student engagement).
Self-efficacy plays an essential position in determining
student engagement. Students’ who have possessed In Order to study the influence of self-efficacy on
high self-efficacy are very much more engaged in their student engagement ANOVA has been applied on the
studies. It is same as in the case that Student engagement influence of self-efficacy on student engagement.
124 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 5: Summary of Anova by Regression

Model Sum of square Df Mean of square F Sig

Regression 673.494 1 673.494
Residual 6050.203 398 15.202 44.304 .000*
Total 6723.698 399

According to the above table shows that the results revealed that Self-efficacy has significant influence on
of ANOVA of self-efficacy on student engagement. Student engagement. So there exists significant influence
It is clear that acquired F-value is (44.304) which are of Self-efficacy on Student engagement. Therefore,
statistically significant at 0.01 level of significance which regression analysis is allowed and feasible.
shows the statistically significant Relationship Between
self-efficacy and Student engagement. The predictive Therefore hypothesis 4, namely “there exists be
variable (Self-efficacy) can influence the criterion no significant influence of Self-efficacy on Student
variable (Student engagement). The above findings engagement” stands rejected.

Table 6: Summary of coefficient of regression

Unstandardized Coefficient Standardizes Coefficient

Model T Sig.
B Std. Error Beta
(Constant) 66.734 3.422 19.503** .000
.316
Self-efficacy .263 .040 6.656* .000

According the above table with B=.263 and t=6.656 School Students had higher Self-efficacy than
which is significant at 0.05 level of significance. It Private senior secondary school Students.
implies that Self-efficacy plays an important role in
• There exists Significant Difference Between Senior
predicting Student engagement. So, it can be revealed
secondary school Girls and Boys in their Student
that Self-efficacy had significant Influence on Student
engagement. Boys had higher Student engagement
engagement. The regression equation for predicting
than Girls.
student engagement by the predictor variable i.e. Self-
efficacy. Therefore, the regression equation formulated • There exists significant difference between in
from these two variables is given below: Student engagement among Seniorsecondary school
students on the basis of Type of School. Government
Student engagement = 66.734 + .263× Self-efficacy Senior Secondary School Students had higher than
Private Senior Secondary School Students.
Conclusions
• Self-efficacy had significant Influence on Student
The study presented the following conclusions: engagement. There exists significant influence of
• Based on the result analysis it found that there exist Self-efficacy on student engagement.
significant difference between senior secondary • There exists a Significant relationship between
school Boys’ and Girls’in their self-efficacy. Boys self-efficacy and Student engagement of Senior
of senior secondary school students had higher secondary school students. It also shows that
self-efficacy than girls of Senior Secondary School Self-efficacy had significant Influence on Student
Students. engagement of Senior Secondary School Students.
• There exist significant Difference Between Private Implications of the study: The findings revealed
and Government senior secondary school students that self-efficacy is significantly correlated with Student
in their Self-efficacy. Government Senior Secondary engagement; this also has some suggestion. Since self-
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 125
Efficacy alludes to an individuals’ opinion of their References
capability to arrange and achieve the plan of activity
1. Bandura A. Self-efficacy: toward a unifying theory
essential to bring about prearranged sorts of engagement
of behavioural change. Psychological review. 1977
and worried about the estimation of what one can
Mar; 84(2):191.
achieve with the aptitudes one presently achieves. It
suggests that students who are Self-efficacious will in 2. Schunk DH. Self-efficacy and academic motivation.
general produce and test elective strategies of activities Educational psychologist. 1991 Jun 1;26(3-4):
when they don’t at first make progress. This implies that 207‑31.
students ought to be positive to create, have or develop 3. Pajares F, Britner SL, Valiante G. Relation between
efficacy disposition. This is essential in light of the fact achievement goals and self-beliefs of middle school
that it could fill up in as a defense that may support the students in writing and science. Contemporary
students up regardless of their experience to be engaged. educational psychology. 2000 Oct 1;25(4):406-22.
If students are given tasks that are challenging but not too 4. Eccles JS, Wigfield A. Motivational beliefs, values,
difficult and they experience success upon completion of and goals. Annual review of psychology. 2002
these tasks that Self-efficacy to learn may increase. As Feb;53(1):109-32.
Self-efficacy to learn increases, so will interest, value, 5. Bashir, L, Abdullah, B. Mental health among
and utility. A strategy such as this one would be very senior secondary school students in relation to life
useful for teachers to implement. Teachers can organize skills and self-efficacy. RESEARCH REVIEW
and design their instructions to have a constructive result International Journal of Multidisciplinary, 2018
on students’ self-efficacy to learn which would lead to Sep 3(9).
improved Student engagement and improved learning.
6. Lane J, Lane AM, Kyprianou A. Self-efficacy, self-
Declaration of Conflict of Interests: The author(s) esteem and their impact on academic performance.
declared no potential conflicts of interests with respect Social Behavior and Personality: an international
to the research, authorship, and/or publication of this journal. 2004 Jan 1;32(3):247-56.
paper. 7. Choi N. Self‐efficacy and self‐concept as predictors
of college students’ academic performance.
Ethical clearance: All procedures performed in this
Psychology in the Schools. 2005 Feb;42(2):197-
paper were in accordance with the ethical standards of
205.
the institution and the national research committee.

Funding: The author(s) received no financial

support of the research, authorship, and /or publication
of this paper.
126 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Psychological Effects of Trauma to Anterior Teeth

Lakshmi Nidhi Rao1, Aditya Shetty2, Mithra N. Hedge3

1Lecturer, 2Additional
Professor, 3Vice Principal and Head of the Department, Department of Conservative
Dentistry and Endodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte Deemed to be University,
Deralakatte, Karnataka State, India

Abstract
Dental trauma has a very distressing experience on physical, emotional and psychological aspects of the
patient. The aim of the study was to determine the psychological effects of anterior dental trauma on patients.

A questionnaire study was carried out to know the psychological aspects of trauma to anterior teeth based
on the Oral Health Impact Profile (OHIP-14) index. It is regarded as the most comprehensive tool for
measuring Oral Health Related Quality of Life. This study concentrated only on psychological discomfort
and psychological disability. Each item was scored on a five-point scale ranging from “never” (coded 0) to
“very often” (coded 4).

The statistical significance of the scores thus obtained and the mean levels of the severity scores between
genders and age groups were calculated using the statistical chi-square test. In our study psychological effects
to anterior teeth trauma was most observed in the age group of 18-25. Interestingly when the observation
was monitored across genders, we observed large psychological effect in females when compared to male
gender.

Keywords: Anterior dental trauma, psychological effects, OHIP index.

Introduction Oral Health Related Quality of Life (OHRQoL)

forms an integral part of general health and well-being
Health is described “a complete state of physical,
and is recognized by the WHO as an important segment
mental, and social well-being of an individual and
of the Global Oral Health Program (WHO, 2003).[2]
not just mere absence of disease” (WHO, 1948). This
It is imperative to evaluate the extent to which the
concept of health embraces the bio-psychosocial model
oral diseases impacts on ones normal functioning and
of health into which physical functioning, symptoms,
psychology.[3]
emotional and social well-being are holistically
incorporated (Kleinman, 1988). Hence health related In the field of dentistry, OHRQo Laddress four
researchers have rightly focused on health as a multi- dimensions: pain and discomfort; functional aspects
dimensional construct.[1] concerning the ability to chew and swallow food without
difficulty, speaking and pronunciation; appearance
and self-esteem; and social aspects reflecting social
interaction with others.[4]

Corresponding Author: So it is fair to qualify that oral health affects various

Dr. Lakshmi Nidhi Rao aspects of social life, including social interaction, self-
Lecturer, Department of Conservative Dentistry and esteem, school and job related performance, specifically
Endodontics, A.B. Shetty Memorial Institute of Dental when the issues related to anterior dental trauma are
Sciences, Nitte Deemed to be University, Deralakatte, involved. Incidents arising from physical fight, traffic
Karnataka State, India accident and sporting injuries contributes the major
e-mail: [email protected] cause of anterior dental trauma. [5]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 127
Dental trauma is usually a pain filled experience psychological levels of the patient which is a matter of
for most people which can impair oro-facial function, great concern.[8,9,10]
negatively affecting growth, aesthetics and occlusion.[6]
Unlike a chronic condition, severe dental trauma causes OHIP-14 index assesses seven dimensions of impacts
immediate and unexpected pain. The obvious economic of oral conditions on one’s quality of life including
cost apart, it can trigger a series of socio-economic functional limitation, physical pain, psychological
consequences affecting the quality of life and possibly discomfort, physical disability, psychological disability,
lead to the absence from college or work, disturbances social disability and handicap.[11] This is widely regarded
during sleep and changes in the normal daily schedule. as the most comprehensive assessment for measuring
This could be further compounded by the stress patients OHRQoL.
may experience as a result of unhelpful behaviour by The aim of the study was to determine the
their peers, society and family members. The impact psychological effects of anterior dental trauma on
is quite significant when anterior dental trauma is patients and to assess the impact of these injuries on the
involved, which is what this study tries to document via quality of life based on OHIP-14 index.
Oral Health Impact Profile (OHIP-14) survey.

Since anterior dental trauma is often caused by

Materials and Method
accidents that cause life-threatening injuries, limb The study was conducted in the Department of
fractures or concussion, emergency care prioritizes on Conservative Dentistry & Endodontics, AB SMIDS,
more important issues. As a consequence of this delay, Karnataka, India. Ethical clearance was obtained from
sometimes it becomes impossible to provide timely Nitte (Deemed to be University), Cert.No: ABSM/
treatment that would have otherwise allowed the affected EC07/2019.
front tooth to be saved.[7]
The total numbers of subjects were 256 based on
Dental trauma frequently affects the upper central approximately 20% incidence of anterior tooth fractures.
incisors, most likely because of their position in the Patients in the age group of 18 and above with anterior
mouth and also having less of a protection in comparison tooth trauma were included in the study. Participation
with the other teeth. Consequently the position and was voluntary, anonymous and started off with patients
appearance of the anterior teeth have very important consent.
psychological and social impacts on the quality of life
of the patient. When injuries to incisors produce pain, Study was carried out to know the psychological
poor aesthetics/disfigurement or other psychological aspects of trauma to anterior teeth based on the OHIP-
effects, patient may avoid smiling or laughing and this 14 index, specifically w.r.t psychological discomfort
can affect their social relationships. So overall this has a and disability. Each item was scored on a five-point
very distressing experience on physical, emotional, and scale ranging from “never” (coded 0) to “very often”
(coded 4).[1,2,10,12]

Findings:
1. Gender comparison
Table 1: Psychological discomfort scores

Psychological discomfort scores

Total
Never Hardly ever Occasionally Fairly Often Very Often
Count 5 18 112 22 1 158
Male
% within gender 3.2% 11.4% 70.9% 13.9% 0.6% 100.0%
Gender
Count 2 1 8 75 12 98
Female
% within gender 2.0% 1.0% 8.2% 76.5% 12.2% 100.0%
Count 7 19 120 97 13 256
Total
% within gender 2.7% 7.4% 46.9% 37.9% 5.1% 100.0%

Chi-Square- 13.438 P= 0.001 sig

128 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 2: Psychological disability scores

Psychological disability scores

Total
Never Hardly ever Occasionally Fairly Often Very Often
Count 0 128 21 5 4 158
Male
% within gender 0.0% 81.0% 13.3% 3.2% 2.5% 100.0%
gender
Count 6 15 51 18 8 98
Female
% within gender 6.1% 15.3% 52.0% 18.4% 8.2% 100.0%
Count 6 143 72 23 12 256
Total
% within gender 2.3% 55.9% 28.1% 9.0% 4.7% 100.0%

Chi-Square-108.365 P= 0.001 sig

2. Age comparison:
Table 3: Psychological discomfort scores

Psychological discomfort scores

Total
Never Hardly ever Occasionally Fairly Often Very Often
Count 14 12 20 90 2 138
18-25
% within age 10.1% 8.7% 14.5% 65.2% 1.4% 100.0%
Count 0 1 50 34 1 86
age 25-35
% within age 0.0% 1.2% 58.1% 39.5% 1.2% 100.0%
Count 9 12 10 1 0 32
35-45
% within age 28.1% 37.5% 31.2% 3.1% 0.0% 100.0%
Count 23 25 80 125 3 256
Total
% within age 9.0% 9.8% 31.2% 48.8% 1.2% 100.0%

Chi-Square=108.433 p=0.001

Table 4: Psychological disability scores

Psychological disability scores

Total
Never Hardly ever Occasionally Fairly Often Very Often
Count 2 6 14 88 28 138
18-25
% within age 1.6% 4.7% 10.9% 63.8% 21.9% 100.0%
Count 1 10 42 23 10 86
age 25-35
% within age 1.2% 11.6% 48.8% 26.7% 11.6% 100.0%
Count 2 9 11 8 2 32
35-45
% within age 6.2% 28.1% 34.4% 25.0% 6.2% 100.0%
Count 5 25 67 119 40 256
Total
% within age 1.9% 9.7% 26.1% 46.4% 15.6% 100.0%

Chi-Square=67.451 p=0.001

The OHIP-14 data were captured and details were The statistical significance of the scores and the mean
entered into SPSS tool (v.16; IBM Corp, Somers, NY) levels of the severity scores between genders and age
for further analysis. The dependent variables were based groups were calculated using the statistical chi-square
on the responses to the OHIP-14 were made on a five- test.
point ordinal scale ranging from ‘‘never’’ coded as ‘‘0’’,
‘‘hardly ever’’ coded ‘‘1’’, ‘‘occasionally’’ coded ‘‘2’’, Above Tablescaptures the percentage distribution
‘‘fairly often’’ coded ‘‘3’’, to ‘‘very often’’ coded ‘‘4’’. of patients responses across the two dimensions namely
psychological discomfort and psychological disabilityfor
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 129
the scale ranging from “never” to “very often” (p=0.001). Among these anterior dental trauma forms an
important and visible part of human anatomy. These are
In Table-1, which is related to psychological characterized as major public health problems due to
discomfort scores related to breakdown w.r.t gender, their high prevalence and serious aesthetic and functional
around 70.9% of the male individuals experienced consequences. Such trauma can significantly disrupt
“occasional” psychological discomfort compared to patients’ normal functioning and impact dramatically on
76.5% impact of “fairly often” in females (p=0.001). the quality of life.
In Table-2, which is related to psychological Since anterior dental trauma is often caused by
disability scores related to breakdown w.r.t gender, accidents that cause life-threatening injuries, limb
around 81% of the male individuals experienced “hardly fractures or concussion, emergency care prioritizes
ever” psychological disability compared to 52% impact initially on more critical issues. As a consequence of
of “occasional” in females (p=0.001). this delay, sometimes it becomes impossible to provide
In Table-3, which is related to psychological timely treatment that would have otherwise allowed the
discomfort scores related to breakdown w.r.t age, around affected front tooth to be saved.[8]
48.8% of the individuals experienced the impacts of The psychological and social impact of dental trauma
“fairly often”. Largest contribution to this came from is widely recognized as having consequences that can
the age group of 18-25 with 90 individuals out of affect emotional balance, social contact and also well-
138(65.2%) experiencing this impact (p=0.001). being of the patient. There is an evidence of increasing
In Table-4,which is related to psychological necessity to use indices for measuring the impact of oral
disability scores related to breakdown w.r.t age, around health on the quality of life. OHIP-14 index has been the
46.4% of the individuals experienced the impacts of flag bearer in this regard and is thus used for this study.
“fairly often”. Largest contribution to this came from OHIP-14 index is used to measure patient’s
the age group of 18-25 with 88 individuals out of 138 perceptions of the social impact of oral disorders on their
(63.8%) experiencing this impact (p=0.001). general well-being. It provides a comprehensive system
Age group 18-25 showed higher scores in the of measurement for dimensions related to discomfort,
psychological disability and discomfort dimension. self-reported dysfunction and related disability arising
The comparison across genders showcased a from oral conditions.[12]
similar significantly higher uptick for women in the According to Lockeret al., OHIP-14 is a patient-
psychological dimensions. centred assessment. It gives a greater weight to
behavioural and psychological outcomes and is found
Discussion to be better at detecting psychosocial impacts among
Psychological trauma occurs as a consequence of individuals. Hence it also satisfies the main criteria for
an overwhelming amount of stress experienced that the measurement of OHRQoL.
exceeds one’s ability to cope or integrate the emotions
involved with that experience. Effects of the trauma The study outcome capturedin above set of tables
varies according to one’s subjective experiences. So, show cases the percentage distribution of responses
not all who experience a traumatic event will become across age and gender respectively for the two
traumatized psychologically. psychological dimensions for category scale ranging
from ‘‘never’’ to ‘‘very often’’ as captured in the OHIP-
Traumatic injuries constitute painful and distressing 14 index. The purpose of this paper was to review
event with multilevel consequences for patient and their the impact of anterior dental trauma on psychological
families. Despite being confined in a small body region discomfort and psychological disability attributes across
as is the oral cavity, dental trauma constitutes a relatively various age categories and gender respectively.
common finding in population-based studies. Andersson
noted that although the oral region comprises 1 percent Psychological effects dimension based on
of the total body area, oral injuries account for almost 5 agecriteria: When this psychological effect dimension
percent of all injuries and for a higher proportion among was reviewed based on age criteria, it was observed
early adults. that lowest measured age group of 18-25 had the most
130 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
psychological impact at 65.2% with the issue tapering 2. Loss of “hours of schooling/work” with economic
down with age. consequences. Being able to take time from
school/work for these procedures might become
The younger age group with little maturity has cumbersome if the dental clinics are not located at
higher psychological impact than the older more mature comfortable points.
groups post 25 years of age. Severity of the issue could
be higher among lower age groups, since usually nature 3. Perception of work peers, friends and family
of accidents occurs from sports or accidents involving members.
rash driving of youngsters. Additionally visit to dental emergency can trigger
dental anxiety/fear responses among first time visitors.
Psychological impacts of dental trauma for this age
Hence calming effect of dental surgeon, explanation of
group may be severe so aesthetic considerations should
the procedures in an easy way and anon-hospital like
not be neglected. It is found to be one of the important
environment goes a long way in helping the patient settle
considerations of the age group 18-25. Usually dental
down and reduce the psychological impact.
conditions are the most severe among health issues
in early stages of adulthood, however as one age, The data presented in this study provide a insight
other health considerations dominate including life into patients’ feelings and should be considered essential
threatening ones. It is quite likely as a result of this, older when evaluating further treatment options. In addition to
age groups manage the situation in a better way resulting the prognosis and outcomes, clinicians should consider
in reduction of psychological discomfort as compared to patients’ preferences and perceptions as well as the
younger generation. influence each therapy may have on their quality of life
both short-term and long-term.
Equally important is the fact that younger age group
usually is just about starting to become independent Health psychologists have recognized that
financially. Hence this is a in-between phase wherein behavioural assets such as resilience, social
they are largely still reliant on the family for financial connectedness and optimism have a direct correlation
support. As a result may neglect the dental treatment at with an individual’s quality of life and howwell one is
the appropriate time and the effects become severe later able to cope with health conditions.[1]
on.
Conclusion
Psychological effects dimension based on gender:
Interestingly when the observation is monitored across In our study psychological discomfort to anterior
gender, we observe large discomfort in females in teeth trauma was most observed in the age group of
comparison with male gender. 18-25. Interestingly when the observation is monitored
across genders, we observe large discomfort in females
Aesthetic dimension forms akey part for female in comparison with male gender.
gender, considerations encompass:
The study covered suburban areas of Dakshina
1. Beauty affected hence social impact Kannada district, further studies need to be carried out
2. Societal pressureof friends, family, peers and social for a larger population set. Irrespective of age and gender,
media like Facebook, Instagram etc. psychological impact if not handled appropriately could
have a life-long impact and affect the general well-being
It is quite likely this impact would be a lot lower of the patient.
among lower income groups as day to day survival is
more important compared to other factors. This study will help to create need based and critical
psychological adjunct services which can be incorporated
There are general attributes which adds to the into various community-based projects, with the basic
psychological impact and which usually cuts across idea of integrating dental health with overall well-being
gender and ages: and quality of life of the patient.
1. Affect by presence of blood and visible nature of the Communication and positive reinforcement method
dental trauma. is most effective way in reducing the psychological
impact and should be considered a valuable investment.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 131
This is aptly highlighted by Andersson in his editorial: 5. Andersson L. Trauma in a global health perspective.
“empathy for our trauma patients is the common Dent Traumatol 2008;24:267
denominator.”It helps to build a trusting relationship and 6. Intrusion injuries of primary incisors. Part I:
plays a key role in relieving the distress experienced by Review and management, Diab M, elBadrawy
the patient. HE, Quintessence Int 2000; 31(5): 327-34.[PMID:
11203943]
Conflicts of Interest: There are no conflicts of
interest. 7. Review of recommendations for the management
of dental trauma presented in first-aid textbooks
Source of Funding: Self. and manuals, Emerich K, Gazda E, Dent Traumatol
2010; 26: 212–6.
References 8. Traumatic oral vs.non-oral injuries, Peterson
1. Oral health-related quality of life: what, why, how, EE, Anderson L, Sorensen S, Swedish Dent J.
and future implications, Sischo L, Broder HL, J 1997;21:55.
Dent Res 2011, 90:1264–1270. 9. Textbook and Color Atlas of Traumatic Injuries to
2. What do measures of ‘oral health-related quality the Teeth, Andreasen JO, Andreasen FM, 3rd ed.
of life’ measure?, Locker D, Allen FP, Community Copenhagen: Munksgaard; 1994.
Dent Oral Epidemiol 2007, 35:401–411. 10. Prevalence of fractured incisal teeth among
3. Quality of life measured by OHIP-14 and GOHAI children in Harris County, Alonge OK, Narendran
inelderly people from Bialystok, north-east Poland, S, Williamson DD, Texas. Dent Traumatol.
Ewa Rodakowska, Karolina Mierzyńska, Joanna 2001;17:218–21.
Bagińska and Jacek Jamiołkowski 11. Development and evaluation of the Oral Health
4. Slade GD. Assessment of oral health-related quality Impact Profile,Slade GD, Spencer AJ, Community
of life. In: Inglehart MR, Bagramian RA, editors. Dent Health 1994, 11:3–11.
Oral Health-Related Quality of Life. Chicago, IL: 12. Assessment of oral health related quality of life.
Quintessence; 2002. pp. 66–79. Health Qual Life Outcomes, Allen PF, 2003, 1:40.
132 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Effect of Aerobic Exercises on Selected Physiological Variables

among College Long Distance Men Athletes

M. Senthil Kumar1, P.R. Nagaraj2, Ampili3

1Asst. Professor, 2M.Phil. Scholar, Dept. of Physical Education and Sports Sciences, Srmist, Kattankulathur,
3Ph.D. Research Scholar, Dept. of Physical Education, Annamalai University

Abstract
The study aims to evaluate the effect of aerobic exercises on selected physiological variables among college
long distance men athletes on systolic blood pressure and diastolic resting heart rate. Thirty (N=30) college
men, long distance runners who is selected St. Joseph’s Prime Sports Academy Chennai Tamilnadu who
have been participating in inter collegiate athletics meet was randomly selected as subjects. The age limit is
from of old 18 to 25 years respectively Subjects. Subjects who selected were randomly II team groups each
15. Has been under taken as Group I with aerobic exercises acted as experimental group and Group II acted
as the Control group.. The duration of the practice period was restricted to twelve weeks of aerobic practice.
The pre-test on the chosen criterion variables was taken prior to the administration of the aerobic exercises
and the post-test was taken at the end of the twelfth week. The data obtained from the groups prior to and
immediately after the training on the chosen criterion variables were analyzed statistically using the t- test to
determine whether the groups differ significantly among the pre and post test means. The confidence level
was maintained at 0.05 in all the cases to evaluate the hypothesis. The training effects of aerobic practices
evidenced significant influence over the physiological variables of college level long distance men athletes.

Keywords: Aerobic exercises Physiological variables, Systolic blood pressure, Diastolic resting heart rate.

Introduction method of training.3

Training with actual effect depends upon various Importance of training: An individual is said to
factors such as training loads, means of recovery, be physically fit, when he is completely healthy. At long
assessment of load and performance capacity, sports last, it involves time and inspiration to proceed when
equipment, nutrition, psychological characteristics and the tip top competitor needs to dedicate a few hours
method adopted for imparting theoretical instruction. per day to preparing. Endurance Training, continuance
Physical Education and Sports is a thirsty area which is the capacity to take part in action for quite a while
needs many kinds of training means and method to without exhaustion.4 Perseverance is produced through
improve the overall performance of the sportsperson.1 all medium and physical organs and frameworks.
To improve the sports performance the athlete needs to Continuance is ability to keep up a high caliber of work
take part in systematic training by the way of scientific despite weakness. Every athletic ability and occasions
method of training. Actual effect of training depends upon expect continuance to some degree; anyway the vitality
several factors such as training loads, means of recovery, prerequisites of amazingly concise aptitudes, for
assessment of load and performance capacity, sports example, a solitary punch are typically met effortlessly.5
equipment, nutrition, psychological characteristics and Aerobic exercise at a drawn out and moderate power
method adopted for imparting theoretical instruction.2 enhances vigorous limits.
Physical Education and Sports is a thirsty area which
needs many kinds of training means and method to Aerobic Exercises: High-impact importance with
improve the overall performance of the sportsperson. oxygen is on focus for healthy body. Indeed, even so
To improve the sports performance the athlete needs to the elements of the thought are more convoluted than
take part in systematic training by the way of scientific inferred by the definition. High-impact can be seen as a
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 133
mind boggling arrangement of real free market activity. were presented. The purpose of this study was to
That is the body needs vitality for any sort of action and find out the effects of aerobic exercises on selected
the need is filled by consuming 10 off the sustenance physical and physiological variables of college long
that eat. Oxygen is the start the fuel needs to consume distance of runners. Thirty (N=30) college men, long
although heart stimulating exercise is the word as a rule distance runners who is selected St. Joseph’s Prime
use.6 Sports Academy Chennai Tamilnadu who have been
participating in inter collegiate athletics meet was
Health benefits: The physiological benefits randomly selected as subjects. The age limit is from of
are highly significant where stable autonomic old 18 to 25 years respectively Subjects.
nervous system equilibrium, with a tendency toward
parasympathetic nervous system dominance rather Subjects who selected were randomly II team
than the usual stress– induced sympathetic nervous groups each 15. Has been under taken as Group I with
system dominance, pulse rate, respiratory rate and blood aerobic exercises acted as experimental group and
pressure decrease, cardiovascular efficiency increases, Group II acted as the Control group.. The duration of the
respiratory efficiency increases (respiratory amplitude practice period was restricted to twelve weeks of aerobic
and smoothness increase, tidal volume increases, vital practice. A written consent has also been obtained from
capacity increases, breath–holding time increases), the subjects. However, they can withdraw their consent
endurance and energy level increases, weight normalizes, in case they felt any discomfort during the period of
sleep improves, immunity and pain decreases. their participation. These are the dropouts in this study.
The same Exercise will be followed, and intensity,
Statement of the problem: The research aims is increased week by week, for 6 week, weekly three
to evaluate the effect of aerobic exercises on selected days Monday, Wednesday, and Friday .Before exercise
physiological variables among college long distance warm–up 10 Min, after exercise warm down 5 min,
men athletes on systolic blood pressure and diastolic subjects were followed.
resting heart rate.
Statistical Analysis: The above study or project
Methodology pays attention mainly on the testing between means from
This procedures and method applied in the selection two treatment groups and also deals with the increase
of subjects, selection of variables, selection of tests, of means between each group from base line to the post
competency of the tester, reliability of the instruments, treatment for various measures. The statistical was tool
reliability, orientation to the subjects, validity of the used for those which are the individualized effect that
questionnaires, procedure of scoring, pilot study, are analyzed aerobic exercises ratio. The pre and post
practice programmed, collection of data, administration practice performance of the groups is analyzed with ‘t’
of tests, experimental design and statistical technique ratio the level of significance is 0.05 level of confidence.

Results and Interpretations

Table I: Analysis of t ratio on selected physiological variables

Variables Scores Control Group Experimental Group

Mean 78.07 77.73
Pre test
SD 2.53 3.09
DBP Mean 75.47 73.80
Post test
SD 3.13 2.99
t value 2.05 7.34*
Mean 122.30 121.07
Pre test
SD 3.61 5.77
SBP Mean 116.43 111.17
Post test
SD 3.51 3.92
t value 2.07 7.76*
134 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table I indicates that experiment and control deviation of long distance runners. The experimental
group’s resting diastolic blood pressure (DBP) Mean group pre and Posttest mean values are 121.07 and
and Standard deviation of long distance runners. The 111.17 and standard deviation values are 5.77 and 3.92
experimental group Pre and Posttest mean values are and obtained ‘t’ value 7.76* which are greater than table
77.73 and 73.80 and standard deviation values are 3.09 value of 2.05 with df of 14 also with control group mean
and 2.99 and obtained ‘t value 7.34* greater 2.0 of 14 value are 78.07 and 75.47 and standard devotion are 2.53
also with control group mean value are 78.07 and 75.47 and 3.13. The result of ‘t’ value 2.07 which is lesser than
and standard devotion are 2.53 and 3.13. The result table value 2.05. The findings of the study indicate that
of ‘t’ value 2.05 which is lesser than table value 2.05. experimental group showed significant improvement on
It showed significant improvement on DBP aerobic SBP aerobic training on long distance runners. The mean
training on long distance runners. difference pre and posttest on physiological variables are
presented in figure-I.
Table I indicates that experiment and control group’s
resting systolic blood pressure (SBP) Mean and Standard

Figure I: Bar diagram shows mean values of pre and post-test of experimental group and control group on
physiological variables

Discussion on Findings Conclusions

The results of SBP shows that the obtained’ ratio 1. There was a significant improvement on systolic
of experimental group is 7.76 which are greater than blood pressure of the subjects who underwent
required table value of 2.05 with 0.05 level of confidence. twelve weeks of aerobic training.
It also shows that there was a significant improvement
2. There was a significant improvement on diastolic
on their SBP of this experimental group. Hence this
blood pressure of the subjects who underwent
hypothesis was accepted.
twelve weeks of aerobic training.
The results of DBP shows that the obtained ‘t’ Ethical Clearance: Nil
ratio of experimental group is 7.34 which are greater
than required table value of 2.05 with 0.05 level of Source of Funding: Self
confidence. It also shows that there was a significant
Conflict of Interest: Nil
improvement on their DBP of this experimental group.
Hence this hypothesis was accepted.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 135

References 4. Åstrand PO, Rodahl K, Dahl HA, Strømme SB.

Textbook of work physiology: physiological bases
1. Plowman SA, Smith DL. Exercise physiology
of exercise. Hum Kin; 2003.
for health fitness and performance. Lippincott
Williams & Wilkins; 2013 Feb 25. 5. Sharma J. EXERCISE PHYSIOLOGY HEALTH
FITNESS AND PERFORMANCE. Horizon Books
2. Tanner R, Gore C. Physiological tests for elite
(A Division of Ignited Minds Edutech P Ltd); 2015
athletes. Hum kin; 2018 Nov 15.
Mar 1.
3. Birrer D, Morgan G. Psychological skills training
6. Maughan R, Shirreffs S. Exercise in the heat:
as a way to enhance an athlete’s performance in
challenges and opportunities. J sports sci. 2004 Oct
high‐intensity sports. Scand J Med & Sci Sports.
1;22(10):917-27.
2010 Oct;20:78-87.
136 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

A Descriptive Study to Assess the Knowledge on Pre-

Menopausal Symptoms among Middle Aged Women in a
Selected Village at Kanchipuram District, Tamilnadu, India

M. Deepan Babu1, S.Vasuki1, K.Sangeetha1, D. Joaniepriya2

1IIIrd Year B.Sc.(N) Student, 2Asst. Professor-Guide, Chettinad College of Nursing,

Rajiv Gandhi Salai, Kelambakkam, Kancheepuram, District Tamil Nadu, India

Abstract
A descriptive study to assess the knowledge on pre-menopausal symptoms among middle aged women in
a selected village at Kanchipuram district, Tamil Nadu, India. The objectives are to assess the knowledge
of premenopausal symptoms among middle aged women in a selected village at Kanchipuram district,
Tamil Nadu, India. To find out the association between level of knowledge with demographic variables.
The convenience sampling technique was used to select 109 samples. Validity and reliability data collection
tools were established. The data were collected by self-administered questionnaires. The collected data were
tabulated and analyzed. Descriptive and inferential statistics were used. The study shows that 0% of the
women had adequate knowledge, 15% of the women had moderate knowledge, and 94% of the women had
inadequate knowledge regarding pre-menopausal symptoms.

Keywords: Knowledge, Pre-menopausal symptoms, Middle aged women.

Introduction transmission between two phases of a women life.

Menopause is the time in a female life when she gets a
Background of the Study:
formal, official signal from her body that she is getting
“Menopause is just puberty’s evil older sister” older. This is the time when her menstruation is on the
verge of a complete die down. The hot flashes, irritation,
Menopause is the permanent end of menstruation mood swings, insomnia, fatigue etc some symptoms of
and fertility defined as occurring 12 months after the menopause, and there are many more. These symptoms
last menstrual period. Menopause is natural biological can be unpleasant and tedious to manage[2].
process, not a medical illness. Even so the physical and
emotional symptoms of menopause can disrupt your Many women experience a variety of symptoms
sleep, say your energy and at least indirectly trigger as a result of the hormonal changes associated with
of sadness and loss. Most women being menopause the transition through menopause .around the time of
between the ages of 45 and 60. Early menopause usually menopause, women often lose bone density and their
refers to onset before age 40[1]. blood cholesterol levels may worsen, increasing their
risk of heart disease[3].
Menopause the time when a women stops having
menstrual periods, is not a disease or an illness it is a According to National Institute on Aging (2010)
usually menopause happens naturally, but some women
develop symptoms of menopause and stop having
Corresponding Author: menstrual cycles much earlier than expected. Before
Mr. M. Deepan Babu age 40, a menopause-like condition can happen for no
IIIrd year B.Sc. (N) Student, Chettinad College known reason, or it can be caused by radiation treatment,
some medicines like those used in chemotherapy,
of Nursing, Rajiv Gandhisalai, Kelambakkam,
an autoimmunity (some of a women’s own body
Kancheepuram District, Tamil Nadu, India
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 137
cells attacking herovary or ovaries),or genetic errors. Ethical Clearance: Summary, Findings,
Radiation can make the ovaries stops workings, as can Discussion, Implication, Limitataion, Recommendation
some treatments likechemotherapy for cancer.[4] and Conclusion.

Research Methodology The essence of any research project lies in reporting

in the findings. This chapter gives a brief account of
A Quantitative approach with descriptive design the present study including conclusion drawn from the
was used in the study. The study was conducted among findings, recommendations, limitation, suggestion for
middle aged women at selected village, Kanchipuram future studies and nursing implication.
District, Tamil Nadu, India. A purposive sampling
technique was used to select 149 samples with the Summary: The study is to assess the knowledge
following inclusion criteria. Pre-menopausal women regarding pre-menopausal symptoms among middle
who are willing to participate in the study, the women aged women in a selected village. This will enhance the
who are under the age group of (45-60)years and who middle aged women to improve knowledge regarding
could speak English and Tamil. pre-menopausal symptoms.

Tool for the Study: Self-structured questionnaire The objectives of the study were: Assess
used to elicit the demographic variables and to assess the knowledge on Pre-menopausal symptoms among middle
knowledge on pre-menopausal symptoms among middle aged women.
aged women.
Associate the knowledge on Pre-menopausal
Scoring and Interpretation: symptoms among middle aged women with selected
demographic variables.
Scoring Level of Knowledge
Above 75% Adequate Knowledge The study attempted to examine the following
51-75% Moderated Knowledge null hypothesis that
Below 50% Inadequate Knowledge
H0: There is no significant association between
Study Findings: The majoriy (36%) of the women demographic variables and knowledge on pre-
were under the age group of 31-40 years, (78.9%) of menopausal symptoms among middle aged women in a
the women had attained menarche at the age of 11-15 selected village at Kanchipuram District, Tamil Nadu,
years, (47.7%) of the women have 2 children, (90.8%) India.
of women does not have menstrual irregularity, (51.3%)
The review of literature enabled the investigator to
of women living in nuclear family, (72%) of the women
develop methodology of the study literature review was
taking mixed diet, (100%) of the women living in the
done and organized as studies related to knowledge on
village, (66%) of the women had married at the age of
pre-menopausal symptoms among middle aged women.
21-25 years, (43.1%) 0f the women were unemployed,
(54%) of the women had monthly income of Rs.5,000- The research approach used was quantitative
10,000. approach with descriptive design. The main study was
done in a selected village at Kanchipuram District, Tamil
The Chi-square association revealed there was no
Nadu India. 109 samples were selected by convenience
significant association between demographic variables
sampling.
in related with the knowledge aspects of middle aged
women with aspects of knowledge on pre-menopausal The self-administered questionnaire was used to
symptoms. It shows that there is no significant collect the data regarding demographic variables and
association between knowledge aspects with Age of the knowledge on pre-menopausal symptoms among
the women (X2=2.65), Age at menarche (X2=7.41), middle aged women. The data gathered were analyzed
Menstrual irregularity (X2=1.72), Types of family by using descriptive and inferential statistical method.
(X2=0.33), Dietary pattern (X2=7.21), Area (X2=O), Age The findings were presented on the basis of objectives
at marriage (X2=7.44), Occupation (X2=10.1), Monthly of the study.
income (X2=1.09).There is Significant Association
Between No. of . children (X2=28.67).
138 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Findings: Findings of the study were presented dietary pattern and level of knowledge of pre-menopausal
under the following headings based on the study symptoms. X2=7.21, (P<0.05).
objectives
Finding-7: Area and level of knowledge of pre-
Objective 1: Assess the level of knowledge on pre- menopausal symptoms.
menopausal symptoms
There is no significant association between the area
The finding of the present study reveals that and level of knowledge of pre-menopausal symptoms.
X2=0, (P<0.05).
0 (0%) had adequate knowledge
Finding-8: Age at marriage and level of knowledge
15 (13.8%) had moderate knowledge of pre-menopausal symptoms.
94(86.2%) had inadequate knowledge There is no significant association between the age
Objective 2: Associate demographic variables with at marriage and level of knowledge of pre-menopausal
the level of knowledge on pre-menopausal symptoms. symptoms. X2=7.44, (P<0.05).

Finding-1: Age and level of knowledge of pre- Finding-9: Occupation and level of knowledge of
menopausal symptoms. pre-menopausal symptoms.

There is no significant association between the age There is no significant association between the
and level of knowledge of pre-menopausal symptoms. occupation and level of knowledge of pre-menopausal
X2=2.65, (P<0.05). symptoms. X2=10.1, (P<0.05).

Finding-2: Age at menarche and level of knowledge Finding-10: Monthly income and level of
of pre-menopausal symptoms. There is no significant knowledge of pre-menopausal symptoms.
association between the age at menarche and level of There is no significant association between the
knowledge of pre-menopausal symptoms. X2=7.41, monthly income and level of knowledge of pre-
(P<0.05). menopausal symptoms. X2=1.09, (P<0.05).
Finding-3: Number of children and level of Implication: The findings of the study have
knowledge of pre-menopausal symptoms. implication in Nursing services and research.
There is significant association between the number Nursing Service: Community health nurse conduct
of children and level of knowledge of pre-menopausal educational programs to improve knowledge on pre-
symptoms. X2=28.67, (P>0.05). menopausal symptoms. In hospital Nurse can provide
Finding-4: Menstrual irregularity and level of health education to create knowledge.
knowledge of pre-menopausal symptoms. Limitation: Middle aged women only included in
There is no significant association between the the study.
menstrual irregularity and level of knowledge of pre- Recommendation: This study can be replicated
menopausal symptoms. X2=1.72, (P<0.05). an large sample studies can be conducted in different
Finding-5: Type of family and level of knowledge settings to validate findings
of pre-menopausal symptoms. A similar study can be conducted on general public
There is no significant association between the type regarding pre-menopausal symptoms.
of family and level of knowledge of pre-menopausal
symptoms. X2=0.33, (P<0.05).
Conclusion
This study helps the middle aged women to
Finding-6: Dietary pattern and level of knowledge understand about the pre-menopausal symptoms, it
of pre-menopausal symptoms. becomes necessary to involve the middle aged women
There is no significant association between the as and when during pre-menopausal symptoms and
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 139
it can also able to prevent the complications during 4. Shoenfeld H. When are Menopausal Symptoms
menopause. Becomes Psychiatric”. Medline; 1999. 5. Lakshmi
Seehadri. Essentials of Gynecology, 1st ed; 2010. 6.
Source of Funding: Self Dewhurst. Textbook of obstetrics and gynaecology,
Conflict of Interest: Nil 7th ed: D. Keith Edmonds; 2011.
7. Jeremy Oats, Suzanna Abraham. Fundamental of
Reference Obstetrics and Gynaecology. London: Elsevier
Mosby; 2005. 8. Howkins and Bourns Shaw.
1. Bachmann . G.A and Leiblum SR . The impact of
Textbook of Gynecology, 13th Ed. Elsevier; 2004.
Harmones on Menopausal sexuality Medline; 2004.
9. Sanjeeve. Basic bio statistic, 2nd ed. 2003.
2. Irene M. Boback and Margaret Duncan Jensen.
“Maternity and gynaecological Care”. USA: Mosby 10. Shama. SK. Nursing Research and Statistic, 1st ed.
Publications; 1993 . Elsevier Publisher; 2011.
3. Thayamalar G. Gomala . “Menopause Special Guide 11. D.C. Duttas. Textbook of Gynaecology, 6th ed.
for Ladies crossing above 40 years” :AvalVigaden 2008.
Publications; 2004. 12. Decohrst . Textbook of obstetrics and gynaecology,
8th ed; 2009.
140 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Health Care Services Under Consumer Protection Laws of

Union Territories of Jammu and Kashmir:
A Socio-Legal Mapping

M.Z.M. Nomani1, Ajaz Afzal Lone2, Alaa K.K. Alhalboosi2, Aijaj A. Raj2, Zubair Ahmed2
1Professor, 2Research Scholar, Faculty of Law, Aligarh Muslim University, Aligarh, U.P., India

Abstract
Ever since the passing of the Jammu & Kashmir Consumer Protection Act, 1987, the doctor-patient’s
relationship came under critical scrutiny, controversy and litigation. The inadequacy of consumer protections
laws results in unavoidable contingency, spiralling cost shifting and inordinate health care complexities. It
examines health care services as a matter of consumer rights under Consumer Protection Act, 1986, Jammu
and Kashmir Consumer Protection Act, 1987 and Consumer Protection Act, 2019. It makes consumers
to navigate between hope and despair for access to health care. The paperis driven to analytical study of
inadequacy of consumer laws in dealing effectively deficiency of medical service, insufficiency of health care
services,lack of medical professionalism and negligence in Sher-i-Kashmir Institute of Medical Sciences
(SKIMS), Srinagar by encompassing a legislative survey of consumer laws in inculcating Consumer Right
Awareness (CRA) and toning of structural governance of grievance redressal mechanism. The gap between
the precept and practice of consumer justice and compensation in health care services is identified for
adoption of a robust infrastructural and schematic revamping.

Keywords: Health Care Services, Consumer Right Awareness, Grievance Redressal Mechanism, Consumer
Justice and Compensation.

Introduction institutions in the state which is considered the highest

number of hospitals in the country. The annual budget
The health care facilities to the people of the
for the health sector in J & K is Rs. 2,423-crore. The
erstwhile state of Jammu and Kashmir (J & K) is marred
per capita spending under plan, non-plan and centrally
by constraints of financial resources, difficult topography
sponsored schemes is estimated at Rs. 1,931 crore.2
and terrain, poor road connectivity, low presence of
According to the State’s Economic Survey Report,
private sector, low accessibility and affordability by
2017,there were 4,433 government health institutions
under- privileged segments of the population. There has
in J & K at the primary, secondary and tertiary levels
been a gradual decay in the health services of J & K
with 6,674 doctors.3 The paper examines the efficacy ofJ
over the last three decades. The state is under shadows of
& K Consumer Protection Act, 1987 to give effect to
infectious diseases like tuberculosis, RTI, UTI diarrhoea
Consumer Protection Act, 1986 to take care of consumer
disease.1 there is growing shadow of chronic diseases
right awareness among patients for robust health care
like hypertension, coronary artery disease, cancers, and
services in two Union Territories of J & K under Jammu
diabetes. Factually speaking there are 3,807 health care
and Kashmir Reorganisation Act, 2019.

Corresponding Author:
Materials & Method
M.Z.M. Nomani The material and method applied for the study
Professor, Faculty of Law, Aligarh Muslim University, include analytical method of legal research by
Aligarh-202001 (U.P./India) undertaking the legislative survey and scrutiny of
e-mail: [email protected] consumer laws at central and state levels. These laws
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 141
are studied under Parsonian Effecttheory in the context the same Consumer Protection Act, 1986 The court noted
of health care services.4 The comparative consumer law that the issues arising in the complaints against medical
study of Consumer Protection Act, 1986,J & K Consumer negligence can be speedily disposed of by the procedure
Protection Act, 1987 and Consumer Protection Act, 2019 being followed by consumer disputes redressal agencies.
is based on established canons of statutory interpretation. Thus the Consumer Protection Act, 1986 is pioneering
The material and method partakes an empirical frame law in protection of consumer from the standpoint of
work of SKIMS, Srinagar a premier medical institution health, environment and consumer justice.10
in J & K state. The case study is based on Consumer
Right Awareness (CRA) under four major parameters J & K Consumer Protection Act, 1987:TheJ
which include consumer right awareness, redressal & KConsumer Protection Act, 1987 aims to provide
against medical negligence, and recourse to deficiency effective safeguards to the consumers against defective
of medical service and compensation and consumer goods, deficient services and unfair trade practices.The
justice. Act provides speedy redressal to consumer complainants
by setting up of a District Consumer Redressal Forum
Findings: It is important to note that the both and State Commission having jurisdictionto claim of
Consumer Protection Act, 1986, J & K Consumer Rs. 10 lakhs and Rs. 30 lakhs respectively. The State
Protection Act, 1987 and Consumer Protection Act, 2019 Commission will be vested with appropriate appellate
are public welfare legislation and has been designed to and revisional powers. It shall apply to all goods and
avoid procedural technicalities, delays, and requirement services except those which are specially exempted by
of court fees to protect consumers availing medical notification by the state government did not specifically
facilities and health care services.5 It contains three- exempted health care services provided by government
tier consumer disputes redressal system at the District, hospitals. It seems profitable to refer section 2(1) (0) as
State and National levels along with Central Consumer under:
Appellate Authority (CCAA) including right to health
and environment.6 “Service” means service of any description which
is made available to potential users and includes the
Central Consumer Protection Act, 1986: The provision of facilities in connection with banking,
Consumer Protection Act, 1986 forms the basis of J & financing, insurance, transport, processing, supply of
K Consumer Protection Act, 1987 therefore a perusal of electrical or other energy, board or lodging or both,
this law in brief is imperative. The Act seeks to promote entertainment, amusement or the purveying news or
and protect the interest of consumers against deficiencies other information, under a contract of personal service.
and defects in goods or services.7 It also seeks to
secure the rights of a consumer against unfair trade The necessary penal and punitive provisions have
practices, which may be practiced by manufacturers been incorporated for effective redressal of unfair trade
and traders. The Act applies to all goods and services practices, defect in the goods, and deficiency of services.
unless specifically exempted by the Union Government The Consumer Commissions are authorized to impose
and covers all sectors, whether private, public, or penalties on trader or person against whom complaint is
cooperative. It ordains simple, speedy and inexpensive made if he fails to comply with the order of the redressal
machinery for redressal of consumer’s grievances, the agency.
marketing of goods and services to consumers, as well as J & K Government Doctors (Relaxation of
the relationships, transactions and agreements between Restrictions on Private Practice) Rules, 1987: It will
the consumers and the producers, suppliers, distributors, be appropriate to see the application of J & K Consumer
importers, retailers, service providers and intermediaries Protection Act, 1987 and J & K Government Doctors
of those goods and services.8 The application of (Relaxation of Restrictions on Private Practice) Rules,
Consumer Protection Act, 1986 to health services 1987 in holistic perspective in regard to doctor patient
derives life breath and sustenance from Supreme Court relationship and health care services. This is also
ruling in Indian Medical Association v. V.P. Shantha.9 important to see this law in the context of penalty or
In this casethe question raised was whether the treatment punishment may involve imprisonment for a period
provided by medical practitioners to their patients would not more than 3 years or a fine or both. The complaint
constitute “service” under the meaning of the Act and mechanism by a consumer voluntary organization,
whether patients would be treated as ‘consumers’ under registered society, company and state government will
142 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
also be scrutinised in pragmatic discourse. Therefore, Discussions
it is also worthwhile to inquire the synergy of both
The study of health care services under consumer
legislations from the lens of the executive and judicial
protection laws of J & K health institutions is an
attitude towards disciplining doctors and foster health
empirical study of SKIMS with 900 bedded tertiary care
care services to patient vis-a-vis banning private
hospital and undergraduate medical college with intake
practice. The J & K High Court in Dr. Ashutosh Gupta
capacity of 100 students. According to survey there are
v.State of J & K, 11while hearing petition for quashing
total 1648 health institutions in J & KState.13
of Government Order No. 43/HME of 2013 dated
17.01.2013 regarding of banning of private practice Selection of Area of Study: SKIMS being premier
by doctors of government medical college, associated medical institution in India, it provides additional
hospitals and dental colleges upheld the impugned order services including prevention, treatment, rehabilitation,
of the Government. In Sukesh Chander Khajuriav. State obstetrics, substance abuse, health education, and
of J & K,12 the J & K High Court dismissed the writ screening for cancers and other diseases.14
petition regarding validity of J & K Government Doctors
(Relaxation of Restrictions on Private Practice) Rules,
1987.

The case study of SKIMS is based on four major Consumer Right Awareness & Health Care
parameters viz; consumer right awareness, 15redressal Services: By this analogy persons who are rendered free
against medical negligence, recourse to deficiency of service are “beneficiaries” and as such come within the
medical service and compensation and consumer justice definition of “consumer” under Section 2(1) (d) of the
under the J & KConsumer Protection Act, 1987 and J Act. Similarly the deficiency of service is spelt out under
& K Government Doctors (Relaxation of Restrictions Section 2(1) (g) which covers diagnostic, surgical and
on Private Practice) Rules, 1987. Located in Soura area therapeutic service.17 A sample survey of 100 patients
of Srinagar, this is the largest medical Institute under admitted to SKIMS was conducted regarding consumer
Sher-i-Kashmir Institute of Medical Sciences, (Grant of right awareness to healthcare.18 The following table
Degrees) Act, 1983.16 The J & K Consumer Protection and chart-1 shows the nature and depth of consumer
Act, 1987 is not applicable to government hospitals right awareness among randomised number of patients
because of free medical care services to patients. But the is in and out patient department. The simple question
medical services rendered by doctors and hospitals falls regarding the legal literacy of consumer law and
within the ambit of a “service” as defined in Section 2(1) redressal agencies were put to these patients.
(o) of the Act.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 143
Table 1: CRA & Health Care Services

Patients Respondents Yes %age No %age Indifferent %age

In Patients 50 10 20 35 70 05 10
Out Patients 50 12 24 34 68 04 08
Total 100 22 88 79 79 09 09

Source: Field work

The above table clearly shows that 22% respondents about the complaint mechanism for the deficiency in
have knowledge about consumer law or redressal medical services is also in abysmally low. When we
agencies while as 79% respondents said that no they asked patients about the deficiency of medical services
were not having any knowledge about consumer laws gives rise to grievance redressal at appropriate consumer
however 9% respondent didn’t said anything about forum almost 2/3 respondents feign ignorance about it.
the information of consumer laws. The legal literacy

Table II: CPA & Grievance Redressal Mechanism

Patients Respondents Yes %age No %age Indifferent %age

In Patients 50 10 20 35 70 05 10
Out Patients 50 11 22 34 68 05 10
Total 100 21 21 69 69 10 10

Source: Field Work

The medical negligence on as the part of health in consumer forums on the basis of data received from
care provider is frequent in J & K that is why the patient respondents 69% respondents said that they were not
affected by medical negligence have faint idea about the aware about the concept of complaints in consumer
complaint mechanism as victims. The Table II shows forums, however 10% respondents didn’t say anything
that 21% respondents have knowledge about complaints about the complaints in consumer forums.

Table III: CPA & Medical Negligence

Patients Respondents Yes %age No %age Indifferent %age

In Patients 50 10 20 34 68 06 12
Out Patients 50 13 26 32 64 05 10
Total 100 23 23 66 66 11 11

Source: Field Work

The Comptroller and Auditor General (CAG) of Health Care & Medical Negligence: The
India has reported that ‘even the emergency medicine knowledge regarding negligence in health care services
department has been found to be not fully equipped to reveals that 23% respondents were aware about the
deal with cases of road traffic accidents having multiple complaints mechanism. The ordinary prudence about
organ injuries including orthopedic injuries.’ This is also medical negligence depicts that 66% respondents
pathetic to note that ambulances meant for patients have don’t have knowledge about grievance redressal and
been found mis-utilized to the extent of 40 to 47 per cent 11%remain indifferent to liability of doctors and hospital
during 2008-12.19 authorities.
144 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table IV: Health Care Services & Medical Negligence

Patients Respondents Yes %age No %age Indifferent %age

In Patients 50 11 22 36 72 03 06
Out Patients 50 10 20 35 70 05 10
Total 100 21 21 71 71 08 08

Source: Field Work

Compensation & Consumer Justice: the knowledge about penal provisions against doctors.20
compensation incase of medical negligence to the Still majority of patients to the tune of 71% said that they
patients and their kith and kin also represent empathtic were not having any information related penal provisions
and ignorance. The patient interviewed regarding their where as 8% are either ignorant or indifferent didn’t say
response to compensation in case of medical negligence anything about penal action can be initiated in case of
reveals that 21% respondents show that they have medical negligence on part of hospital and doctor.

Table V: Compensation & Consumer Justice

Patients Respondents Yes %age No %age Indifferent %age

In Patients 50 08 16 38 76 04 08
Out Patients 50 09 18 36 72 05 10
Total 100 17 17 74 74 09 09

Source: Field Work

The apex court ruling has played seminal role in overburden needs proper regulation. This becomes more
curbing medical malpractice and making compensation important in the wake of unrest of decades has worsened
an integral part of consumer justice that 17% respondents the health status of people especially of population
have knowledge about compensation given by consumer living below poverty line. The only salacious aspect is
forums and 74% said that they were not having any to note that the purpose and object with which the J &
information related compensation related consumer K Consumer Protection Act, 1987 has been passed has
forums however 09% respondents didn’t say anything substantially achieved in the ambit of patient’s rights
about compensation provided by consumer courts. This notably compensatory justice. But the SKIMS have
places the consumer justice in a conundrum especially in been found inadequately equipped to deal with accidents
the aftermath of Supreme Court decision. and trauma prevention and gross mis-utilisation of
ambulance services despite rich infrastructure. The most
Conclusion significant and equally multifaceted as well complex
The analysis of health care services under consumer service in the field of consumer grievances is that of
laws of erstwhile J & K state now Union Territories of medical malpractice and the doctors of SKIMS and
J & K under Jammu and Kashmir Reorganisation Act, other government hospitals of state need to be more
2019 reveals that health status of the people has not been circumspect and careful towards medical services to
able to keep pace with the national targets. The state patients to enlarge the realm of consumer justice, access
has a considerable segment of population living below to health and compensatory jurisprudence.
poverty line, inadequacy of healthcare and burden of Conflict of Interest: No
disease in an environmentally benign setting.20 The J
& KConsumer Protection Act, 1987 has not achieved Source of Funding: self
consumer right awareness and assertiveness in realisation
health care services. The health services and disease Ethical Clearance: No
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 145

References Available from: http://jkhealth.org/new2017/

govorder.php#
1. World Health Organization. The World Health
Reports 2002. Reducing Risk, Promoting Healthy 14. Sher-i-Kashmir Institute of Medical Sciences:
Life: World Health Organization; 2002. [Internet]. Available from: https://en.wikipedia.
org/wiki/Sher-i-Kashmir_Institute_of_Medical_
2. GOI. National Health Policy - 2002. Department
Sciences
of Health, Ministry of Health and Family Welfare.
Govt of India: New Delhi; 2002. 15. Nomani, M.Z.M. & Azvar Khan. Consumer Right
Awareness and Its Enforcement in Rural and Urban
3. Economy Survey, 2017. [Internet]. [Cited on 2014
Areas of Muzaffarnagar and Saharanpur District of
Sept 15]. Available from: http://ecostatjk.nic.in/
U.P [Ph.D. Thesis] A.M.U. Aligarh; 2006.
Economic%20Survey%202017.pdf
16. Sher-i-Kashmir Institute of Medical Sciences:
4. Parson, Talcott. Action Theory and the Human
(Grant of Degrees) Act, 1983 (Act of 12 of 1983).
Condition: Free Press. New York; 1978.
[Internet]. [Cited 2019 July 05]. Available from:
5. Nomani, M.Z.M. Public Interest Litigation http://www.bareactslive.com/JK/JK297.HTM
Movement and Consumer Protection in India:
17. Jammu and Kashmir Consumer Protection Act;
In: A. R. Kidwai, Ed. New Directions in Higher
1987: (Act No.16 of 1987) (Dated 29.8.1987).
Education in India. Viva Books: New Delhi; 2014.
[Internet]. Available from: http://www.bareactslive.
p. 152-165.
com/JK/JK056.HTM
6. Nomani, M.Z.M. Right To Health: A Socio- Legal
18. Nomani, M.Z.M. et.al.,Consumer Right Awareness
Perspective. 56 Uppal Publications. New Delhi;
& Development of Rural Marketing Strategies in
2004.
Shamli District of Uttar Pradesh: An Empirical
7. The Consumer Protection Act, 1986. (Act 68 of Mapping. in Babita Agarwal Ed. Role of Rural
1986). Government of India: [Internet]. Available Consumer Awareness in Development of Rural
from: http://ncdrc.nic.in/1_1.htm Marketing Strategies, Managlam Publisher &
8. Pilgaokar Anil. Doctors and Consumer Protection Distributors, Delhi; 2013. p. 79-93.
Act: 1986; Edinburgh Medical and Surgical 19. Kashmir’s dream hospital has seen 12,860 deaths in
Journal. 1845; p. 63-176. last 5 years: CAG. The Hindu [Internet]. Available
9. Indian Medical Association v. V.P. Shantha, [AIR from: https://www.thehindu.com/news/national/
1996 SC 550]. other-states/kashmirs-dream-hospital-has-seen-
10. Nomani, M.Z.M. ‘Climate Change, Environment 12860-deaths-in-last-5-years-cag/article4585689.
Sustainability and Consumer Justice: IV [7 ece.
& 8] International Journal of Environmental 20. Sharma Anand. VibhakarMansotra, Sourabh
Consumerism, 2009; p. 52-63. Shastri. An Exploratory Analysis of Public
11. Dr. Ashutosh Gupta v. State of J & K, Jammu Healthcare Data: A Case Study of Jammu &
[SWP No 326 of 2013]. Kashmir State: Asian Journal of Computer and
12. SukeshChander Khajuria v. State of J & K,[SWP Information Systems. Volume 03, Issue 05,
No. 407/1992 vide judgment dated 14.02.1994]. December 2015.

13. Department of health and medical education Jammu

& Kashmir: [Internet]. [Cited on 2019 July 05].
146 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Comparison of Morphological Features of Second Cervical

Vertebra between Genders Using Computed Tomography

Madhavan T.S.1, Sharath S.2, Rahul P. Kotian3

1Assistant Professor, 2Post Graduate, 3Assistant Professor (Selection Grade), Department of Medical Imaging
Technology, School of Allied Health Sciences, Manipal Academy of Higher Education

Abstract
Introduction: Gender determination has been the emphasis of many forensic studies and have significance
in mass fatality cases where bodies are damaged beyond recognition, as these factors are essential and
various method are developed that allows gender determination. Second Cervical vertebra due to its ample
degree of sexual dimorphism in its dimension allows sex determination. Forensic investigators can identify
the bone by its morphological characteristics, such as the dens, short spinous process and cervical vertebra
is known to be the best preserved of all the vertebra in cadavers.
Aim: To compare the morphological features of second cervical vertebra between genders using Computed
Tomography.
Materials and Method: This was a retrospective study which included subjects visiting for CT (Computerized
Tomography) of cervical spine in Department of Radio-diagnosis and Imaging, Kasturba Medical College,
Manipal, Karnataka, India. Sample size was calculated using the formula for estimation of population mean
which gave a total sample of 160. A total of 160 patients underwent computed tomography of cervical
spine on MDCT Brilliance 64 slice Philips with routine protocol and later post-processed into Multiplanar
imaging. In present study nine measurements of the second cervical vertebra were taken. Anthropometric
measurements were performed which was calculated using the measurement tools. The data was analyzed
using SPSS (V.20.0).
Results: Discriminant function analysis was performed to calculate the mean and standard deviation.
Standardized canonical discriminant function was performed to find out the variable dependency and was
found that maximum distance measured from the most lateral edges of the superior articular facets (DMFS)
contributed much of the separation between genders. Step wise discriminant function test was performed to
predict the categorical dependent variable, a multivariable model was generated which showed that maximum
distance measured from the most lateral edges of the superior articular facets (DMFS) and Maximum sagittal
length (AS) reached the accuracy of 77.5% in gender discrimination. The most discriminant variable for the
C2 was DMFS followed by AS, with expected accuracies of 73.8% and 71.9%. Among nine variables seven
variables (AS, LMA, DMFS, DSD, DTD, WVF and DTMC) showed correct prediction rates approximately
78.8% and two variables (DA, DSMC) yielded no result.
Conclusion: DMFS contributed much separation with high accuracy in comparison to others, affirming that
there is considerable sexual dimorphism with respect to the second cervical vertebra which could determine
the gender of human based on CT measurements of second cervical vertebra.
Keywords: Anthropometry, Cervical spine, Gender determination, Sexual dimorphism.

Corresponding Author: Introduction

Mr. Madhavan T.S. Gender determination has been the emphasis of many
Assistant Professor, Department of Medical Imaging forensic studies and have significance in mass fatality
Technology, School of Allied Health Sciences, Manipal cases where bodies are damaged beyond recognition,
Academy of Higher Education as these factors are essential and various method
e-mail: [email protected] are developed that allows gender determination[1-3].
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 147
DNA technologies are rational, narrowed down due set which were included in the study were sent to Phillips
to the accessibility of forensic legal laboratories and Extended Brilliance workstation and the acquired axial
the cost effectiveness. For gender determination the sections were reformatted into coronal and sagittal
most reliable parts are skull and pelvis which exhibits sections using MPR (Multi-Planar Reconstruction)
sexual dimorphism [2,4]. However, some human skeletal technique [6]. Anthropometric measurements were
parts are found to be damaged due to decomposition performed on the following section; the maximum
and carnivore modification, other parts that are less length of the parameter was measured on axial and
dimorphic such as tibia, humerus, hyoid bone, foramen sagittal sections. The Maximum height of the Dens (DA)
magnum should be considered for gender determination, and Maximum sagittal length (AS) was measured from
and thus new techniques that deal with such parts should the sagittal section where tilts can be checked. The axial
be considered. Second cervical vertebra due to its ample and coronal planes were used to correct the image to
degree of sexual dimorphism in its dimension allows get the orientation of the second cervical vertebra. The
sex determination. Forensic investigators can identify other measurements were taken from the axial sections
the bone by its morphological characteristics, such as which were checked for tilts and corrected using sagittal
the dens, short spinous process and cervical vertebra and coronal images to acquire the center of the second
is known to be the best preserved of all the vertebra in cervical vertebra. Maximum height of dens (DA) is
cadavers [3,5]. Therefore, the aim of the present study was defined as length from the superior point on the dens
to assess the sexual dimorphism from the 12th thoracic to the anterior-inferior point on the vertebral body
and the first lumbar vertebra measurements and data and Maximum sagittal length (AS) i.e., Length from
was obtained from reformatted images of multi-slice the anterior-inferior point on the vertebral body to the
computed tomography (MSCT). posterior point on spinous process [Fig-1]. Dens Sagittal
Diameter (DSD), (Maximum sagittal diameter measured
Materials and Method between the anterior and posterior points on dens). Dens
A retrospective observational study was carried Transverse Diameter (DTD), (Maximum transverse
out at Department of Radio-Diagnosis and Imaging, diameter of dens measured between most lateral edges
Kasturba Hospital, Manipal, Karnataka, India, using of the dens) [Fig-2]. (Maximum distance measured from
Phillips Brilliance 64-SLICE CT. Approval was the most lateral edges of the superior articular facets)
acquired from institution research committee, School of (DMFS) [Fig-3]. Maximum width of the axis (LMA)
Allied Health Sciences and ethical committee, Kasturba shown in [Fig-4], Width of Vertebral Foramen (WVF)
hospital. Sample size was calculated using the formula (Maximum internal width of the vertebral foramen) [Fig-
for estimation of population mean which gave a total 5]. Maximum sagittal diameter of the body (DSMC)
sample of 160. Data from 160 samples (80 males and (The maximum sagittal diameter of the body measured
80 females) were obtained, who were referred to the from the anterior-inferior point on the board to posterior-
Radio-diagnosis department by the treating physician inferior point). Maximum transverse diameter of the
for CT cervical spine over the period of 12 months. body (DTMC). (The maximum transverse diameter of
Patients with trauma, major injuries and fractures of the body measured between the most lateral edges of the
cervical spine were excluded from the study. CT of body) [Fig-6], were measured using the measurement
cervical spine was performed with patients positioned tools provided by the Phillips extended brilliance work
on the CT couch in supine head first position, with area station.
coverage from tip of mastoidto sternal notch. Scan of
the required area of interest was performed on acquired
scanogram keeping in mind that the scan is performed
with no loss of anatomical structure, axial sections of
cervical spine was obtained with 0.9 mm slice thickness
and slice increment of 0.45 mm with detail D filter
producing standard bone resolution images. Informed
consent was obtained from the patient before the start of
examination. The original series of cervical spine with
slice thickness of 0.9 mm and slice interval of 0.45 mm [Fig-1]: Figure showing maximum height of the dens
were selected for the study, Axial images per patient data (DA) and maximum sagittal length (AS).
148 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

[Fig-2]: Figure showing Dens Sagittal Diameter

(DSD) and Dens Transverse Diameter (DTD).
[Fig-5]: Figure showing Width of Vertebral
Foramen (WVF).

[Fig-3]: Figure showing maximum distance between

superior facets (DMFS).

[Fig-6]: Figure showing maximum sagittal diameter

of the body (DSMC) and maximum transverse
diameter of the body (DTMC).

Statistical Analysis: The metric data obtained were

analyzed by using SPSS Version 20.0 and statistical
difference in the cervical vertebra measurements of
males and females were assessed using discriminant
function analysis to predict the categorical dependent
variable and to compare the canonical discriminant
function coefficients to recognize which independent
variable was more segregating than alternate variables.
Discriminant function analysis test was used to evaluate
the mean and standard deviation for the anthropometric
parameters of both male and female. Standardized and
[Fig-4]: Figure showing maximum width of the axis unstandardized canonical discriminant function was
(LMA). determined to assess the variable dependency.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 149

Results Function 1
The Mean and standard deviation of both sexes DTD -.044
for all the nine variables are reported using descriptive WVF .125
statistics as shown in [Table-1]. DSMC .000
DTMC .034
[Table 1]: Descriptive statistics for the nine (Constant) -20.946
variables are reported which shows mean and
standard deviation of both sexes. Discriminant function analysis was used to predict
a categorical dependent variable (called a grouping
Variable Sex Mean Standard Deviation variable) by one or more continuous or binary
Male (80) 85.18 421.27 independent variables (called predictor variables). On
DA
Female (80) 82.33 421.48 comparing canonical discriminant function coefficients,
Male (80) 46.35 5.009 it was conceivable to recognize that DMFS showed
AS
Female (80) 43.18 2.727 much differentiation followed by WVF, AS, DTMC,
Male (80) 54.54 5.202 DSD, DTD and LMA as shown in [Table/Fig-8].
LMA
Female (80) 54.83 44.98
Male (80) 45.33 2.515 The most discriminant variable for the C2 is DMFS
DMFS
Female (80) 42.05 2.267 followed by AS, with expected accuracies of 73.8%
Male (80) 12.39 10.703 and 71.9%. Among nine variables seven variables (AS,
DSD
Female (80) 10.17 1.248 LMA, DMFS, DSD, DTD, WVF andDTMC) showed
Male (80) 9.841 1.092 correct prediction rates approximately 78.8% and two
DTD
Female (80) 9.616 3.629 variables (DA, DSMC) yielded no result. The equation
Male (80) 22.77 1.567 for sex estimation using the seven variables is as follows:
WVF
Female (80) 21.95 1.364
Male (80) 17.02 1.399
Z=-020.946+0.082 (AS)+(-0.002) (LMA)+0.321
DSMC (DMFS)+0.024 (DSD)+ (-0.044) (DTD)+0.125
Female (80) 32.88 159.2
Male (80) 21.24 2.630 (WVF)+0.034 (DTMC). The values ranging from -0.758
DTMC to 0 is assigned as Female and 0 to 0.758 is assigned as
Female (80) 19.81 2.450
Male.
[Table-2]: Canonical discriminant function
coefficients. Stepwise discriminant function analysis was
performed which resulted in multivariable model. Two
Function 1 variable models reached the accuracy of 77.5%. The
DA .000 equation for gender estimation using two variables is as
AS .082 follows.
LMA -.002
Z=-19.453+0.082 (AS)+0.361 (DMFS) The values
DMFS .321
ranging from -0.723 to 0 is assigned as Female and 0
DSD .024
to 0.723 is assigned as Male as shown in [Table/Fig-9].

[Table-3]: Stepwise discriminant function analysis.

Group Centroids Prediction Accuracy

Variable Unstandardized Coefficient
Male Female Male Female
AS 0.082
0.723 -0.723 76.3 23.8
Constant -19.453
DMFS 0.361
0.723 -0.723 21.3 78.8
Constant -19.453
150 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Discussion Stepwise variable selection resulted in a multivariable

model a two variable model reached an accuracy rate of
In present study 160 patients (80 males and 80
77.5%. Torimitsu S et al., reported in his study the most
females) were included who were referred for the CT
discriminant variable for the C2 was DMFS followed by
scans of the neck and cervical spine where the C2
LMA with an accuracy of 83.5% and 83.1% respectively
vertebra is seen, in which the measurements can be [5]
. In the present study, the most discriminant variable
taken.
for the C2 is DMFS followed by AS with an accuracy of
In the present study the overall mean value of the 73.8% and 71.9% respectively.
males is larger than the females; this shows the existence
Gama I et al., performed a study in documented
of sexual dimorphism. Torimitsu S et al., conducted a
Portuguese skeletal sample at University of Coimbra.
study on sexual determination based on multidetector
In present study, investigator performed t-test analysis
computed tomographic measurements of the second
to identify differences among sexes and found that out
cervical vertebra in a contemporary Japanese population.
of 13 dimensions one measurement was not showing
Multiple DFA with stepwise variable selection resulted
significant differences and reported that LMA-followed
in multi variable models a five-variable model reached
by DSMC are the most dimorphic dimensions of the
an accuracy rate of 92.9% [5]. In the present study,
second vertebra with the level of dimorphism of 11.18%
descriptive statistics for nine variables were included
and 10.6% respectively [7]. In the present study the most
and all the nine variables demonstrated significant sexual
discriminant variable for the C2 is DMFS followed by
dimorphism. In the present study, descriptive statistics
AS with an accuracy of 73.8% and 71.9% respectively.
for nine variables were included where only seven
Gama I et al., performed logistic regression analysis
variables (AS, LMA, DMFS, DSD, DTD, WVF, and
with stepwise variable selection to develop a model and
DTMC) demonstrated significant sexual dimorphism
reported a multivariate model with four variables reached
and two variables (DA, DSMC) yielded no result.
an accuracy of 89.7% as shown in [Table/Fig‑10] [5,7].

[Table-4]: Table showing previous studies percentage accuracy.

Study No of Patients Result Accuracy

Sugur Torimitsu, et al 224(112 males & 112 females) 92.9%.
st
1 Sample 190(99 males & 91 females)
Ines Gama, et al 89.7%
2nd Sample 47(24 males & 23 females)
Current study 160(80 males & 80 females) 78.8%

Stepwise variable selection resulted in a multivariable second cervical vertebra were taken out of which seven
model a two variable model reached an accuracy rate of variables were good discriminators where DMFS
77.5%. In the present study DMFS showed significant contributed much separation with high accuracy in
variability among males and females which suggests comparison to others. The results allow affirmation that
that measurements of DMFS can be obtained and used there is considerable sexual dimorphism with respect
to differentiate between the genders. to the second cervical vertebra which could determine
the gender of human based on computed tomographic
Limitations: The study has certain limitations such measurements of second cervical vertebra.
as all the parameters measured did not show significant
values and were not efficient discriminators among the Conflict of Interest: Nil
gender group. Further studies can be carried out using
larger sample size which may lead to better accuracy and Funding: Nil
reveal a stronger conclusion.
References
Conclusion 1. Xu W, Bo F, Liang K, Tian Y, Lai Y, Song W, et
In the present study nine measurements of the al. Sex assessment using measurements [1]of the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 151
first lumbar vertebra. Forensic Sci Int. 2016;219(1- 5. Torimitsu S, Makino Y, Saitoh H, Sakuma A,
3):285.e1-285.e5. Ishii N, Yajima D, et al. Sexual [5]determination
2. Zheng WX, Cheng FB, Cheng KL, Tian Y, Lai based on multidetector computed tomographic
Y, Zhang WS, et al. Sex assessment [2] using measurements of the second cervical vertebra in
measurements of the first lumbar vertebra. Forensic a contemporary Japanese population. Forensic
Sci Int [Internet]. 2012;219(1-3):285.e1-285. Sci Int [Internet]. 2016;266(2016):588.e1-588.
e5. Available from: http://dx.doi.org/10.1016/j. e6. Available from: http://dx.doi. org/10.1016/j.
forsciint.2011.11.022 forsciint.2016.04.010
3. Hou W Bin, Cheng KL, Tian SY, Lu YQ, Han 6. Badr El Dine FMM, El Shafei MM. Sex determination
YY, Lai Y, et al. Metric method for [3] sex using anthropometric [6] measurements from multi-
determination based on the 12th thoracic vertebra in slice computed tomography of the 12th thoracic and
contemporary north-easterners in China. J Forensic the first lumbar vertebrae among adult Egyptians.
Leg Med [Internet]. 2012;19(3):137-43. Available Egypt J Forensic Sci [Internet]. 2015;5(3):82-
from: http://dx.doi.org/10.1016/j.jflm.2011.12.012 89. Available from: http://dx.doi.org/10.1016/j.
ejfs.2014.07.005
4. Torimitsu S, Makino Y, Saitoh H, Sakuma A, Ishii
N, Hayakawa M, et al. Stature [4] estimation in 7. Gama I, Navega D, Cunha E. Sex estimation using
Japanese cadavers based on the second cervical the second cervical vertebra: [7] a morphometric
vertebra measured using multidetector computed analysis in a documented Portuguese skeletal
tomography. Leg Med [Internet]. 2015;17(3):145- sample. Int J Legal Med. 2015;129(2):365-72.
49. Available from: http://dx.doi.org/10.1016/j.
legalmed.2014.11.003
152 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Acceptance of PBL by Students to Learn Pre-Clinical Sciences

Malini Dutta1, K. Aditya2, Dilip Mathai3

1Professor of Physiology, 2Assistant Professor of Physiology, 3Professor of General Medicine,
Apollo Institute of Medical Sciences & Research, Hyderabad, Telangana

Abstract
Introduction: Medical education needs to be changed both in content and in teaching methodology .
The students need to be prepared with high level of knowledge, analytical skills, critical thinking, self-
directed learning and group dynamism. Problem Based Learning (PBL) can be used as a tool for teaching
undergraduate students. PBL is not problem solving but problem analysing. Here the students need to analyse
the problem after they have been taught in the conventional method.

Objectives: Find The attitude of students towards PBL.

Methodology: After a year of PBL practise, a twenty two set feedback questionnaire based on Elizondo–
Montemayor with 5 point Likert scale was taken from 98 students with 1 as least acceptable to PBL, 5 as
most acceptable and 3 as ambivalent response. The data was analysed by using one sample Wilcoxon’s test
for two- tailed hypothesis.

Results: Search phase and preparation phase had a median score greater than 3, indicating a positive attitude
for these phases. Presentation phase showed ambivalent response towards PBL objectives. Overall response
had a mean location above 3 suggesting students acceptance towards the objectives of PBL.

Conclusion: The future PBL sessions can be modified, planned accordingly and executed in a more productive
way so as to nurture the development of reflective learning in students to bring maximum improvement in
the educational outcome. To have better educational outcome, PBL must be used as an adjunct along with
the traditional method.

Keywords: Problem Based Learning, Self directed learning, medical students, attitude, brain storming.

Introduction the teaching and assessment are not aligned . Students

are evaluated on the basis of declarative knowledge. So
Medical teaching is undergoing radical changes. In
the curriculum needs to be revised and changed. One of
India the curriculum has not been revised since 30 years.
the changes is to introduce PBL to the UG students.
The most challenging is to design a curriculum that
delivers an optimum level of required knowledge, skills, PBL is in alignment of professional practice and
critical thinking and self- directed learning that would learning . This would provide functioning knowledge
prepare students for professional practice1. Currently, that can be put to work immediately on graduates or
in real life works. This will improve relevance and
motivation for learning. PBL is not problem solving
Corresponding Author: but problem analyzing . Here, a medical problem is
Dr. Malini Dutta presented to a small group of students for discussion
Professor of Physiology, Apollo Institute of Medical under the guidance of a facilitator . The students have to
Sciences & Research, Jubilee Hills, Hyderabad, analyze the problem after they have been taught in the
Telangana-500092 conventional method. The problems are constructed in a
e-mail: [email protected] way that the goals of PBL areachieved.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 153
• Activates students constraint knowledge that can be participation and required self directed learning for
put to work. meeting the learning outcomes.
• Integrate and apply new knowledge to solve the Guidelines Followed for Constructing a Problem:
problem.
• Title–Given in a way to guide the students in a
• Increases self directed learning, self management
particular direction.
skills, attitude, knowledge and develops professional
wisdom. • Trigger material –A story or a description of
phenomena orevents.
• Enhances and optimises the educational outcomes.
• Size - Short as meant only for the 1styear MBBS
• Develops and motivates group skills2.
students.
Material and Method • Number of Issues- Direct learning into a limited
We have introduced integrated PBL in Apollo number of issues.
Institute of Medical Sciences & Research (AIMSR), • Distractions - Less distractors.
Hyderabad, Telangana to the 1st year students of 2017-
18 batch from September 2017 to April 2018. Horizontal • Style - The structured problem was constructed in a
integration of the 1st year subjects was done. Twelve way that indicated gaps in what the students already
problems have been constructed on real life situations knew.
on the topics which were covered in the first three Each topic of PBL consisted of two sessions with
semesters. one weeks gap between the two sessions. Each session
was for two hours .
• Hematology - Erythroblastosisfoetalis
• Gastro Intestinal Tract - Obstructivejaundice The first session is called as the brain storming
session where the students attend the session with a note
• Cardio vascular system -Hypertension book and a medical dictionary to search for unfamiliar
• Cardio vascular system - Myocardial infarction terms. A leader and a scribe was selected by the students
in this session . The job of the leader was to see that each
• Respiratory system–Chronic Obstructive Pulmonary student participated actively in the group discussions.
Disease The scribe made notes of all the important points that
• Renal system - Acute Renal Failure were discussed. After going through the problem, the
students analyzed the problem and came to ahypothesis.
• Endocrine system - Pituitaryadenoma
• Endocrine system -Hyperthyroidism Then the students came with the learning objectives
pertaining to the problem. As the group comprised of
• Endocrine system - Diabetes mellitus twenty students, so twenty objectives were made and
• Reproductive system - Poly cystic ovarian disease numbered accordingly. The role of the facilitator in this
session was passive. The facilitator guided the students
• Reproductive system - Infertility if the discussions went out of track and facilitated them
• Central Nervous System -Hemiplegia till the students came with all the twenty objectives
correctly. The names of reference text books, research
100 students were divided into five groups of twenty
articles and website links related to the problem were
students each guided by a facilitator. The faculty of
given by the facilitator during this session. At the end
pre clinical departments constructed the problem with
of this session, the facilitator gave the feedback to
prior discussions . Care was taken in constructing the
the students based on their participation in the group
problems, so that it covered all the objectives pertaining
discussion.
to the subjects of Anatomy, Physiology and Biochemistry
which were expected to be learnt by the 1st year MBBS Activity in 1st Session:
students. The structured problem promoted discussions,
• Presentation of the problem
activated and incorporated knowledge, required new
knowledge that students did not know, stimulated active • Analysis of the problem - review the facts of the
problem.
154 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
• Generation of Hypothesis–explain various aspects find out what factors were enhanced or inhibited in the
of the problem. learning process through the PBL methodology. The
questionnaire consisted of a set of twenty two questions
• Formulate learning objectives–to identify the
with five point Likert scale scoring based on the
content that needs to be learnt in depth.
modified version of standard questionnaire developed
• Identify the proper learning resources - (e.g. by Elizondo–Montemayor3 . The questionnaire set was
textbooks, internet, etc)–from where to search and prepared for three phases of PBL. Search phase with
gather information regarding the problem. eight questions, preparation phase with six questions and
• Assign tasks to group members - to search for presentation phase with eight questions.
information related to the topic. The students were assembled and after briefing them
In the week to follow, all the group members have and taking consent, the questionnaire was distributed.
to learn all the objectives that were framed in the first The students were given 20 minutes to complete the
session. They could either do group study or study alone questionnaire. They were asked to indicate their degree
according to their convenience by taking the help of the of agreement for each statement with a tick according
references that was provided by the facilitator. For any to: 1 = strongly disagree, 2 = disagree, 3 = moderate, 4 =
doubts, the students could meet the facilitator or any agree, 5 = strongly agree. Care was taken to ensure that
faculty of the concerned department. they do not discuss among themselves. Confidentiality
and anonymity was maintained .
Activity in 2nd Session: At the end of the 1st week,
the same group of students and the facilitator met at the Statistical Analysis:
same time and same place for the second session which • For every individual, median score was calculated
is called as the presentation session. In this session, all from the Likert scaledata.
the students of the group came prepared with all the
twenty objectives that they made in the brain storming - A score of 1 was interpreted as being least acceptable
session. The scribe made twenty lots numbered from 1 and 5 as most acceptable
to 20 according to the number given for each objective • One sample Wilcoxon’s test was used to statistically
. Each student had to pick one lot so that everyone got analyze the score for two- tailed hypothesis.
one objective. After this, each student presented the
objective according to the number mentioned in the – Median score of 3 for an individual was assumed
lot picked by them. In this session too, the role of the to represent ambivalent or uncertain acceptance
facilitator was passive. The facilitator only gave them of PBL.
any additional knowledge that the students might have – Median score greater than 3 was taken to
missed and clarified if any doubts arose regarding any of represent definitive positive acceptance.
the objectives or the problem . The session ended with a
– Median score less than 3 implied that PBL was
summary presented by the leader.
less acceptable as a learning method.
• Share - the gathered knowledge and information • Null hypothesis : median score=3
among the group members
• Alternate hypothesis : median score ≠3
• Re-analyze - the problem.
• α = 0.05 was used as the criterion for statistical
• Refine and reformulate - the hypotheses. significance.
• Integrate and apply - the refined hypotheses to
explain the issues related to the problem.
Results
Totally 98 students of MBBS 1st year of 2017 batch
• Resolve and summarize - the problem
participated in the study. The median on the overall score
Institutional research committee permission was for twenty two questions of the questionnaire was less
taken to undertake a cross sectional study on 1st year than 3 for 16 students . For 41 students the median was
MBBS students of 2017 batch in the Department of equal to 3 and for the remaining 41 students the median
Physiology, AIMSR. At the end of 3rd semester, a was greater than 3. One sample Wilcoxon’s test for
feedback questionnaire was given to the students to overall score indicated that the true location for median
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 155
score was above 3 suggesting students acceptance and
adherence of overall PBL objectives (p=0.005919).
Figure 1.

Figure 3

The presentation phase suggested their ambivalent

influence on the PBL objectives for this phase with a
median score less than 3 for 28 students as well as equal
Figure 1 number of students having a median score more than
three. 42 students had a median score equal to 3. So
In the search phase, 54 students had a median score
the true location of median score was not significantly
greater than 3(p<0.001). 24 students with a median
different from 3(p=0.9633). Figure 4.
score equal to 3 and 20 students with a score less than 3,
indicating a liking for this phase of PBL. Figure 2.

Figure 4

Discussion
Figure 2 Knowledge of medical sciences was previously
Even the preparation phase indicated a positive based on learning plain empirical and observational facts
attitude of the students towards this phase of PBL with which was memory oriented. With the rapid explosion
a median score greater than 3(p<0.001) for 62 students. of information, old method of teaching and learning are
Where else 21 students had a median score equal to 3 no more tenable. The situation demands a paradigm shift
and remaining 15 students had a median score less in our teaching and learning4,5. In order to tune to these
than3. Figure 3. situations a series of experiments are going on at global
156 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
level with regard to the changing modes of teaching and that the students from abroad are already exposed to the
learning. These transformations are in conformity to the PBL approach9.
structure of the human brain where the capacity of short
term memory is small but there is infinite capacity for Discussions in small groups paved the way for better
long termmemory6. learning process10. Even the present study has shown
an overall acceptance to PBL objectives with the true
In this study, more than fifty percent of the students location of median score above3.
[54(55.10%)] have agreed to be benefitted by reading
the literature from diverse sources which improved their Conclusion
understanding on the topic concerned with an increase in Based on the feedback results of the questionnaire,
knowledge. A previous study done in Kasturba Medical the future PBL sessions can be modified, planned
College, Manipal University, Mangalore, Karnataka accordingly and executed in a more productive way
also reported a 53.75% increase in reading diverse and so as to nurture the development of reflective learning
recent bibliographic sources for PBL 7. in students to bring maximum improvement in the
Van den Hurk et al. noted that the performance educational outcome. The shortcomings seen in the
in the presentation phase is a direct reflection on the presentation phase should be bridged to develop the
process of preparation for the problem8. If the students attitude and professional wisdom of the students. Also,
are well versed on how to search for the literature from students can have a personal insight of their strengths
the given references, then the learning becomes more and limitations with respect to a given area of learning11.
easy, under stable and interesting. In the present study To have better educational outcome, PBL must be used
also the students have shown a positive attitude in the as an adjunct along with the traditional method.
preparation phase of PBL where the median score was Limitations: The study was done only to know the
more than three for [62(63.26%)] students. Proper students perception towards PBL and not the level of
search of literature with analytical understanding of the knowledge gained by using it as a teaching methodology.
concepts and making notes and summaries goes a long
way in making PBL successful. Conflict of Interest: There was no conflict of
interests.
The present study has reported uncertain acceptance
for PBL [42(42.86%)] in regards to presentation phase. Source of Funding: Self funding .
The percentage for acceptance as well as non acceptance
for PBL was found to be same [28(28.57%)]. This Ethical Clearance: Ethical committee clearance
could be due to the fact that some of the students are has been given by institutional research committee vide
not comfortable to open up in front of their faculty and letter no. AIMSR/IRB/RC/2018/06/35
peer to answer or clear any doubts that they had for fear
of being ear marked by the teachers or due to lack of
References
confidence level. It may also be due to the presence of 1. Applin H, Williams B, Day R, Buro K. A
strict faculty or due to lack of interest by the student comparison of competencies between problem–
on the subject. The facilitator needs to play a very based learning & non-problem- based graduate
important role in identifying such students and give nurses . Nurse Educ today 2011;31:129-34.
them timely counselling to boost up their morale and 2. Prince KJ, Van Ejis PW, Boshuizen HP, vander
self confidence. A study done by Bijli Nanda of Sharda Vleuten CP, Scherpbier AJ. General competencies
University, Greater Noida, Uttar Pradesh has reported of problem based learning (PBL) and non-PBL
that majority of the students coming from abroad graduates. MedEduc 2005;39:394-401.
believed that there was similarity in the student–teacher
3. Elizondo-Montemayor LL. Formative and
relationship in both the traditional method as well as in
summative assessment of the problem based
the PBL methodology. Whereas one third of the Indian
learning tutorial session using a criterion -
students found PBL to be better, another third felt both
referenced system. JIAMSE2004;14:8-14.
the method to have equal weight and the remaining third
opted for the traditional method in regards to student- 4. Neufeld VR, Woodward Christel A, MacCleod
teacher relationship. This could be due to the fact that SM. The McMaster M.D. program: a case study
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 157
of renewal in medical education. Acad Med 8. Van der Hurk MM, Dolmans DHJM, Wolfhagen
1989;64:423-32. IHJP, Muijtjens AMM, Van der Vleuten CPM.
5. Spaulding WB. Revitalizing Medical Education: Impact of individual study on tutorial group
NcMaster Medical School, The Early Years 1965- discussion . Teach Learn Med.1999;11:196-201.
1974. Philadelphia: BC Decker,1991. 9. Bijli Nanda, Shankarappa Manjunatha .Indian
6. YazdaniSh, Hatami S. General practioner in medical students perspectives on PBL experiences
Iran,duties and training needs, gastro- intestinal in the undergraduate curriculum: One size does not
diseases. Iranian journal of medical sciences. fit all. J EducEval Health Prof2013,10:11.
2003;14(5):2-8.Persian. 10. Shankar RP, Nandy A, Balasumramanium R,
7. Nitin Joseph, Sharada Rai, Deepak Madi, Chakravarty S. Smallgroup effectiveness in a
Kamalakshi, Shashidhar M Kotian, Supriya K. Caribbean medical school’s problem based learning
PBL as an effective learning tool in Community sessions. J Educ Eval Health Prof 2014;11:15.
Medicine: Initiative in a Private Medical College of 11. Spaulding WB. Revitalizing Medical Education:
a Developing Country. IJCM 2016. NcMaster Medical School, The Early Years 1965-
1974. Philadelphia: BC Decker,1991.
158 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Effect of Dance Therapy on Stress and Anxiety in

Working Women

Manali B. Badave1, Khushboo Bathia2, Smita Kanase3, Amrutkuvar Jadhav4

1Faculty
of Physiotherapy, Krishna Deemed to be University, Karad, Maharashtra, India, 2Department of
Musculoskeletal Sciences, Faculty of Physiotherapy, Krishna Deemed to be University, Karad, Maharashtra,
3Department of Musculoskeletal Sciences, Faculty of Physiotherapy, Krishna Deemed to be University, Karad,

Maharashtra, India4 Department of Musculoskeletal Sciences, Faculty of Physiotherapy, Krishna Deemed to be

University, Karad, Maharashtra, India

Abstract
Objective: To find out the effect of dance therapy on stress and anxiety in working women.

Method: A total of 41 women between age group 25 to 40 years were randomly selected to receive aerobic
dance therapy. The program was conducted for 4 weeks, scheduled three days in a week, with a session of
10-20 minutes each day. Outcome assessment included perceived stress scale (PSS) and Hamilton anxiety
rating scale (HAMA) which was recorded before and after completion of sessions.

Result: There was a reduction in levels of stress and anxiety after 4 weeks of aerobic dance therapy (p value
< 0.0001) which was found to be statistically significant; whereas correlation between working hours and
scores of PSS (r value -0.16) and HAMA (r value -0.06) Scales were statistically insignificant.

Conclusion: On the basis of results of our study we concluded that aerobic dance therapy was effective in
reducing stress and anxiety in working women.

Keywords: Aerobic dance, Stress, Anxiety.

Introduction working population.5 There is an increase in the amount

of stress level as women have to deal with both the stress
The lifetime prevalence of stress and anxiety among
from home as well as stress from work.6 Symptoms
general population of adolescent age group and young
associated with stress such as insomnia, fatigue,
adults ranges between 5-70% in India.1 The prevalence
irritability, headache, depression, unhealthy behaviors
found worldwide for anxiety in men and women was
like poor eating habits are commonly seen in working
10.6% and 16.6% respectively, with a ratio indicating
women.5 Also prolonged stress can adversely affect the
that prevalence is approximately twice among women
cardiovascular, endocrine and central nervous system.
than men.2 From the people working for longer duration,
Chronic stress is the leading cause of anxiety. Symptoms
it was found out that 8.2% males and (10%) females
produced due to anxiety are frequent panic attacks, phobic
were suffering from symptoms of anxiety.3 Prevalence
disorders like agoraphobia, social phobia and unpleasant
of stress in working population for males was 13% and
thoughts.7 Negative affective conditions are associated
in females was 3%.With the developing industrialization
with concept of stress. Also, with precipitation of the
and urbanization, the status of women has been
episodes of anxiety and depression, a stress event of life
changing due to which the levels of stress are seen to be
leads to a characteristic stress response with involvement
elevated;the prevalence of stress was found to be 37%
of chronic arousal and impaired functions. Consider as
and for anxiety it was 40% among working women in
a mental state, the concept of a stress response has clear
India.4
affinities with anxiety.8
Rapid changes in lifestyle and increasing
There are certain physiological and biochemical
competitiveness have led to a marked stress among
changes that occur in the body with response to stress.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 159
Physiological changes triggered by stress include regulates serotonin and dopamine level.17
There are
increased respiration and volumetric consumption various types of dance which helps to reduce the stress
(VO2), dilation of bronchioles and airways. Due to and anxiety like ballroom dance, street dance, jazz, ballet
simultaneously increase in cardiac output and blood dance and Zumba but aerobic dance has a highly positive
pressure there will be an increase in blood flow impact in management of stress and anxiety.18 Aerobic
to heart, muscle and skin.9 Biochemical changes dance is one type of aerobic exercise, word aerobics
triggered in stressful conditions activate two main means “with oxygen”.19Analysis revealed improvements
pathways, sympatho-adreno-medullary axis (SAM) in fatigue, stress and anxiety were seenafter 10 minutes
and Hypothalamus-pituitary-adreno axis (HPA). These of exercise, with progressive improvements after 20
two factors are activated by Corticotrophin Releasing minutes and there was no additional improvement over
Hormone (CRH) which causes release of ACTH by longer period.20
pituitary gland. In SAM, ACTH stimulates the adrenal
medulla which releases catecholamines epinephrine Studies have shown a beneficial effect of aerobic
and norepinephrine. In HPA axis, Adrenocorticotrophic dance on stress and anxiety;A study was done the effect of
hormone (ACTH) acts on adrenal cortex which releases aerobic exercise on depression, anxiety in middle- aged
Cortisol. Cortisol changes the metabolism of liver by adults, they concluded aerobic training had significant
increasing glucose and ATP which repairs the cells in effects and according to the results they concluded that
response to stressful conditions.9 aerobic dance can improve mental health and enhance
life quality.21
Along with physiological and biochemical changes
there are some psychological symptoms of stress and No study is conducted till date hence, this study is
anxiety such as, mental fatigue, depressed mood, sleep necessary to find out effect of aerobic dance on stress
disturbances which aggregate distress and also affect the and anxiety among working women. The purpose of
quality of life;10 hence, it is necessary to quantify stress the study is to determine the effect of dance therapy on
and anxiety. Various method used to quantify stress stress and anxiety in working women.
may includes, Singh’s Personal Stress Source Inventory
(SPSSI)5, Cortisol for measuring stress level. Pss has
Materials and Methodology
good reliability score ICC, 0.86 with good supporting Study Design: Pre and post test, Sample size-41,
validity.11 Also,there are various method used to quantify study place-Krishna hospital, Karad, study duration- 3
anxiety includeThe State and Trait Anxiety Inventory months, sampling method- simple random sampling,
(STAI) instrument, Structured Interview Guides for sessions duration-4 Weeks
Hamilton Anxiety Rating Scales (SIGH-A)12but, the
test-retest reliability score for Hamilton anxiety rating Participants:
scale is ICC, 0.86 and validity score is ICC, 0.57 which Inclusion Criteria: Working women of age group
iseasy way to measure severity of anxiety symptoms.13 25-40, who had mild to moderate stress and anxiety on
There are various pharmacological and non- PSS and HAMA scale scores and women who work for
pharmacological therapies used for the treatment of more than 6 hours per day were taken in the study.
stress and anxiety. Pharmacological treatment consists Exclusion Criteria: Women with psychological
of antidepressants, antipsychotic and anxiolytic drugs14 ailments, past history of surgery, pain anywhere in
and non-pharmacological treatment includes progressive the bodyof varying intensity, any physical injury, and
muscle relaxation technique (PMRT),5 yoga, behavioral subjects with cardiac and respiratory conditions were
therapy, psychoanalytical therapy, group therapy.12 Also excluded from the study.
there are some art therapies such as painting, playing,
sculpting, dance therapy and music therapy.15 Astudy Outcome Measures: Outcome measures were
was done on effect of music intervention on stress and recorded prior to the 4 week aerobic dance therapy
anxiety, results of study indicated that music interventions program and again recorded at the end of the program.
are effective in reducing stress and anxiety.16 It has been
documented that music interventions can decrease the 1. Perceived Stress Scale 14- PSS 14was given to
level of stress and anxiety and increasing psychological the subjects which consisted of 14 questions and
well being, relieving physical, mental tension and subjects were asked to fill it by circling the numbers
160 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
given in them where, 0=Never, 1= Almost never, 2= Warm up- Stretching of pectorals, stretching of
sometimes, 3= fairly often, 4=very often and scores neck muscles, capsular stretching, hamstring stretch,
were obtained by reversing the scores on the seven quadriceps stretch, calf stretch, trunk side flexor
positive items 4,5,6,7 and 9 and then summing stretch,lunge stretch, arm rotations, neck rotations, waist
across all 14 items.11 A total score range of PSS -14 twist, wrist rotation, hip rotation,half squats, jumping
was 0-56 where <14 indicates mild stress, 15-28 jacks.
moderate stress and 43-56 indicates severe stress.24
Training program- Heel digs, grapevine, V- box,
2. Hamilton Anxiety Rating-The scale consisted of A-box, front lunges, side lunges, shower dance, skipping,
14 questions which were filled by the subjects by diagonal toe touch, punches, hamstring curls, criss cross
marking the numbers given in the scale. In which with arm movement, toe touch, marching, grapevine
0= Not present, 1= mild, 2 = moderate, 3= severe, with hamstring curls.
4=very severe. After addition, a total score range
of 0–56, where <17 indicates mild severity, 18–24 Cool down- Stretching of pectorals, stretching of
mild to moderate severity and 25–30 moderate to neck muscles, capsular stretching, hamstring stretch,
severe.13 quadriceps stretch, calf stretch, trunk side flexor stretch,
lunge stretch, hand kicks, jumping jacks, half squats.
Interventions: The study was designed into three
parts as pre-test, the specific training program and post- Dance therapy was conducted in well ventilated
test. The program was continued for 4 weeks, scheduled room and it was carried out in standing position. In
three days in a week, having sessions of increasing warm sessions and cool down sessions, the hold time for
intensity and duration. In 1st and 2nd week aerobic dance stretching was maintained for 10 seconds. From 3rd week
intensity was low and duration was 10-15 minute. In onwards, the main workout session was done twice.
3rd week and 4th week intensity of aerobic dance was
moderate to high and duration was 20- 25 minutes. The Results
training program scheduled as follows.
1. Age distribution in the study:
Table No. 1: Dance therapy session protocol Table No. 2: Age distribution
1st week 2nd week 3rd week 4th week Age No. of Subjects
Warm-up 2 min 2 min 2 min 5 min 20-30 32
Aerobics 5 min 10 min 15 min 15 min 30-40 9
Cool Down 2 min 2 min 2 min 5 min

2. Comparison of pre and post scores in stress and anxiety:

Table No. 3 comparison of pre and post in stress and anxiety using pss and hama scale

Parameters Pre Mean ± SD Post Mean ± SD Mean DIFF t value p value

PSS 28.61±4.73 26.29±4.07 2.31 4.629 < 0.0001
HAMA 16.02±8.79 13.17±8.42 2.85 8.783 < 0.0001

3. Correlation between working hours, PSS and From the above table it is clear that effect of aerobic
HAMA scale: dance in working women with the use of the parameters
PSS and HAMA scales was found to be statistically
Table No. 4: Correlation between working hours,
extremely significant as both the p-value were noted to
PSS and HAMA scale
be (< 0.0001).
Parameters ‘r’ value Remark
Statistics: The outcome measures were used to
PSS -0.16 Not significant
assess, before the sessions and after completion of
HAMA -0.06 Not significant
sessions. Data analysis was done using paired t test
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 161
and analysis was performed using SPSS (version 22). that the correlation between working hours, stress
Statistical significance was accepted for values of p<0.05 and anxiety was statistically not significant. But
at 95% confidence interval. there was statistically significant difference between
pre-interventional and post-interventional values of
Discussion stress and anxiety in a group of working women thus,
Stress and anxiety are highly prevalent in the concluding that there is a positive effect of aerobic dance
general population.1 Ability to cope with improving on stress and anxiety in working women.
industrialization and competitiveness, the level of
Conclusion
stress is increased. Stress and anxiety is more common
in women who work for more than 55 hours a week.22 On the basis of the results of our study, it was
In the current study, 41 women between the age group concluded that aerobic dance therapy was significantly
of 20‑45 years fulfilling the inclusion criteria were effective in reducing stress and anxiety in working
included. women. And it has highly positive impact in management
of stress and anxiety related problems.
Statistically the present study showed that, there
were considerable changes in the outcome measures Ethical Clearance: Ethical Clearance is taken from
with significant difference seen in stress (mean Institutional Ethics Committee of Krishna Institute of
difference=2.31) (p value <0.0001) and anxiety (mean Medical Sciences Deemed to be University, Karad.
difference 2.85) (p value<0.0001) levels in working
women. In our study we analyzed that the changes in Conflict of Interest: The authors declare that there
perceived stress scale for stress and Hamilton anxiety is no conflict of interest concerning the content of the
rating scale for anxiety, after incorporating aerobic dance present study.
therapy for total 12 sessions in duration of 4 weeks were Source of Funding: This study was funded by
found significant results. It has been studied that aerobic Krishna Institute of Medical Sciences Deemed to be
dance therapy offers a way for an individual to defend University, Karad.
against stress and anxiety by releasing endorphins and
neurotransmitters that increases the feeling of well References
being which can relieve the stress and anxiety and
also it gives positive effects on both musculoskeletal 1. Sahoo S, Khess CJ. Prevalence of depression,
and cardiovascular system and hence maintain good anxiety,and stress among young male adults in
fitness.23 A study investigated effects of 12 weeks of india: a dimensional and categorical diagnoses-
dance intervention on psychiatric patients with stress based study. The journal of nervous and mental
and depression they found out that significantly less diseases. 2010;198(12):901-904
depression in subjects who participated in dance group 2. Manzoni GM, Pagnini F, Castelnuovo G,
than the subjects in music therapy session.15 Molinari E.Relaxation training for anxiety: a ten
years systemic review with meta analysis.BMC
A study was done on effect of aerobic dance for Psychiatry 2008,8(1):41
1 hour session conducted each day for 6 weeks. They
3. Andrea H, Bultmann U, Swaen GMH, Van Schaycic
found that aerobic dance has highly positive impact in
CP, Kant IJ. Anxiety and depression in the working
the management of stress related problems and practicing
population using the HAD scale. Social Psychiatry
aerobic dance has been shown to improve and sustain
and Psychiatric Epidemiology 2004; 39(8):637-646
physical as well as mental efficiency.19 A study was done
on effect of dance therapy on cardiovascular parameters 4. Patel PA, Patel PP. Impact of occupation on stress
for 4 weeks they found out that dance therapy was and anxiety among indian women. Women &
effective on cardiovascular parameters23 similarly,we set Health 2017; 57(3):392-401
the program for 4 weeks to check whether dance therapy 5. Kermane MM. A psychological study on stress
is effective in reducing stress and anxiety, the results among employed women and housewives and
were found to be significantly effective in reducing its management through progressive muscular
stress and anxiety in working women. relaxation technique (PMRT) and mindfulness
breathing. Journal of Psychology and Psychotherapy
In our study at the end of 4 weeks, it was recorded 2016;6(1):1-5.
162 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
6. Fan LB, Blumenthal JA, Watkins LL, Sherwood A. 15. Koch SC, Morlinghaus K, Fuchs T. The joy dance
Work and home stress: associations with anxiety specific effects of a single dance interventions on
and depression symptoms. Occupational medicine psychiatric patients with depression. The arts in
2015;65(2): 110-116. Psychotherapy 2007; 34(4):340-349
7. Liebowitz MR. Social Phobia. Anxiety 1987; 16. Murcia CQ. Emotionaland neurohumoral responses
22:141-173 to dancing tango argentino: The effects of musicand
8. Lovibond PF, Lovibond SF. The structure of partner. Music and Medicine. 2009; 1: 14-21
negative emotional states: comparison of the 17. Chanda ML, Levitin DJ. The Neurochemistry
depression anxiety stress scales (DASS) with the of Music. Trends in cognitive sciences. 2013;
beck depression and anxiety inventories. Behaviour 17(4):179-193
research and therapy 1995; 33(3):335 -343 18. Sivvas G, Batsiou S, Vasoglou Z, Filippou D.
9. Dusek JA, Benson H. Mind body medicine: A Dance contribution in health promotion. Journal of
model of the comparative clinical impact of the physical education and sport. 2015;15(3):484
acute stress and relaxation responses. Minn Med 19. Biswas S. Effect of aerobic dance on stress. Int J Res
2009; 92(5):47-50 Pedagogy Technol Educ Mov Sci. 2012;1(2);14-17
10. Klink JJ, Blonk RW, Schene AH, Dijk FJ.The 20. Hansen CJ, Stevens LC, Coast JR. Exercise duration
benefits of interventions for work- related stress. and mood state: How much is enough to feel better?
American journal of public health 2001; 91 (2)270 Health Psychology. 2001;20(4):267-275
11. Wiegner L, Hange D, Bjorkelund D, Ahlborg G Jr. 21. King AC, Taylor CB, Haskell WL, Debusk
Prevalence of perceived stress and associations to RL. Influence of regular aerobic exercise on
symptoms of exhaustion, depression and anxiety psychological health: a randomized, controlled trial
in a working age population seeking primary care- of healthy middle -aged adults. Health Psychology.
an observational study. BMC Family Practice 1989;8(3):305
2015;16(1):38
22. Virtanen M, Ferrie JE, Singh Manoux A, Shipley
12. Shapiro SL, Schwartz GE, Bonner G. Effect of MJ, Stansfeld SA, Marmot MG,et al. Long working
mindfulness- based stress reduction on medical hours and symptoms of anxiety and depression: A
and premedical students.Journal of Behavioral 5 years follow up of the whitehall II study. Psychol
Medicine 1998;21(6):581-599 Med. 2011;41(12):2485-2494
13. Shear MK, Vander BJ, Rucci P, Endicott J, Lydiard 23. Aweto HA, Owoeye OBA, Akinbo SRA, Onabajo
B, Otto MW, et al. reliability and validity of a AA. Effects of dance movement therapy on selected
structured interview guide for the Hamilton anxiety cardiovascular parameters and estimated maximum
rating scale (SIGH-A). Depression and Anxiety oxygen consumption in hypertensive patients.
2001;13(4):166-178 Nigerian quarterly journal of hospital medicine.
14. Youngstedt SD, Kripke DF. Does bright light have 2012;22(2):125-29
Anxiolytic effects? An open trial. BMC Psychiatry 24. Chandan N, Sherkhane MS. Assessment of stress
2007; 7(1):62 and burnout among medical graduates using pss-14
and MBI-SS scales. 2016;6(1):44-49
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 163

A Study on Effect of Favorite Film Songs on Heart Rate

Variability (HRV) and Heart Rate (HR) with
Moderate Exercise

Manibalanvijayaraman

Assistant Professor, Department of Physiology, Vinayaka Mission’s Medical College & Hospital,
Karaikal–609609, Puducherry

Abstract
Introduction: Heart rate variability (HRV) is the physiological event of variation in the time interval
between heart beats. It is measured by the variation in the beat-to-beat interval (R-R interval).The present
study aimed at determining the effect of favorite film songs on HRV and HR with moderate exercise.

Materials and Method: This was a cross sectional observational study conducted in the department of
physiology, Vinayaka mission’s medical college & hospital. Participants were allowed to select favorite
slow tempo and fast tempo film songs. Selected songs were played (4-5 minutes) before and during exercise,
with 30 minute interval (each day N=10) and their HRV and HR were measured by using time and Frequency
domain method. (Standard instrumental protocol was followed).

Results: In this study, participants were able to do exercise at a lower HR with a slow tempo film song when
compared to no music or film song during exercise the cardiac activity the HR and HRV was improved and
fast recovery too. It was observed that the musical therapy improved the time and frequency domain indices
of HRV.

Conclusion:The present study clearly indicates that, a particular favorite tempo of a film song or music has
a beneficial effect on HRV and HR changes through the involvement of the PSNS and SNS.

Keywords: Favorite film songs, Heart rate variability, Heart rate.

Introduction rhythm of the heart. Further, HRV testing is a prognostic

(predictive) indicator of cardiac condition, fitness, stress
Heart rate variability (HRV) is the physiological
levels, aging, health risk levels and chronic disease
event of variation in the time interval between heart
condition.[2]
beats. It is measured by the variation in the beat-to-beat
interval (R-R interval).[1] The beat-to-beat alterations HRV is the immediate variation in heart rhythm
in HRV, is an accurate and reliable reflection of the due to ANS influences on the Sinoatrial node (SA
many physiological factors modulating the normal node).Previous researchers showed that the high HRV
indicating good health and a high level of fitness, whilst
decreased HRV is linked to stress, fatigue and even
Corresponding Author: burnout. The intervention of music indicating positive
Manibalanvijayaraman effect on HRV. [3]An individual’s relaxation response
Assistant Professor, Department of Physiology, is based on his music generi, which is composed of
Vinayaka Mission’s Medical College & Hospital, different basic compositional elements, such as melody,
Karaikal–609609, Puducherry rhythm, harmony, and tonality. Earlier studies had
Mobile No.: 9941163012 shown the relaxation effects of classical music at both
e-mail: [email protected] the subjective and objective levels.[4]
164 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
It was also indicated that the music therapy has B. For favorite fast tempo film song intervention, a
positive effects on HRV in sick patients and also complete fast tempo song was played (4-5 minute)
soothing music has a significant effect on decreased HR before and during exercise, with 30 minute interval
and improved HRV in healthy youth. HRV alterations (each day N=10) and their HRVand HR.
relate to the rhythm of the particular type of music.[3]
Exercise: In this study, Bicycles Ergometer for
The classical, meditation or relax music are capable
exercise was used. All the participants were instructed
of bringing out a number of health benefits including,
pre-test one week before the testing to overcome factors
raising states of consciousness, lowering stress level,
that could alter HRV. They will be asked to avoid
changing moods and accessing different states of mind.[5]
heavy physical activity, smoking and alcohol and other
Individualizing the type of music used is vital to the beverages affect physical activity.
success of music therapy and the degree of love towards
HRV Analysis: Time and Frequency domain
music is the most important factor in relaxation. In
method. (Standard instrumental protocol was followed)
recent years, most of the individuals prefer film songs
as a part of relaxation and also individual’s preference Inclusion Criteria: Participants (N= 310) included
may vary such as slow tempo or fast tempo songs. These 160 males and 150 females with an average age of 19
days most of the people while jogging, doing exercise years (ranging from 18 to 23) with normal body weight.
or fitness training frequently, listen to music through the All the participants were tested initially -physical
headphone or earphone. fitness, body mass index (BMI), height, waist and hip
circumference, The participant’s weight was calculated
The present study aimed at determining the effect
by a digital balance (INCO, India), BMI and with normal
of favorite film songs on HRV and HR with moderate
body weight and further the participants reported no
exercise.
significant hearing loss and no cardiac conditions were
Materials and Method: This was a cross sectional included in the study.
observational study conducted in the department of
Exclusion Criteria: The participants were screened
physiology, Vinayaka mission’s medical college &
for self-reported hearing loss and cardiac history using
hospital. Study was explained to the participants and
a screening questionnaire. Participants with significant
informed consent was obtained. Study was approved by
hearing loss or cardiac anomalies, diabetic, pregnant,
institutional ethical committee.
heart failure, acute and chronic renal failure or any
Song and Music Selection: Prior to the experimental chronic diseases were excluded from the study.
session, participants were asked to self-report a title of
Statistical Analysis: Descriptive data are expressed
their most favorite film songs (Song by the human voice
as mean ± SD, ONE WAY ANOVA was used to analyze
with composed instrumental music) orally confirmed.
the HRV and HR. The level of significance was analyzed.
Depending on their interest, the fast and slow tempo
All data were analyzed using SPSS for Windows version
selected film songs played, then the songs or music were
17.0.
separated based on tempo, the tempo was calculated
based on beats/ minute. The Piston soft BPM Detector Results
software was used to find the tempo of a song. 70-80
beats/ minute (BPM) consider as slow tempo, 140-160 A total of 310 participants included in the study. 160
beats/minute songs were fast tempo, medium tempo 90- males and 150 females with an average age of 19 years
100 beats/ minute. (ranging from 18 to 23). This present study showed that
the selected young subjects were able to do exercise at
Film song Intervention: a lower HR with a slow tempo film song or slow tempo
A. For favorite slow tempo film song intervention, a instrumental music when compared to no music or film
complete slow song was played (4-5 minutes) before song during exercise the cardiac activity the HR and
and during exercise, with 30 minute interval (each HRV was improved and fast recovery too.
day N=10) and their HRV and HR were measured.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 165
Table 1: Effect of slow tempo film song on HR. (Frequency Domain Analysis)

Parameters No song played Slow tempo film Exercise only No song Exercise + slow tempo
P value
normalized units (nu) (baseline) Mean ±SD song Mean ±SD played Mean ±SD film song Mean ±SD
Low frequency(LF)Hz 39.82±5.25 39.02±4.21 50.48±5.31 49.08±4.81 P<0.001
High frequency (HF)Hz 60.74±5.47 63.33±3.39 48.91±5.80 54.95±6.37 P<0.001
LF/HFms² 0.864±0.05 0.602±0.05 1.07 ±0.16 0.88±0.23 P<0.001

Mean values of low frequency (LF), High Frequency (HF) and LF/HF. (Values are Mean ± SD), Pvalue<0.001
is significant. (N=310)

Table 2: Effect of fast tempo film songs on HRV (Frequency Domain Analysis)

Parameters No song played Fast tempo Exercise only No song Exercise + Fast tempo
P value
normalized units(nu) (baseline) Mean ±SD song Mean ±SD played Mean ±SD song Mean ±SD
Low frequency(LF)Hz 61.44±5.36 63.32±3.24 51.61±6.80 56.83±5.23 P<0.001
High frequency(HF)Hz 41.83±6.22 36.02±4.31 50.49±4.31 45.06±4.21 P<0.001
LF/HFms² 1.391±0.04 1.839±0.06 1.013 ±0.04 1.214±0.18 P<0.001

Mean values of low frequency (LF), High Frequency (HF) and LF/HF. (Values are Mean ± SD), P value<0.001
is significant. (N=310)

Table 3: Effect of Slow tempo film song on HR and HRV SDNN and RMSSD (Time domain analysis)

No song played Slow tempo Exercise only No song Exercise + slow tempo
Parameters P value
(baseline) Mean ±SD song Mean ±SD played Mean ±SD film song Mean ±SD
Mean RR(ms) 804.32±11.92 706.75±10.5 550.54±6.11 700.74±6.99
SDNN(ms) 64.10±11.11 55.11±2.11 50.32±14.32 76.84± 3.11
Mean HR (beats/minute) 78.24±3.2 68.5±11.21 98.2±3.4 80±3.96 P<0.001
RMSSD(ms) 45.17±13.21 40.32±7.88 45.22±12.3 70.99±4.67
NN50 7.67±5.4 6.55±4.37 5.76±11.89 15.81±6.48

The R-R Interval between R to R,Heart rate (HR), The Standard deviation of normal-to-normal R-R intervals
(SDNN), the percentage of the adjacent RR intervals with a difference of duration greater than 50 ms (pNN50)
and root-mean square of differences (RMSSD) between the adjacent normal RR intervals in a given time interval
(N=310).

Table 4: Effect of Fast tempo song on HR and HRV SDNN and RMSSD (Time domain analysis)

No song played Fast tempo Exercise only No song Exercise + Fast tempo
Parameters P value
(baseline) Mean ±SD song Mean ±SD played Mean ±SD film song Mean ±SD
Mean RR (ms) 704.33±11.92 606.76±13.5 600.54±7.11 807.84±6.99
SDNN (ms) 65.10±12.11 60.12±10.11 55.32±14.32 77.84± 3.11
Mean HR (beats/mintes) 78.24±32 89.7±11.21 100.2±3.9 120±3.56 P<0.001
RMSSD (ms) 45.17±13.21 40.32±7.88 45.22±12.3 70.99±4.67
NN50 10.67±13.4 8.56±4.37 6.77±12.89 15.81±8.98

The RR interval between R to R, heart rate (HR), The Standard deviation of normal-to-normal R-R intervals
(SDNN), the percentage of the adjacent RR intervals with a difference of duration greater than 50 ms (pNN50) and
root-mean square of differences (RMSSD) between the adjacent normal RR intervals in a given time interval.
166 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Discussion old with normal BMR. Moreover, only healthy subjects

were evaluated in order to homogenize the study sample.
In this study, participants were able to do exercise
at a lower HR with a slow tempo film song when
Conclusion
compared to no music or film song during exercise the
cardiac activity the HR and HRV was improved and fast The present study clearly indicates that, a particular
recovery too. The relation of music to emotion has been favorite tempo of a film song or music have a beneficial
studied for decades and the literature is fruitful.[6] effect on HRV and HR changes through the involvement
of the PSNS and SNS.
Our results showed that the favorite slow song has
a definite peaceful effect on exercise induced changes Ethical Clearance: Taken from institutional ethical
in HRV which is in agreement with the work of Pal et committee
al.[7]In their study, the practice of relaxation of song
Source of Funding: Self
therapy has significant effect in lowering the LF/HF
ratio of HRV inparticipants. The present study showed Conflict of Interest: Nil
that, listening to slow tempo film songs during exercise
increases the HF and listening fast tempo film song or References
fast tempo music listening during exercise increases the
1. Task Force of the European Society of
LF. Increased HF indicates PSNS tone increased. [8]But,
Cardiology the North American Society of Pacing
LF index communicates to both vagal and sympathetic
Electrophysiology. Heart Rate Variability: Standards
influences on the heart, yet providing predominance of
of Measurement, Physiological Interpretation, and
the sympathetic component.[9]
Clinical Use. Circulation.1996;93(5):1043–65.
Chuang and co-workers investigated the effects 2. Vanderlei LC, Pastre CM, Hoshi RA, Carvalho
of long-term, 8-month music therapy intervention on TD, Godoy MF. Basic notions of heart rate
autonomic function in anthracycline-treated breast variability and its clinical applicability. Rev Bras
cancer patients. Theauthors observed that the musical Cir Cardiovasc. 2009;24(2):205-17.
therapy improved thetime and frequency domain indices 3. Chuang CY, Han WR, Li Pc, Young S.T. Effects
of HRV.[10]Studies on competition stress have been of music therapy on subjective sensations and heart
observed to decrease HRV and alter the power spectrum rate variability in treated cancer survivors: a pilot
by decreasing the High Frequency (HF) component, study. Complement Ther Med.2010;18(5):224-6.
increasing the Low Frequency (LF) component.[11]
4. Perez-Lloret S, JoaguinDiez, Maria Natalia
Experimental studies have also shown that athletes
Dome, Andrea Alvarez Delvenne, Nestor Braidot,
report increased positive affect and reduced negative
Daniel P Cardinali, Daniel Eduardo Vigo.
effect in conditions where they listen to arousing music,
Effects of different ‘relaxing’ music styles on the
compared to no music, during moderate to high intensity
autonomic nervous system. Nosie and Health. A
activity.[12]
Bimonthly Inter-disciplinary International Journal.
As per the study conducted by Lathaet al. The 2014;16(72):279–284.
observations obtained revealed that heart rate and mean 5. Basagaoglu I, Kalkan M. and Sari N.Thephysio-
RR intervals showed significant changes between the logical and psychological effects of classical music
music and non-music group in both genders and there and pop music on female high school students.
was a significant decrease in the RMSSD, SDNN Yeni Sympo-sium.2004; 42:82-90.
and PNN50 in the male population suggesting a shift 6. P.N. Juslin and J. A. Sloboda, Eds., Handbook
towards enhanced vagal activity. From this it could be of Music and Emotion: Theory, Research,
inferred that music has beneficial effect on the heart rate Applications, Oxford University Press, 2010
variability thus favouring cardiovascular health in its
7. Pal GK, Ganesh V, Karthik S, Nanda N, Pal P. The
long run.[13]
effects of short-term relaxation therapy on indices
The present study had limitations that affect of heart rate variability and blood pressure in young
generalized ability of its results. The study was adults. Am J Health Promot. 2014;29(1):23-28
conducted acute, only in the age group of 18 to 23-years- 8. Yamashita S, Iwai K, Akimoto T, Sugawara J,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 167
Kono I. Effects of music during exercise on RPE, 11. Isowa, T., H. Ohira and S. Murashima. Immune,
heart rate and the autonomic nervous system. J endocrine and cardiovascular responses to
Sports Med Phys Fitness. 2006;46(3):425-30. controllable and uncontrollable acute stress. Biol.
9. De Abreu LC. Heart rate variability as a functional Psychol. 2006; 71: 202-213.
marker of development. Journal of Human Growth 12. Baldari, C., D. Macone, V. Bonavolonta and
and Development. 2012; 22(3):279-82. L. Guidetti. Effects of music during exercise in
10. Chuang CY, Han WR, Li PC, Song MY, Young ST. different training status. J. Sports Med. Phys.
Effect of Long-Term Music Therapy Intervention Fitness. 2010; 50: 281-287.
on Autonomic Function in Anthracycline- 13. R. Latha, K. Tamilselvan, E. Susiganesh Kumar and
Treated Breast Cancer Patients. Integrat H. Sairaman. Effect of Classical music on heart rate
Cancer Ther. 2011;10(4):312-6, http://dx.doi. variability between genders. International Journal
org/10.1177/1534735411400311 of Biomedical Research 2015; 6(03): 192-195.
168 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

A Proximate Analysis of Phytochemical in Sonalum Trilobatum

after the Addition to Leavened Yeast Goods with Sensory
Evaluation

Manivel K.1, John R. William1, Moyeenudin H.M.1

1Asst. Professor, School of Hotel and Catering Management, Vels Institute of Science,
Technology & Advanced Studies, (VISTAS), Chennai, India

Abstract
Herbs are used as a medicine in curing various diseases, Due to many reasons in recent days the Respiratory-
related health issue has become one of the major problems faced by most developing countries. The constant
rise in pollution from vehicular traffic, factory smoke emissions and other factors have to lead to a steady
rise in global warming. As a result of these factors, certain allopathy medicines fail to have its complete
usefulness on ones Therefore to achieve the natural changes and progress a neutralised therapy will help
resolve this problem. By incorporating solanum trilobatum in bread we can gradually indicate respiratory-
related health issues effectively. Since bread is the widely used commodity all over the world. It will help in
resolving the deficit. The objective behind this study is to make over the human body in tune with nature. It
is our effort to introduce solanum trilobatum in 3 different proportions into bread by testing it on the basis of
liking, acceptance, taste, etc. It was observed that the procedure resulted in a product that can be effectively
accepted and implemented.

Keywords: Solanum trilobatum, bread products, anti-oxidant.

Introduction People in India usually use them in a powder form after

dehydrated by sun light; and stored in air tight container.
Solanum Trilobatum is one among the Indian
This powder is mixed along with cooking commodities
traditional herbs that helps to cure many diseases in
or can be made as decoction and is commonly consumed
the human body. It has been elaborately used in Siddha
an empty stomach as per elderly advice1. There are
medicines. The nature of this is, its leaves are covered
numerous home recipes are not revealed out of which
by thorns, the flower is purple in color,and fruit is red in
to maintain its traditional secrecy. Many of the herbal
color. AS the thorn is toxic, it should be removed before
recipes not recorded. This kind of recipes in every day
using it. Solanum trilobatum is known for its nutritional
food or medicines when consumed more than prescribed
value and numerous health benefits, such as sodium
levels can cause adverse side effects. Proper knowledge
potassium, phosphorous,zinc magnesium and iron.
of right ratio before intake is most essential before using
Each part of this plant can be used for various purpose.
this for consumption This research was aimed at the
incorporation of the the solanum trilobatum in bread
as a medicine substitute to help recover from diseases2.
In this research, we have used solanum trilobatum for
Corresponding Author: making herb bread with different proportion ranging
John R. William from (10%, 20%, and 30%) in a normal bread dough
Asst. Professor, School of Hotel and Catering recipe such as soup stick, bun and rusk. The sample
Management, Vels Institute of Science, Technology & were then allowed to be examined by forty untrained
Advanced Studies, (VISTAS), Chennai, India customers and were used hedonic scale asked to rank
e-mail: [email protected] their observation. Then the results were concluded from
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 169
the sensory evaluation of the observation provided by breads which would not raise sufficiently Cottage bread
the customers. The tested products were found to have is moist and flaky. It has, however, a somewhat coarser
better taste, texture, aroma,and appearance observed by texture than other white loaves. Baked in a casserole, it
the customers. Most of the multi-grains used in bakery is easy to preparein the oven in about an hour. When it
industry comes out of the oven an hour later, brush with melted
butter, sprinkle with salt and serve6.A Middle Eastern
Cereals used in bread: Though the cereals are bread these small loaves puff into hollow balls that can
used to be cultivated in the Nile region and the major be filled with sandwich spread or butter and honey.5
source of the good and best quality bread making wheat Buttermilk bread has a country kitchen lilt, and this loaf
flour and all-purpose flours. There are many different has a country –kitchen taste. It is light, of good texture,
varieties the durum wheat type is best known for RYE has a golden-brown crust and creamy white insides6. It
(Secalecereal): Probably of southwest Asian Origin, rye keeps for a long period deep frozen and makes delicious
is similar in composition to wheat3. In Europe, it is used toast. 6Fork bread: Bread is rich and tenders a deep, dark
mainly for making rye bread and crisp bread (particularly brown crust surrounding a lovely yellow interior. 6Bran,
in Scandinavia). It is also used in the manufacture of the brown, flaky outer covering of the wheat kernel, has
drinks: whiskey in America, Beer in Russia. Millet a nut-like flavor and is often mistaken for one of several
(Panicum miliaceum): The kernel obtained from the breakfast portions of cereal with almost the same name.
cultivation is widely consumed as a cereal in continents They are bran, too, but of different texture and form.
likeAfrica and Asia. It is also used as a source of starch Hardly as exotic in flavor or appearance as its place of
in Russia. CORN (Zea mays): which is Native to origin- Hilo, on the big island of Hawaii-this bread, from
Mexico and in some parts of South America, The major a recipe member of the Hilo women’s club, is a good
grain commonly consumed is corn kernels and it is straightforward bran loaf .bran and molasses bread.
consumed in various forms during their meal like tortilla There is an unusual wheat flavor about this bran bread
made out of corn flour. The corn flour is used in making that is underscored by the dark 7unsulphured molasses.
many Mexican specialties like burritos, Tacos, Nacos, The bran particles are believed to cut the gluten stands
Quesadillas, and Enchiladas. This consumes additional which reduce the size of the loaf compared to a loaf
time and liquid than normal grain. off-white made with the same volume of flour. Oats
Herbs: The herbs accessible has its bioactive parts bread Oats have had a plebeian upbringing, mentioned
which help to turn away and fix any disease. Thesolanum as a weed by the classical writers of Rome, and used
trilobatum is an herb in like manner contains all of the infrequently in medicines7. In the early Christian era
8 principal amino acids making it one of just a bunch they grained some stature as a foodstuff, yet despite their
couple of plants that give an all of protein source4. It is ability to add flavor and good texture to the bread, oats
well off in flavonoids, including Quercetin, Kaempferol, have come down through the centuries principally as a
Beta-sitosterol, caffeoylquinic destructive, and zeatin. food for livestock. Blended bread. The bread made with
As well as the herb like Rosmarinus officinalis, the blended grains are coarser, denser, and darker than
generally called nursery rosemary, is a nearby to the most other loaves. They taste of no one grain but the
Mediterranean zone. This herb is a native to mint family, meld of them all. In the seven recipes, there is a total
it is an evergreen bramble in like manner related to basil, of seven different flours and cereals of French bread
marjoram, and oregano. It is typically found creating by in France, bread is seldom baked in the home because
the ocean, and its Latin name thinks about to “dew of the the boulangerie is just around the corner producing its
sea.” 4Oregano begins from Origanum, an assortment bounty of golden loaves, six days of the week potato
of the mint family. Oregano at first began from warm bread. The potato grew wild in Peru and was taken to
environments in western and southwestern Eurasia and Europe by Spanish explorers in 1530.
the Mediterranean locale. Oregano is a suffering plant
that has the properties of herbs, green and leaflike, with
Materials and Method
round framed leaves 5. The ingredient was sourced as whole grains from a
local grocery store as whole grain. It was then combined
Types of Bread: White bread has a variety of together and further milled and then stored in airtight
tastes and texture that add delight to meals and snacks. containers before its actual use. The recipe was tried in
White flour is also an important ingredient in many dark the department of Hotel and Catering Managementat
170 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Vels University, Chennai during 2018-2019 in the proportion sample. It was observed that the dough did
month of January not crack in spite of having lesser gluten percentage8.
The dough shaped into soup sticks, sunrise, mini buns
Recipe: etc. The shaped rolls were placed on a clean baking tray
Serial Number Ingredients Quantity
and further rested for 15 minutes. It was then baked in an
oven at 170*c for 18 minutes to a color of light golden
1 Multigrain flour 200g
brown.
2 Yeast 5g
3 Salt 3g
Results
4 Water 120ml (100ml-120ml)
5 Gingely oil 20ml Sensory Evaluation: The bread prepared with the
6 Sugar 20g addition of solanum trilobatum in various ratios and
shapes was sent for sensory evaluation and their likes
A percentage of 2 grams, 4 grams and 6 grams and dislikes are identified through hedonic scale.
solanium trillobatum was used in three different

Table 1: Sensory Evaluation of Soup Stick

Neither
Disliike Dislike Dislike Dislike Like Like Like Very Like
Like Nor
Extremely Very Much Moderarely Slightly Slightly Moderately Much Extremely
Dislike
Colour 0 0 0 1 2 10 11 2 1
Taste 0 0 1 1 3 10 12 0 0
Aroma 0 0 0 3 5 11 6 2 0
Appearance 0 0 0 1 0 0 0 0 0
Texture 0 1 1 2 0 0 0 0 0
Acceptance 0 0 2 1 0 0 0 0 0

Table: 2 Sensory Evaluation of Sunrise Shape

Disliike Dislike Very Dislike Dislike Neither Like Like Like Very Like
Like Slightly
Extremely Much Moderarely Slightly Nor Dislike Moderately Much Extremely
Colour 1 0 1 2 3 4 3 9 3
Taste 0 0 0 0 3 5 7 10 1
Aroma 0 0 0 0 1 9 2 11 2
Appearance 0 0 2 1 1 6 6 10 1
Texture 1 0 0 1 3 6 6 9 1
Acceptance 0 0 0 0 0 6 3 8 3

Table: 3 Sensory Evaluation of Bun Shape

Disliike Dislike Very Dislike Dislike Neither Like Like Like Very Like
Like Slightly
Extremely Much Moderarely Slightly Nor Dislike Moderately Much Extremely
Colour 0 0 2 3 6 4 5 3 3
Taste 0 0 0 5 4 9 4 2 2
Aroma 0 1 2 2 6 5 5 3 2
Appearance 0 0 1 2 1 6 10 2 4
Texture 0 0 2 0 5 4 6 7 2
Acceptance 0 1 0 4 1 6 3 3 4
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 171

Discussion Table 5: Mineral composition of powder

The bread products made with the addition of Contents Sample Extract (mg/100g)
Solanum trilobatum is used as a sample, taste, texture Calcium 165.43
and colour was good and found to be acceptable in Potassium 127
this survey through sensory evaluation in Table 1, Magnesium 88
Table 2, Table 3. The taste of this product shows Zinc 12.42
higher percentage in Table 3 as colour and aroma also
Iron 65.87
satisfactory. and this food is tested for its phytochemical
Phosphorous 132.45
compounds present after the cooking process the results
shows likes and dislikes with the prepration method and Phytochemicals Study: The Phytochemicals
In the present examination, the Multigrain Bread fused hasNutraceuticals significance ofelements which
with thuthuvalai and healthful screening and capacity support in advance wellbeing is happen with a
were researched10. The proximate, basic, phytochemical convergence in sustenance of pharma businesses14.
investigation of sustenance test analyzed. The outcomes Thesematerials will go to separated supplements,
were talked about as underneath. The real constituents in nutritional enhancements with explicit weight control
the consumable bit are water, protein, sugar, lipid (fat or plans to hereditarily built originator sustenance’s,
oil) and fiery remains (minerals). Investigation of these natural items, prepared nourishments and refreshments.
essential constituents is frequently alluded to proximate Isoflavonoids, Phytochemicals present in the herb are
examination11. Proximate investigations of nourishment comprehensively depicted as phytosterols,limonoids,t
test assume a pivotal job in surveying their dietary erpenoids, carotenoids, phytoestrogens, polyphenols,
hugeness and help to get to the nature of the example flavonoids, anthocyanidins and glucosinolates15. They
(Pandey et al., 2006). Consequences of the proximate have gigantic effect on the social insurance framework
sythesis in examined test materials are given in Table 4. and may give therapeutic medical advantages including
the counteractive action and additionally treatment
Table 4: Proximate configuration of Extract
of ailments and physiological issue. Lion’s share of
Content Quantity sustenances, for example, entire grains, beans, natural
Moisture content (%) 8.46 products, vegetables and herbs contain phytochemicals
Ash (%) 3.41 of nutraceutical significance16. These element of
Crude fibre (%) 4.23
phytochemicals more over unaided as well as in blend,
have colossal restorative potential in relieving different
Protein (%) 63.75
sicknesses including malignant growth, diabetes,
Fat (%) 3.42
stomach ulcer, Heart related infections, and blood
Carbohydrate (%) 17.12
pressure and so on. In the present examination, tannin,
Minerals are gotten from the soil outside layer. flavonoids, steroids, alkaloid and polyphenol were
Through the impacts of the climate, shakes that contain available in the tried example. The nearness of these
minerals are ground into littler particles, which at that mixes shows the beneficial outcome on the wellbeing.
point become some portion of the dirt. The mineral
substance in the dirt is consumed by developing Conclusion
plants12. The plants are devoured by the two creatures The phytochemical study of solanum trilobatum
and individuals as sustenance. This mineral turns out to herb shows that it is loaded with various minerals with
be a piece of the natural way of life. The real minerals good nutritive value and an proximate analysis of this
fill in as basic parts of tissues and capacity in cell and herb states that this can be stored for a longer period
basal digestion and water and corrosive base parity13. when it is prepared with a combination of all-purpose
Consequences of the significant minerals are yielded flour and other yeast made ingredients like sugar,
Table 5. salt,water,solanum trilobatum powder to make a bread6.
172 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
The sensory evaluation of this bread on taste, texture and by Undergraduate Students in Food Science and
appearance gave maximum satisfactory levels, also we Technology at the University of Trinidad and
believe the tested products using it can help people with Tobago. Journal of Curriculum and Teaching.
respiratory problem as it has magnesium and iron in it. 2014; 3(1), p.10-27
The popularity of bread products in the market gluten- 7. Li, Xue et al. “Short- and Long-Term Effects of
free bread wholemeal bread rye bread Repopulation is Wholegrain Oat Intake on Weight Management
taken place in the bakery industry due to the various and Glucolipid Metabolism in Overweight Type-2
lifestyle-related diseases in the search of healthy products Diabetics: A Randomized Control Trial.” Nutrients,
with this intention multigrain bread commonly known as Sep. 2016; 8 (9), p. 549
one traditional grain leaving more healthy bean used in
8. Aruna Bhatia et al, Antioxidant activity of native
the bakery for making of a variety of bakery products.
and micropropagated Tylophora Indica leaves
Ethical Clearance: Not required for this article. Extract: A comparative study: JNPPB7Journal of Natural
Production Plant Resources, 2013; 3, (1), p. 1-7.
Conflicts of Interest: Conflict of Interest declared
9. Nieto G, Ros G, Castillo J. Antioxidant and
none.
Antimicrobial Properties of Rosemary (Rosmarinus
Source of Funding: Self officinalis, L.): A Review. Medicines (Basel)
2018;5, (3), p. 1-13
References 10. David J.R. Fulton et al, Reactive Oxygen and
1. P. Swapna Latha and K. Kannabiran, Antimicrobial Nitrogen Species in the Development of Pulmonary
activity and phytochemicals of Solanumtrilobatum Hypertension, MDPI Antioxidants, 2017; 6, 54.
Linn, African Journal of Biotechnology December 11. R. Nair, et al. Antibacterial Activity of Some
2006, 5, (4), p. 2402-2404. Selected Indian Medicinal Flora. Turk J Biol, 2005,
2. Doss, H. Mohammed Mubarack and R. p. 41-47.
Dhanabalan, “Pharmacological importance of 12. Ncube N. S. et al, Assessment techniques of
Solanum trilobatum” Indian Journal of Science and antimicrobial properties of natural compounds
Technology, Feb. 2009,2 (2), p. 41-43. of plant origin: current method and future trends.
3. Reetta Holma, et al, Constipation Is Relieved More African Journal of Biotechnology Vol. 7 (12), 17
by Rye Bread Than Wheat Bread or Laxatives June, 2008; 29, pp. 1797-1806,
without Increased Adverse Gastrointestinal Effects, 13. Prusti, A., et al, Antibacterial Activity of Some
The Journal of Nutrition, March 2010; 140, p. 534– Indian Medicinal Plants. Ethnobotanical Leaflets
541. 2008; 12, pp. 227-230
4. Evert, Alison B et al. “Nutrition therapy 14. Jawhar M, et al, Rapid proliferation of multiple
recommendations for the management of adults shoots in solanum trilobatum L. Plant Tissue
with diabetes.” Diabetes care 2013; 36 (11), p. Culture; 2004; 14 (2) pp. 107-112.
3821-3842. 15. Shahjahan M, et al, Effect of medicinal plants on
5. Dhillon G K et al, Effect of Oregano Herb on Dough tumurogenesis Ind. J. Med.Res. 2004; 123 (5-8),
Rheology and Bread Quality, International Journal pp. 23-27
of Food Science, Nutrition and Dietetics,, 2013;2 16. Purushothaman Balakrishnan et al, A perspective
(4), p. 40-44 on bioactive compounds from Solanum
6. Dimple Singh-Ackbarali, Rohanie Maharaj. trilobatum,Journal of Chemical and Pharmaceutical
Sensory Evaluation as a Tool in Determining Research, 2015; 7, (8), pp. 507-512.
Acceptability of Innovative Products Developed
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 173

Satisfaction Level of Physiotherapy Students in North India

Manoj Malik1, Charu Gera2, Jaspreet Kaur1, Vandana Yadav1

1AssistantProfessor, Department of Physiotherapy, 2Student, Bachelor of Physiotherapy,
Guru Jambheshwar University of Science and Technology, Hisar, Haryana. India

Abstract
Background: Physiotherapy or physical therapy is one of the allied health services that is used to improve
patient’s quality of life without use of drugs. This service helps in restoration and improvement of function
by applying manual therapy, physical modalities, therapeutic exercises and hydrotherapy etc.

Study Design: A Randomized Survey Design.

Objectives: To find out satisfaction level among physiotherapy students of North India.

Method: Total 161 students from Physiotherapy colleges of North India, voluntary participated in the study
among which 55 were male and 106 were female. Inclusion criteria were students of third-year and fourth-
year of Bachelor of Physiotherapy degree; both male and female with age limit 19-24 years. First-year and
second-year students, Postgraduate students, interns and professionals were excluded from the study.

Results: Average score of DREEM Questionnaire was 127. In the questionnaire, there were five questions
(i.e. 1, 2, 10, 18 & 19) that scored highest value and showed high satisfaction rate. Total 142 students
(88.19%) were happy to choose this particular field while 19 students (11.18%) were unhappy.

Conclusion: Out of 161 students, 142 students (88.19%) were happy to choose Physiotherapy field.
Physiotherapy students of North India have high satisfaction level towards Physiotherapy course.

Keywords: Physiotherapy, Satisfaction level, DREEM inventory questionnaire.

Introduction in which physical therapists examines the patients

completely and after that makes an effective treatment
Physical therapy is defined as “the restoration
plan which primarily focuses on relief of pain, increase
or treatment of physical deformities, contractures or
range of motion, improvement infunctions and
pain by applying various exercises, electrotherapeutic
prevention of deformities because of any pathology
modalities, mobilizations, manipulations and
associated with musculoskeletal, neurology, pediatric,
hydrotherapy etc. without use of any medications
sports, obstetrics and gynecological conditions[1].
oroperative procedure”[1]. The APTA (American
physical therapy association) defines Physical therapy Evolution: Electrotherapy (such as water
therapy, hot, cold and electric current) mainly used
by physiotherapists were developed in Greece by
Hippocrates, who is considered as Father of Western
Corresponding Author: Medicine. Various exercises were used in the era of
Vandana Yadav, MPT 1500s, 1600s, and 1700s in Europe for the treatment of
Assistant Professor, Dept. of Physiotherapy, Guru myopathies, degenerative disorders, bony dysfunctions
Jambheshwar University of Science and Technology, and many more. At the time of 1800s, sensory or muscle
Hisar-125 001, Haryana, India re-education were used to treat various neurological or
Mobile: 09034627420 orthopedic disorders and injuries. Physiotherapy mainly
e-mail: [email protected] originated during the World War I which required the
174 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
treatment of army soldiers mainly injured in war. The Methodology
outburst of poliomyelitis in the United States during
Eligibility criteria: The present study was
1920 to 1930 resulted in urgent need of physical therapy.
randomized survey design. Inclusion criteria were3rd &
Many individuals in the United States required short
4thyear undergraduate students,both males & females
term and long term Rehabilitation after the 2nd World
with age from 19 to24 years pursuing Bachelor’s of
War. This raised the physical therapy standard [2].
Physiotherapy degree.An exclusion criterion wasfirst-
Physical Therapy Course Work: To raise the year and second-year students, Postgraduate students,
profession, university decided to start the basic level interns and Physiotherapy professionals.
course for physical therapy to train the nurses and
Tools and Instrumentation: Student’s satisfaction
individuals. To initiate this, University of Southern
level was evaluated by using “DREEM (Dundee Ready
California in 1992 and Creighton University of Nebraska
Educational Environment) inventory questionnaire”
in 1993, start DPT. This was 2 years diploma in physical
and the data collected was kept confidential. DREEM
therapy. Then bachelor’s degree was initiated. Presently,
inventory constitutes 50 questions, that are simple, self-
it isof 4 and 1/2 year degree. Then,Initiation of master’s
allocated and closed-ended questions related to academic
degree programs started in physical therapy. It was 2
environment, teaching and learning[6].Each question
year specialization degree (American Physical Therapy
consists of 4 to 0 score on a “5-point Likert response”
Association, 2003).At present, a number of universities
as follows: [4= strongly agree; 3 = agree; 2 = unsure;
are offering PhD program in Physiotherapy.
1= disagree and 0 = strongly disagree]. Averagescores
Career in physiotherapy: Physiotherapists are between 3 and 4 mainly indicatetheir satisfaction,
offered clinical jobs ingovernment as well as private questions with anaverage score of 2 represents
hospitalsand academic jobs in institutes, colleges and dilemmaand scoresof 0 and 1 indicate dissatisfaction.
universities. Physiotherapy services are also required There were some negative questions that are question
in geriatric and pediatric rehabilitation centers as well number 4, 8, 9, 17, 25, 35, 39, 48, and 50. Their scoring
as with sports team and individual sports persons. It was reversed.
is also required in corporate sector for prevention and
Procedure: The survey was conducted at different
management of work related injuries.
institutes of north India including Haryana, Chandigarh,
Current issues in physiotherapy: The current issues Punjab, Delhi and Uttar Pradesh. The participation was
in Physiotherapy in India are students’ perceptions voluntary. A stratified random probability sampling was
about their profession, career opportunities, level of used for data collection. The questionnaire was given
remuneration, job satisfaction, job retention, patient to undergraduate physiotherapy students. Voluntarily
referrals and public awareness about physiotherapy etc[3]. participation was there, and the questionnaires were
Student’s perception, learning behavior & education is kept confidential. Total 161 Physiotherapy students
the most important basis for any professional growth and participated in the study voluntarily,among them 55
educational satisfaction among students. Thus, World were males and 106 were females.
Federation for Medical Education focused on evaluating
learning behavior and educational environment[4]. Results
142 students (88.19%) were happy to choose
The rationale for DREEM inventory questionnaire
Physiotherapy field while 19 students (11.18%) were
was to investigate the role of academic environment in
unhappy. Average value of DREEM Questionnaire was
student’s learning, perceiving and any effect on their
127.In this questionnaire, five questions (i.e.1, 2, 10,
growth, profession, progress, behaviour and social well-
18 & 19) that scored highest value and showed high
being[5].
satisfaction rate. Figure-1 demonstrates satisfaction
scale. Figure 2 to 6 demonstrates question’s with highest
Physiotherapy response value.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 175

Fig. 1: Satisfaction level perceived by Students Fig. 4: (Q 10). “I am confident about passing this
year”. (Score-133)

Fig. 5: (Q 18). “The teachers have good

communication skills with patients”. (Score-142)

Fig. 2: (Q 1). “I am encouraged to participate in

class”. (Score -132)

Fig. 6: (Q19). “My social life is good”. (Score-151)

Discussion
The primary objective of this survey was to
assess the student’s perception regarding academic
environment of undergraduate physiotherapy students.
Academic environmentis the most important factor in
student’s behaviour, learning, understanding profession
Fig. 3: (Q 2). “The teachers are knowledgeable”.
and growth[7]. We used DREEM inventory questionnaire
(Score-134)
176 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
for this purpose. DREEM inventory is a reliable and on long term learning as well as enhancing student’s
effective instrument in interpreting the academic practical knowledge. There should be some holistic
environment of various programmes[8]. Present survey knowledge based on values and beliefs.The problem of
was performed in Physiotherapy colleges of North India. “teacher-centered teaching and factual learning” can be
In this study, maximum numbers of students perceived resolved by implementing “Problem Based Learning
the educational environment as positive. (PBL) sessions” and “Short-term Student Research
Project” which makes students independent. “Personal
82% students responded that they were actively and Professional Development (PPD) sessions” can
participating in the class that indicates student’s positive also be implemented to reduce tension and stress [9].
perception towards teaching environment. Furthermore, The students should be encouraged more towards self-
new strategies should be incorporated to enhance the directed learning to raise the confidence of working
more interest like practical sessions, presentations and independently as well as to enhance the student’s
live examples. 48% students expressed that the teachers knowledge, understanding and learning [10].70% of
provide good support system for the students under students expressed that “the teaching time is put to good
stress while others disagreed with this point. Techniques use”. This is a good sign that the time is utilized optimally
like Jacobson Relaxation exercises, breathing exercises by maximum students. Students should be advised to
& regular counseling may be incorporated for effective utilize their time in library, reading room, OPD, and
management of stress. 35% students stated that they are practical room’s etc.18% students stated that the teachers
tired to enjoy this course. Therefore,few extra-curricular not give clear examples. Therefore, simple examples
activities such as sports, annual functions, youth should be given to clear the concept and overcome the
festivals etc should be incorporated for more emphasis. doubts.8% students expressed that “they are not clear
46% students agreed that the “learning techniques which about the learning objectives of the physiotherapy
work for me before continue to work for me now”, but course”. Coordinator should advise to provide clear aims
17% students disagreed. Learning strategies should and objectives of the profession i.e.health promotion,
be modified depending upon student’s capabilities. health education and improve the quality of life.Almost
Teaching should be simple, understandable and clear. 60% students agreed that the enjoyment overweighs the
Novel learning strategies should be incorporated such as stress of study.Excessive stress of the study disturbs
practical training, case studies, audiovisual aids etc. 12% their personal life. Therefore, some extracurricular
students expressed that the teaching is not stimulating. activities and functions should be organized to increase
Therefore, stimulus should be provided such as open their interest in the profession.88.19% students were
discussion, visual presentations to make teaching more satisfied from their education and environment. They
effective. The role of teachers should not be concentrated perceived their education more positive. Results suggest
only on information provider but also a skill facilitator. that educational performance, career and profession
They should develop attitudes and skills required for can be enhanced by developing or planning effective
professional growth. 22% students believed that the and efficient strategic techniques and various plans
school or institute is not time tabled. A pre-planned for better understanding, learning and knowledge[11,
timetable and scheduled plan should be established in 12].Although educational environment needs careful
all departments for better learning. 22.36%students ongoing evaluation on regular basis (such as teaching,
expressed that the teaching is not student-centered learning, curriculum etc.) and requires necessary actions
while. A revised curriculum should be established for and cooperation from both sides (teacher and student).
the long term learning of the students and enhance their The overall average DREEM score for Indian medical
knowledge and confidence. 44% of participant expressed school, Karnataka, was found to be 117/200 (n = 226),
that the cheating is a main issue in this institute which indicating that, students’ perceptions towards their
indicates a serious concern. Therefore, strict rules teaching were more positive[13].The global DREEM
should be included in the school to avoid cheating such scores in other medical institutes such as in Sri Lanka,
as punishments (physical or mental), fine and suspension Nigeria and UK were found to be 108/200 [14], 118/200
etc. [15], and 139/200 [16] respectively. The mean DREEM

Some students (52%) stated that “there is too score for a medical school in India was reported as
much factual learning to memorize” and have reported 107.44/200[17].This survey provides insights to the
similar concern. Therefore, teaching should emphasize concerns and standards of Physiotherapy education in
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 177
North India. It can be generalized and necessary changes 7. Tontus HO. DREEM; dreams of the educational
may be incorporated in curriculum as well as teaching environment as its effect on education result
and evaluation process to improve the satisfaction levels of 11 Medical Faculties of Turkey. Journal of
among the student pursuing Physiotherapy course. Experimental and Clinical Medicine 2010;27,104
-108. Retrieved from https://www.researchgate.
Conclusion net/publication/228663299.
Out of 161 students; 142 students (88.19%) were 8. Yusoff MSB. The Dundee Ready Educational
happy to choose physiotherapy field and 19 students Environment Measure: A Confirmatory Factor
(11.18%) were unhappy. Average score of students was Analysis in a Sample of Malaysian Medical
127. Students pursuing Physiotherapy course in North Students. International Journal of Humanities and
India are satisfied with the course. However, survey Social Science 2012;2(16), 313-321. Retrieved
findings can be incorporated by the administration of from www.ijhssnet.com.
colleges to further improve the level of satisfaction. 9. Abraham R, Ramnarayan K, Vinod P and Torke S.
Students’ perceptions of learning environment in
Ethical Approval: Participants were assured about
an Indian medical School. BMC Medical Education
the confidentiality of the study.
2008; 8(20), 1-5. doi: 10.1186/1472-6920-8-20
Conflict of Interest: The authors report no conflict 10. Doshi D, Reddy BS, Karunakar P & Deshpande K.
of interest. Evaluating Student’s Perceptions of the Learning
Environment in an Indian Dental School. Journal of
Source of Funding: Self Clinical and Diagnostic Research 2014;8(11), 39-
42.doi: 10.7860/JCDR/2014/9901.5128.
References
11. Till H. Identifying the perceived weaknesses of a
1. Merriam-Webster. Definition of physical therapy. new curriculum by means of the Dundee Ready
2018 June 8th Education Environment Measure (DREEM)
2. Jones & Bartlett. The Evolution of physical therapy Inventory. Medical Teacher 2004;26(1), 39–45.
2003. 2nd ed., Chapter 1, 1-38. doi: 10.1080/01421590310001642948.
3. Berry & McKnight B. PTA Update: What Are the 12. Arzuman H, Yusoff MSB & Chit SP. Big
Current Issues Relating to the Physical Therapist Sib Students’ Perceptions of the Educational
Assistant? FSBPT Annual Meeting. 2014 Environment at the School of Medical Sciences,
4. Bakhshialiabad H, Bakhshi M and Hassanshahi Universiti Sains Malaysia, using Dundee Ready
G. Students’ perceptions of the academic learning Educational Environment Measure (DREEM)
environment in seven medical sciences courses Inventory.Malaysian J Med Sci 2010;17(3), 40-47.
based on DREEM. Advances in Medical Education Retrieved from www.mjms.usm.my.
and Practice 2015;6, 195–203. doi: 10.2147/AMEP. 13. Abraham R, Ramnarayan K, Vinod P and Torke S.
S60570. Students’ perceptions of learning environment in
5. Whittle S, Whelan B and Murdoch-Eaton DG. an Indian medical School. BMC Medical Education
DREEM and beyond; studies of the educational 2008; 8(20), 1-5. doi: 10.1186/1472-6920-8-20
environment as a means for its enhancement. 14. Jiffry MTM, McAleer, Fernandoo S & Marasinghe
Education for Health 2017;20(1), 1-9. RB. Using the DREEM Questionnaire to gather
Retrieved from https://www.researchgate.net/ baseline information on an evolving medical school
publication/6191837. in Sri Lanka.Med Teach 2005;27, 348-352. doi:
6. Roff S. The Dundee Ready Educational 10.1080/01421590500151005
Environment Measure (DREEM)—a generic 15. Mayya SS & Roff S. Students’ Perceptions of
instrument for measuring students’ perceptions Educational Environment: A Comparison of
of undergraduate health professions curricula. Academic Achievers and Under-Achievers at
Medical Teacher 2005;27(4), 322–325. doi: Kasturba Medical College, India. Education
10.1080/01421590500151054. forHealth 2004;17:280-291.
178 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
16. Roff S, McAleer, Ifere OS & Bhattacharya 17. Varma R, Tiyagi E & Gupta JK. Determining
S. A global diagnostic tool for measuring the quality of educational climate across multiple
educational environment: comparing Nigeria undergraduate teaching sites using the DREEM
and Nepal. Med Teach 2001;23(4), 378-382. inventory.BMC Med Educ 2005;5(1), 1-8. doi:
doi:10.1080/13576280400002445. 10.1186/1472-6920-5-8.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 179

Prevalence of Lumbar Lordosis in Middle-Aged Females

Manpreet Bajaj1, S. Anandh2

1FinalYear Student, 2Professor, Department of Community Health Sciences, Faculty of Physiotherapy,
Krishna Institute of Medical Sciences ‘Deemed to be’ University, Karad, Maharashtra, India

Abstract
Objective: The objective of the study was to find out prevalence of lumbar lordosis in females aged between
35 to 45 years as per their gravida status.

Method: Ethical clearance was obtained from institutional ethical committee. A total of 100 healthy females
from Karad with age between the age group of 35-45 years were selected for the assessment of their lumbar
lordosis curvature. Individuals with any history of congenital spinal deformities or spinal fracture, surgical
procedures related to spine, pregnant females were excluded from the study. Outcome measure used to
measure lumbar lordosis was flexible ruler. The lordotic angle was calculated using the trigonometric
formula θ=4 arc tan 2 h/L. Demographic data was collected, outcome assessment was recorded and later
data was analyzed.

Results: We found that there is significant presence of hyperlordosis in 45% females from this study
whereas presence of hypolordosis was 2%. Females with normal curvature of lumbar spine were about 53%.
Hyperlordotic females with gravida 1, gravida 2 and gravida 3 showed 35%, 52.83% and 37.03% prevalence
of lumbar hyperlordosis, respectively.

Conclusion: The study results concluded that hyperlordosis was extremely significant in middle-aged
females with gravida 2 whereas hypolordosis was not much significant in this group.

Keywords: Lumbar lordosis, hyperlordosis, hypolordosis, flexible ruler, gravida.

Introduction Any increase or decrease in lumbar curvature can

affect the body balance and cause various anomalies in
Lumbar lordosis is the ventral curvature of the
the lumbar and pelvic regions.(3)
spine formed by wedging of the lumbar vertebrae and
intervertebral discs.(1) Normal lumbar lordosis angle
ranges from 30º to 45º(7) Lumbar lordosis is a key feature
for sagittal plane balance maintenance.(8) The balance of
the muscles around the pelvis is a factor affecting the
lumbar lordosis. Because of relationship between the
sacrum and the pelvis through the spine, any change in
the position of the pelvis leads to changes in the arch of
the spine, especially the lumbar lordosis.(2)

Corresponding Author:
Manpreet Bajaj
Final Year student, Faculty of Physiotherapy, Krishna
Institute of Medical Sciences ‘Deemed to be’
University, Karad, Maharashtra, India
e-mail: [email protected]
Telephone Number: 9860844117 Figure 1: Lumbar Spine and Sacrum
180 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
With normal lumbar lordosis, energy expenditure There will be stretching of the lumbar spine
and stress on the supporting structures is minimised extensors and the posterior lumbar spine ligaments
when balance is maintained between the lumbar spine whereas shortening of the abdominal muscles and the
and abdominal musculature. anterior longitudinal ligament in hypolordotic lumbar
spine.(5)
Normally, the abdominal muscles rotate the pelvis
posteriorly and, the erector spinae muscles tilt the pelvis Hyperlordosis: When the lordotic angle of lumbar
anteriorly. Correct muscle activation patterns result in spine is more than 45º it is termed as hyperlordosis.(7)
normal compressive and tensile forces occurring at the
lumbar spine. There are minimal stresses placed upon In hyperlordosis there is compression of the posterior
the intervertebral disc and the zygapophyseal joints with vertebral bodies and the posterior zygapophyseal
lumbar spine in neutral position. Hence chances of low joints since they are in a close-packed position, which
back pain are minimal.(4) increases intervertebral disc pressure and narrowing of
intervertebral foramina. There is excessive stretching
In lumbar region, the line of gravity lies slightly of the anterior longitudinal ligament and abdominal
posterior which causes extension of lumbar spine. muscles while shortening of lumbar spine extensors,
Passive opposing forces are necessary to counteract this posterior longitudinal ligament, interspinous ligaments
extension which are provided by the anterior longitudinal and ligamentumflavum.(4)
ligament and iliolumbar ligaments as well as, the anterior
fibres of the annulus fibrosus of the intervertebral disc With a hyperlordotic lumbar spine posture there is
and zygapophyseal joint capsules. Active opposing impaction of the zygapophyseal joints. The resultant
forces are also necessary to counteract extension at the alteration in the spinal biomechanics results in decreased
lumbar spine are provided by the abdominal muscles.(5) range of motion of the lumbar spine. The inflammation
from the dysfunction phase of the degenerated
Lumbar curvature is of great significance because it intervertebral disc along with the decreased range of
carries the upper body weight and transfers it directly to motion results in the hypersensitivity of proprioceptors
the pelvis. Any increase or decrease in lumbar curvature and nociceptors in the intervertebral disc, ligaments,
can affect the body balance and cause various anomalies joint capsules, zygapophyseal joints and nerves. This
in the lumbar and pelvic regions. It is believed that the hypersensitivity initiates a reflexogenic response thereby
muscles in this area are one of the factors affecting inducing muscle spasm.(6)
the lumbar-pelvic balance, as well as the performance
of lumbar lordosis and pelvic tilt.(9) Also, weakness Materials and Methodology
of abdominal, dorsal, and lumbar muscles has been Type of study: observational study, place of study:
recognized as the most common factors increasing the Karad., sample size: 100study duration: 3 months
lumbar curvature.(8)
Inclusion Criteria: 1) Age group: 35-45 years 2)
Types of Lumbar Lordosis: Female participants irrespective of low back pain.
Hypolordosis: When the lordotic angle of lumbar Exclusion Criteria: 1) Participants with any
spine is less than 30º it is termed as hypolordosis.(7) congenital spinal deformities. 2) Participants with a
In hypolordosis there is over-compression of history or current status of spinal fracture. 3)Participants
the intervertebral discs anteriorly with posterior who had surgical procedures related to spine. 4) Pregnant
displacement of the nucleus pulposus. females. 5)Participants who are physically disabled.

The zygapophyseal joints are in a close-packed Outcome measures: The spinal assessment specific
position with lumbar spine extension, therefore with a to lumbar lordosis was done using flexible ruler.
hypolordotic lumbar spine, the zygapophyseal joints are Ethical clearance was obtained from institutional
distracted as a result of its anatomical orientation and ethics committee. 100 subjects fulfilling the inclusion
also due to the decreased load on the zygapophyseal and exclusion criteria were included. Prior to testing,
joints posteriorly.(4) each subject read and signed an informed consent form.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 181
To examine the lumbar curvature, a flexible ruler Table 2: Distribution for Gravida 1
was used. To assess the curvature participants were
asked to stand in normal anatomical position. Type Hypolordosis Normal Hyperlordosis
Frequency
First lumbar (L1) and second sacral (S2) vertebrae (Number of 2 11 7
subjects)
were considered as markers for evaluating the lumbar
lordosis. Then flexible ruler was placed on L1 and S2 With gravida 1, 10% females were having
while a hand pressed on it to eliminate the gap between hypolordosis, 55% were having normal lordosis and
the ruler and the skin. The ruler was placed on the graph 35% were having hyperlordosis.
paper and the curve was drawn. Two ends of the curve
were joined and a line L was drawn whose midline Gravida 2: Out of 100 subjects, 53 subjects with
vertically reached the middle of the curve through the h gravida 2, none were having hypolordosis, 25 were having
line. The lengths of h and L lines were calculated and the normal lordosis and 28 were having hyperlordosis.
a forementioned angle was obtained. θ=4 arc tan 2 h/L
Table 3: Distribution for Gravida 2

Type Hypolordosis Normal Hyperlordosis

Frequency
(Number of 0 25 28
subjects)

With gravida 2, 0% females were having

hypolordosis, 47.16% were having normal lordosis and
52.83% were having hyperlordosis.

Gravida 3: Out of 100 subjects, 27 subjects with

gravida 3, none were having hypolordosis, 17 were having
normal lordosis and 10 were having hyperlordosis.
Figure 2: Flexible ruler formula for measuring
lumbar lordosis angle Table 4: Distribution for Gravida 3

Findings: Distribution according to type of lumbar Type Hypolordosis Normal Hyperlordosis

curvature: Frequency
(Number of 0 17 10
Out of 100 subjects, 2 were having hypolordosis, subjects)
53 were having normal lordosis and 45 were having
With gravida 3, 0% females were having
hyperlordosis.
hypolordosis, 62.96% were having normal lordosis and
Table 1: Distribution according to type of lumbar 37.03% were having hyperlordosis.
curvature
We found that there is significant presence of
Type Hypolordosis Normal Hyperlordosis hyperlordosis in 45% females from this study. Presence
Frequency of hypolordosis was not significant from this study.
(Number of 2 53 45
subjects) Females with normal curvature of lumbar spine
were about 53%.
2% females were having hypolordosis, 53%
were having normal lordosis and 45% were having Discussion
hyperlordosis.
This study was conducted to find the prevalence of
Distribution according to Gravida: presence of lumbar lordosis in females between the age
group of 35- 45 years. Among 100 selected females,
Gravida 1: Out of 100 subjects, 20 subjects with hyperlordosis was found significant in 45 females.
gravida 1, 2 were having hypolordosis, 11 were having
normal lordosis and 7 were having hyperlordosis.
182 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Women have more static lumbar sagittal curvature Gravida 1- 55%, Gravida 2- 47.16% and Gravida
(lordosis) than men and there is no difference in lumbar 3- 62.96%
curvature between those with undifferentiated LBP and
those without LBP. Conclusion
Females with hypolordosis were having lumbar We found that there is significant presence of
lordosis angle less than 30°. Among 100 females only hyperlordosis in 45% females from this study whereas
2 females were having hypolordosis. This was about 2% presence of hypolordosis was 2% from this study.
of total females. Females with normal curvature of lumbar spine
Females with normal lumbar lordosis were having were about 53%.
lumbar lordosis angle ranging between 30°-45°. Among Conflict of Interest: Public trust in the peer review
100 females 53 females were having normal lumbar process and the credibility of published articles depend
lordosis. This was about 53% of total females. in part on how well conflict of interest is handled during
Females with hyperlordosis were having lumbar writing, peer review, and editorial decision making.
lordosis angle more than 45°. Among 100 females only Conflict of Interest exists when an author (or the
45 females were having hyperlordosis. This was about author’s institution), reviewer, or editor has financial
45% of total females. or personal relationships that inappropriately influence
(bias) his or her actions (such relationships are also
Out of 20 females with gravida 1, only 2 were having known as dual commitments, competing interests, or
hypolordosis while 11 were having normal lumbar competing loyalties). These relationships vary from
lordosis and 7 were having hyperlordosis. That is, 10% those with negligible potential to those with great
females were having hypolordosis, 55% were having potential to influence judgment, and not all relationships
normal lordosis and 35% were having hyperlordosis. represent true conflict of interest. The potential for
conflict of interest can exist whether or not an individual
Out of 53 females with gravida 2, none were having believes that the relationship affects his or her scientific
hypolordosis, 25 were having normal lordosis and 28 judgment. Financial relationships (such as employment,
were having hyperlordosis. That is, 0% females were consultancies, stock ownership, honoraria, paid expert
having hypolordosis, 47.16% were having normal testimony) are the most easily identifiable conflicts of
lordosis and 52.83% were having hyperlordosis. interest and the most likely to undermine the credibility
Out of 27 females with gravida 3, none were having of the journal, the authors, and of science itself. However,
hypolordosis, 17 were having normal lordosis and 10 conflicts can occur for other reasons, such as personal
were having hyperlordosis. That is, 0% females were relationships, academic competition, and intellectual
having hypolordosis, 62.96% were having normal passion.
lordosis and 37.03% were having hyperlordosis. Source of Funding: Self
There is presence of hyperlordosis in 45% females
from this study. Presence of hyperlordosis in middle-
References
aged females with reference to gravida status is as 1. Vaz G, Roussouly P, Berthonnaud E, Dimnet J.
follows- Sagittal morphology and equilibrium of pelvis and
spine. Eur Spine J 2002; 11:80-7.
Gravida 1- 35%, Gravida 2- 52.83% and Gravida
2. Mohammad E B, Mohammad J P. The Effect of
3- 37.03%
12 Weeks of Exercise Rehabilitation on Improving
Presence of hypolordosis was not significant from Lumbar Lordosis Abnormalities in Addicted
this study. In females with gravida 1 only 10% (2 Patients.IJSS 2014; 4 (12), 1516-1521
females) presented with hypolordosis. 3. Pirani H, Shahmoradi D, Noori S, MohamadzamanT.
Prevalence of spinal abnormalities among the male
Females with normal curvature of lumbar spine
junior high school students of Kermanshah city. J
were about 53%. Presence of normal lumbar lordosis in
Kermanshah Univ Med Sci. 2017; 21(1)
middle-aged females with reference to gravida status is
as follows- 4. Lomas. D. And May. S. Posture, the Lumbar Spine
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 183
and Back Pain. International Encyclopedia of 8. Hasan Pirani, Dariuosh Shahmoradi, Shiva Noori,
Rehabilitation. 2012 Tooraj Mohamadzaman (2017)Prevalence of spinal
5. Levangie, P.K. and Norkin, C.C. Joint Structure abnormalities among the male junior high school
and Function: A Comprehensive Analysis. 2011 students of Kermanshah city J Kermanshah Univ
Med Sci. 2017; 21(1): 42-47
6. Gerber, B.E., Knight, M. And Siebeit, W. Lasers in
the Musculoskeletal System. 2001 9. Kuck JR, Hasson SM, Olson SL. Effect of aquatic
spinal stabilization exercise in patients with
7. Masharawi Y, Dar G, Peleg S, Steinberg N, et. Al
symptomatic lumbar spinal stenosis. JAPT. 2005;
.A morphological adaptation of the thoracic and
13(2):11-20
lumbar vertebrae to lumbar hyperlordosis in young
and adult females. Eur Spine J 2010; 19:768–773
184 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Radiographic Evaluation of Different Combinations of Zinc

Oxide as an Obturating Material in Pulpectomy:
A Comparative in Vivo Study

Kiran N.K.1, Nagalakshmi Chowdhary2, Megha Kumar3, Pavana M.P.4, Aravind Sridhara4
1Professor, 2Professor
and Head, 3Post Graduate, 4Senior Lecturer,
Sri Siddhartha Dental College and Hospital, Sri Siddhartha Academy of Higher Education (SSAHE), Tumkur

Abstract
Background and Aims: The success of an endodontic treatment depends on various factors and use of an
ideal obturating material is one among that.

The aim of this study was to evaluate and compare the radiographic success of different combinations of
zinc oxide as an obturating material in pulpectomy of primary mandibular molars at three and six month
intervals.

Treatment success or failure was determined by a combination of clinical and radiographic findings at three
and six month intervals.

Results: The results at three and six months follow up yielded statistically significant reduction in size
of radiolucency, whereas, the resorption rates of the root and the different materials showed no statistical
significance.

Conclusions: All the materials used in the study have potential obturating material property, which shows
promising results in preserving the tooth in its dental arch.

Keywords: Pulpectomy, Obturation, Endoflas, Calcium hydroxide, Sodium fluoride, Zinc oxide eugenol.

Introduction required for obturation in primary teeth; especially

with regard to the major desirable property of having a
Dental caries in primary teeth remains a considerable
rate of resorption matching that of the physiologic root
dental health problem. In an irreversibly affected
resorption of primary teeth and faster resolution of furcal
pulp tissue, either due to caries or traumatic injuries,
radiolucency.1
endodontic treatment is considered as the best option.
For the success of an endodontic treatment, numerous
Material and Method
materials have been tested as an obturating material but
none of these possess all the ideal requisite properties The present in vivo study was carried out in a
clinical set up; on a sample of one hundred and five
primary mandibular molars of children in the age
group between 4-9 years of both the sexes using simple
Corresponding Author: random sampling technique. A written informed consent
Dr. Megha Kumar and assent were obtained after being advised about the
Post Graduate, Department of Pedodontics and nature of the study according to the protocol approved by
Preventive Dentistry, Sri Siddhartha Dental College and the Ethics and review committee. Inclusion criteria were
Hospital healthy, co-operative children without any systemic
Tumkur, Karnataka, India- 572107 disease, history of spontaneous pain with deep carious
e-mail: [email protected] lesion which is tender on percussion, radiolucency
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 185
involving pulp with loss of continuity of the lamina dura, Social Sciences software (SPSS version 18). Intragroup
radiolucency in inter-radicular not involving permanent data comparison was done by using Wilcoxan Signed
tooth bud, adequate bone support and root length, with Rank Test and intergroup comparison using Kruskal
no radiographically discernible pathological internal or Wallis Test to find out the statistical significance of the
external resorption, without sinus formation and those obtained results. P value of <0.05 was considered to be
children who can report back for the recall visits. Teeth statistically significant.
with abnormal mobility other than the normal exfoliation
were excluded from the study. Findings

A single sitting pulpectomy was carried out in these Out of the treated 105 samples, 34 samples were
samples after administration of local anesthesia using obturated with Endoflas [Group 1]; 35 samples with a
2% lignocaine with 1:80,000 adrenaline, isolation was mixture of zinc oxide powder, calcium hydroxide paste
achieved with rubber dam during the entire procedure. and 10% sodium fluoride solution [Group2] and 36
All the carious tooth structure was removed to gain good samples with zinc oxide eugenol [Group 3] and were
access to the coronal pulp. Access opening was done with evaluated after three and six months [ Figures 1,2 and 3].
No. 2 and 4 round diamond burs and the overhanging In all the three groups, reduction in size of
dentin was removed from the roof of the pulp chamber radiolucency was noticed from preoperative, three and
with Endo-Z carbide bur. Extirpation of pulpal debris six months which was statistically significant except in
from the root canals were done using K and H files of Group 2 between three and six months [Table 1].
sizes 8 and 10 and copious irrigation with normal saline.
After working length determination, the canals were Intragroup evaluation of size of radiolucency and
prepared with K-files and H-files and enlarged upto resorption rate among the three groups after 3 and 6
size 40. The root canals were then thoroughly irrigated months [Table 2].
with normal saline and the final wash of the canals was
done with 0.2% chlorhexidine solution and then dried The change in size of radiolucency and resorption
with sterile absorbent paper points of 0.04 taper. The rates among the different materials after three and six
root canals were then randomly filled with the respective months was statistically not significant [Table 3­ ].
obturating materials based on their groups either with
endoflas [Group 1], or a mixture of zinc oxide powder,
calcium hydroxide paste, sodium fluoride [Group 2] and
zinc oxide eugenol [Group3], as per the manufacturer’s
instructions and were obturated with lentulospirals
mounted in a slow speed hand piece. The teeth were
then finally restored with glass ionomer cement. After
the removal of the rubber dam, immediate post operative
radiographs were taken to assess the endodontic fill. The
patient was recalled after a week for the placement of
preformed stainless steel crowns.

Patients were scheduled for routine recall visits

at every three and six month intervals. During the
Figure 1: Preoperative and postoperative
follow up visits, radiographic evaluation was done by
radiographs of tooth filled with Endoflas:
measuring the difference in size of radiolucency and also
the resorption rate of the material with that of the root (a) Preoperative radiograph, (b) Immediate
using Boley’s gauge. 2 A blinded examiner was asked to postoperative radiograph, (c) Postoperative radiograph
evaluate the changes and the data was recorded. at 3 months, (d) Postoperative radiograph at 6 months
The data obtained from this study were tabulated
and statistically analyzed using Statistical Package for
186 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Figure 2: Preoperative and postoperative

radiographs of tooth filled with a mixture of zinc Figure 3: Preoperative and postoperative
oxide powder, calcium hydroxide paste and 10% radiographs of tooth filled with zinc oxide eugenol:
sodium fluoride solution:
(a) Preoperative radiograph, (b) Immediate
(a) Preoperative radiograph, (b) Immediate postoperative radiograph, (c) Postoperative radiograph
postoperative radiograph, (c) Postoperative radiograph at 3 months, (d) Postoperative radiograph at 6 months
at 3 months, (d) Postoperative radiograph at 6 months

Table 1: Intragroup comparison of size of radiolucency among the three groups after 3 and 6 months

Mean Standard Deviation P value

Variables
Grp1 Grp2 Grp3 Grp1 Grp2 Grp3 Grp1 Grp2 Grp3
Pre-OP 0.36 0.27 0.34 0.658 0.617 0.759 0.007* 0.007*
0.003* (S)
Three Months 0.10 0.08 0.18 0.318 0.289 0.476 (S) (S)
Pre-op 0.36 0.27 0.34 0.658 0.617 0.759 0.003* 0.007* 0. 007*
Six Months 0.01 0.01 0.10 0.086 0.068 0.273 (S) (S) (S)
Three Months 0.10 0.08 0.18 0.318 0.289 0.476 0.041* 0.102 0.041*
Six Months 0.01 0.01 0.10 0.086 0.068 0.273 (S) (NS) (S)
P≤ 0.05 is significant, NS- Not significant, HS- Highly significant

Table 2: Evaluation of size of radiolucency and resorption rate among the three groups after 3 and 6 months

Study Resorption Rate

Time Interval Size of Radiolucency
Group Root>Material Root<Material Root=Material No Resorption
Decrease (n=9) 01 00 00 08
Three months No radiolucency
02 01 01 21
Group 1 (n=25)
(N=34) Decrease (n=2) 00 01 01 00
Six months No radiolucency
03 03 10 16
(n=32)
Decrease (n=7) 00 01 00 06
Three months No radiolucency
Group 2 01 06 00 21
(n=28)
(N=35)
Decrease (n=1) 00 01 00 00
Six months
No radiolucency (n=34) 03 08 06 17
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 187

Study Resorption Rate

Time Interval Size of Radiolucency
Group Root>Material Root<Material Root=Material No Resorption
Decrease (n=9) 01 00 00 08
Three months No radiolucency
Group 3 01 00 00 26
(n=27)
(N= 36)
Decrease (n=6) 03 00 01 02
Six months
No radiolucency (n=30) 02 00 00 28

Table 3: Intergroup comparison of size of radiolucency and resorption rate between three materials at 3 and
6 month intervals

Variables Time Interval Group N Mean Rank P Value

1 34 55.82 0.217 (NS)
2 35 54.71
Three Months
3 36 48.67
Total 105
Size of Radiolucency
1 34 52.04
2 35 53.60
Six Months 0.886 (NS)
3 36 53.32
Total 105
1 34 53.06
2 35 53.20
Three Months 0.993 (NS)
3 36 52.75
Total 105
Rate of Resorption
1 34 51.16
2 35 55.79
Six Months 0.657 (NS)
3 36 52.03
Total 105
P ≤ 0.05 is significant, NS- Not significant, HS- Highly significant

Discussion resulting in a “hollow tube” effect within the canal

wherein the unfilled area is permeated with tissue fluid
A wide variety of materials have been used for
that eventually becomes a site for infection.8
obturation of primary teeth with varying success.
Among these, the most commonly used is zinc oxide A commercially available product- Endoflas, is
eugenol, sets into a dense mass which irritates periapical highly effective against resistant endodontic pathogen,
tissues,3 causes necrosis of bone and cementum,4 resists E. Faecalis, so can be used for management of infected
resorption and has a tendency to be retained even after primary molars.9 It is a hydrophilic material, which
tooth exfoliation causing deflection of the path of when used in humid canals, provides a tight seal,
eruption of the succedaneous tooth.1,2,4,5,6 biocompatible in nature with antibacterial properties.
According to Pandranki J et al,9 it reduces periapical
Calcium hydroxide is virtually an all purpose
inflammatory processes and stimulate periapical healing
medicament in dentistry.1 Despite its antiseptic and
with increased alkaline phosphatase action thus showing
osteoinductive properties, it is not generally preferred
excellent healing capabilities and bone regeneration with
in pulp therapy due to fear of internal resorption as
95%-100% success rates. When Endoflas was extruded
its alkaline pH causes metaplasia of undifferentiated
into the dental follicle, it irritates the follicle and causes
mesenchymal cells to odontoclasts leading to
intense inflammatory reaction resulting in accelerated
resorption.7 It has a tendency to get depleted from the
root resorption. The use of iodoform containing products
canals earlier than the physiologic resorption of roots,1
188 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
raises the safety issue of iodoform being allergic, causing 6 months.13 On evaluating the resorption rates [Table2],
discolouration of teeth and encephalopathy leading to Chawla et al,1 reported that the resorption of the material
coma.1 matched the physiologic root resorption at the end of
two years which is contrary to our study.
To overcome the drawbacks of calcium hydroxide
and zinc oxide eugenol, a few drops of 10% sodium In Group 3, all the 36 samples showed statistically
fluoride solution was added to this mixture in a previous significant difference in size of radiolucency from
study. It was suggested that this obturating material preoperative, 3 and 6 months and also between 3
could leach out fluoride which will be beneficial to the and 6 months [Table 1]. Radiolucency was noticed
erupting tooth and a reaction product of calcium fluoride in 9 samples preoperatively which showed decrease
was formed that added radiopacity to the material in its size at the end of 3 months and only 3 samples
without the addition of another radiopaque material.1 among them showed complete resolution at the end of
6 months [Table 2]. Similar to our study Pandranki et
The present study was done to evaluate and compare al,9 and Rewal,14 showed only 45% reduction in size
the radiographic success of Endoflas, a mixture of zinc of radiolucency with pre existing pathosis at the end
oxide with calcium hydroxide paste & 10% sodium of 9 months. On evaluating the resorption rates [Table
fluoride solution and zinc oxide with eugenol as an 2], similar to our study, Barr et al,5 Chawla et al,1,13
obturating material in pulpectomy of primary mandibular Dogra S 7 and Pandranki 9 showed delay in resorption
molars. of zinc oxide eugenol to that of the root and contrary to
According to Chawla H.S. et al,1 on obturating with our study, Nadkarni and Damle,15 and Coll,16 reported
a mixture of zinc oxide powder, calcium hydroxide paste 88.5% and 86.1% success respectively.
and 10% sodium fluoride solution, a reaction product of There was no statistical significant difference on
calcium fluoride is formed that added radiopacity to the comparing the size of radiolucency and the resorption
material. In the present study it was noted that, even rates of the three materials with that of the root at the end
though the same quantity of ingredients were used for of 3 and 6 months [Table 3].
obturation, the radiopacity of the Group 2 mixture in the
immediate postoperative radiograph was nearly similar Conclusion
to that of the dentin, making it difficult to appreciate the
length of fill of the material in the canals. Hence, it is Although the results did not show any statistically
advisable to add a radiopacifier for optimum evaluation. significant difference, the success rate of all these
materials are quite promising in reduction of the infection
In Group 1, all the 34 samples, showed statistically rate and can be considered as a valuable material for
significant reduction in size of radiolucency from obturating deep carious tooth. However, a longer follow
preoperative and at 3 and 6 months [Table 1]. Similar up period with sufficient sample size is necessary to reach
to our study, there was 100% reduction in furcation sound conclusions regarding their resorption rates, effect
radiolucency with excellent healing capabilities.10,11 The on the succedaneous tooth and the overall radiographic
disparity in the resorption rates noticed in the present success as an obturating material in primary teeth.
study [Table 2], can be attributed to the influence of
various factors such as individuals body resistance;9 Ethical clearance- All the clinical procedures were
preoperative pathologic condition12 and periapical carried out following the protocols approved by the
pathology.9 Ethics and Review Committee of Sri Siddhartha Dental
College and Hospital, Tumkur (IEC 11/2016).
In Group 2, all the 35 samples showed statistically
significant reduction in size of radiolucency from Conflict of Interest: None.
preoperative to 3 and 6 months interval but not between Source of Funding: Self.
3 and 6 months [Table 1]. This result suggests that
maximum resolution of the radiolucency occurs within References
the first 3 months and the resolution rate lessens by
the end of 6 months. Similar to our study, complete 1. Chawla H.S, Setia S, Gupta N, Gauba K, Goyal
obliteration of the radiolucent area and regaining of A. Evaluation of a mixture of zinc oxide calcium
normal bony trabecular pattern was noticed by about 4 to hydroxide and sodium fluoride as a new root canal
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 189
filling material for primary teeth. J Indian Soc molars: 24-month clinical and radiographic
Pedod Prev Dent 2008;26:53-8. evaluation. J Indian Soc Pedod Prev Dent
2. Sadrian R, Coll JA. A long term follow up on 2018;36:173-80.
the retention rate of zinc oxide eugenol filler 10. Ramar K, Mungara J. Clinical and radiographic
after primary tooth pulpectomy. Peditr Dent evaluation of pulpectomies using three root canal
1993;15(4):249-53. filling materials: An in-vivo study. J Indian Soc
3. R. Pramila, M.S. Muthu, G. Deepa, J.M.Farzan, Pedod Prev Dent Jan-Mar 2010;28(1):25-29.
S.J.L.Rodrigues. Pulpectomies in primary 11. Fuks AB, Eielman E, Pauker N. Root canal filling
mandibular molars: a comparision of outcomes with Endoflas in primary teeth: A retrospective
using three root filling materials. International study. J Clin Pediatr Dent 2002;27:41-6.
Endodontic Journal 2016;49:413-21. 12. Holan G, Fuks AB. A comparison of pulpectomies
4. Praveen P, Anantharaj A, Venkataragahavan K, using Zinc oxide eugenol and KRI paste in
Rani SP, Sudhir R, Jaya AR. A review of obturating primary molars: A retrospective study. Peditr Dent
materials for primary teeth. SRM University 1993;15(6):403-7.
Journal of Dental Sciences Streamdent 2011;1(3). 13. Chawla HS, Mathur VP, Gauba K, Goyal A. A
5. Barr E.S, Flaitz C.M, Hicks M.J. A retrospective mixture of calcium hydroxide paste and zinc oxide
radiographic evaluation of primary molar as a root canal filling material for primary teeth: A
pulpectomies. Peditr Dent Jan/Feb 1991;13:4-9. preliminary study. J Indian Soc Pedod Prev Dent
6. Flaitz Cm, Barr ES, Hicks JM. Radiographic 2001;19:107-9.
evaluation of Pulpal therapy for primary anterior 14. Rewal N, Thakur AS, Sachdev V, Mahajan N.
teeth. J Dent Child 1989;56:182-5. Comparison of endoflas and zinc oxide eugenol as
7. Shikha Dogra. Comparative Evaluation of Calcium a root canal filling materials in primary dentition. J
Hydroxide and Zinc Oxide Eugenol as Root Canal Indian Soc Pedod Prev Dent 2014;32:317-21.
Filling Materials for Primary Molars: A Clinical and 15. Nadkarni U, Damle SG. Comparative evaluation
Radiographic Study. World Journal of Dentistry of Calcium Hydroxide and Zinc Oxide Eugenol as
July-Sept 2011;2(3):231-6. root canal filling materials for primary molars: A
8. Garcia-Godoy F. Evaluation of an iodoform paste Clinical and Radiographic study. J Indian Soc Pedo
in root canal therapy for infected primary teeth. J Prev Dent Mar 2000;1-10.
Dent Child 1987;54:30-4. 16. Coll JA, Josell S, Casper JS. Evaluation of a one-
9. Pandranki J, V Vanga NR, Chandrabhatla SK. Zinc appointment formocresol pulpectomy technique for
oxide eugenol and Endoflas pulpectomy in primary primary molars. Peditr Dent 1985;7:123-9.
190 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Development of “Young Planning Clinic” Program as a

Prevention Early in Adolescent Attitude in
Martapura River Areas

Meitria Syahadatina N.1, Atikah Rahayu2, Fauzie Rahman3,

Fahrini Yulidasari2, Dian Rosadi4, Nur Laily3, Hadianor3
1MCH and Reproductive Health Department, 2Nutrition Department, 3Administration and Health Policy,
4
Epedemiology Department, Public Health Study Program, Medical Faculty, Lambung Mangkurat University

Abstract
The highest percentage of early marriage events for the last 3 years in girls <20 years old is found in Banjar
Regency. In 2015 the percentage of early marriages reached 17.36% and in 2016 the percentage of early
marriages in Banjar only slightly decreased to 16.47% while in 2017 early marriages in Banjar Regency in
girls experienced an increase in cases with a percentage of 17.51% . The general purpose of this study is to
explain the “Klinik Dana” Program as an Prevention of early marriage events in adolescents. The design of
this study is analytical, with quasy experimental approach. The research subjects were teenagers at Banjar
Regency. The number of subjects targeted for the activity was 62 teenagers. In this study, the research
instruments were used as follows, questionnaire sheets, knowledge, attitudes and support for adolescent
environments before and after the implementation of the program. The independent variable in this study is
the development of the young clinic planning, while the dependent variable is the knowledge, attitudes and
environment of adolescents. The results showed that before the intervention was obtained less knowledge of
45 respondents (72.6%), negative attitudes of 11 respondents (17.8%), and the environment did not support
3 respondents (4.9%). While the results in the second month obtained good knowledge of 9 respondents
(14.5), negative attitudes of 1 respondent (1.6%), environment did not support 3 respondents (4.83%). At
the final value, the results of the lack of knowledge are 1 respondent (1.6%), negative attitude 0% and
environment that does not support 0%.This activity is proven to be able to increase knowledge, attitudes,
and environmental support for the ideal age marriage. So that the Health Office and Puskesmas can apply
this concept in an effort to reduce the rate of early marriage.

Keywords: Early-age marriage, young clinic planning.

Introduction of child brides, namely 1,408,000 women aged 20 to 24

years have been married before the age of 18 (UNICEF,
According to the National Coordinating and
2016). In Indonesia, in 2015 the Province of South
Family Planning Agency, the ideal age for marriage to
Kalimantan was the second largest province of cases
women is at least 21 years and to men at least 25 years
of early marriage with a percentage of 9% after Central
because at that age the female reproductive organs are
Java (52.1%).
psychologically well developed and strong and ready to
give birth as well as men Men at the age of 25 will be One regency in South Kalimantan which is located
ready to support their family life. Based on data from in the area of the river is Banjar Regency with the main
the United Nations Children’s Fund (UNICEF) 2016 river is the Martapura River. The Martapura River is
every year around 15 million girls in the world marry the largest tributary in Banjarmasin. One of the social
before the age of 18. One out of every seven girls in problems in Banjar Regency is the highest percentage
Indonesia is married before the age of 18. Indonesia is of early marriages for the last 3 years in girls <20 years
one of ten countries with the highest absolute number old in Banjar Regency. In 2015 the percentage of early
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 191
marriages reached 17.36% and in 2016 the percentage percentage form with the Wilxon Test to see differences
of early marriages in Banjar only slightly decreased after and before program development. In addition, it
to 16.47% while in 2017 early marriages in Banjar was also seen an increase in value every week to see the
Regency in girls experienced an increase in cases with a success of the fund clinical program.
percentage of 17.51% . Based on data from the Ministry
of Religion, Kabupaten Banjar, Martapura Kota, was Result and Discussion
ranked first with girls who were married with age <20 1. Univariate Analysis
years which reached 241 cases from 1489 marriages
(16.19%) in 2015, 167 cases from 1173 marriages Table 1 shows the distribution of variables according
(14.24%) in 2016, and in 2017 that is equal to 237 cases to categories that are likely related to the incidence of
from 1410 marriages (17.81%). osteopenia in respondents.

One solution that can be used to provide information Table 1. Frequency distribution of respondent and
and as a preventive effort for early marriage is the family characteristics
embodiment of the “Young Planning Clinic (Dana)”
Variabel Frequency (Person) Percentage (%)
which can be used as a forum for adolescents and parents
Knowledge
of adolescents to be given Communication, Information
a. Less 45 72,6
and Education (IEC) regarding generation planning
in particular early marriage with the formation of b. Well 17 27,4
“HIMUNG (Hope and Impian Menuntung) Cadres” and Attitude
PIK-R (Information and Counseling - Youth Centers). a. Negatif 11 17,8
This program is conceptualized in such a way that it fits b. Positif 51 82,2
the attractiveness of adolescents (Qiao, 2012). Environment
a. Not Supported 3 4,9
Materials and Method b. Supported 59 95,1
The design of this study is analytical, with Based on table 1 What is known is that students
the Quasy Experimental approach, which aims to who are respondents in large numbers are still lacking
determine the effectiveness of the “Clinic Fund” as an in the amount of 45 respondents (72.6%). Knowledge
Prevention of Early Marriage Events in Adolescents in used relates to age calculations, planning generation
the Martapura River. In field research, it usually uses goals programs, restrictions on early marriage, factors
quasi-experimental designs (quasi-experiments). The that influence marriage events, behavior from marriage,
independent variable in this study is the development family functions, children’s rights, and also about
of the Fund Clinic, while the dependent variable is the maturation of marriage time. Of the 45 respondents,
knowledge, attitudes and behavior of adolescents in an most of them still could not find out about the Genre
effort to prevent the occurrence of early marriage1. program, which was as much as 95.5%, unknown about
The research subjects were teenagers who were on the minimum price of a married woman that is equal
the riverbank of the Banjar Regency. The number of to 84.4%, unknown predisposing factors for a person’s
subjects targeted for the activity was 62 adolescents. behavior were 91.1% can not know about the initial
The criteria of the counselor in this study were students action: as much as 88.8%, the abnormalities produced
of the Public Health Study Program at the Faculty of before early as much as 75%.
Medicine, Lambung Mangkurat University who had The results of the study found that the majority
positive knowledge, attitudes and behaviors about the of respondents had a positive attitude towards
prevention of early marriage. The number of counselors early sensitivity, namely 51 respondents (82.2%).
involved was 6 people with a ratio of 1 cadre to 15 young Nevertheless, there are still 11 respondents (17.8%) who
women. have a negative attitude.
In this study, the research instrument was used as The results of the study found that most respondents
follows, the questionnaire sheet was the knowledge, had a supportive environment for marriage with an ideal
attitudes and behavior of adolescents before and after value of 59 respondents (95.1%). Nevertheless, there are
the implementation of the program. Program are made in
192 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
still 3 respondents with the assumption that they do not a non-supportive attitude towards the ideal marriage
support the ideal day money. The environment used in age. After conducting the Dana Clinic program in the
this environment is ideal. The environment that is not first stage, some students, namely 63.6% of 11 female
supportive of marriage during ideal periods because students, changed their attitudes to support the marriage
of being pregnant in a young place is common in the with an ideal age.
respondent’s place, which is 56.4%. Nationally can be
seen by 8% of women 10-59 years of birth 5-6 children, The results showed that the environmental variables
and 3% of children over 7. An ideal woman is pregnant showed that there was a significant change between
at the age of 20-35 years. The impact that will arise in before the implementation of the Fund Clinic and after
pregnancy at an early time is maternal death. Based the implementation of the Dana Clinic with a value of p =
on the 2012 IDHS data, the Maternal Mortality Rate 0.002 (<α). Counseling is one form of health promotion
(MMR) is estimated at 359 per 100,000 live births. that is simple and can cover broad goals. One of the
initial outcomes of counseling activities was increasing
2. Bivariate Analysis knowledge2.
Table 2. pre-test and post-test result Table 2 shows that the activities in the second month
showed significant results between before and after the
Category P-Value Information
implementation of the Dana Clinic with a value of p =
First Month
0.008 (<α) for knowledge so that the results showed
Knowledge 0,0001 Significant
significant changes. The change was caused by an increase
Attitude 0,047 Significant
in the number of female students whose knowledge was
Environmet 0,002 Significant
good, namely from 17 female students (27.4%) to 53
Second Month respondents (85.4%) or 58% increase in knowledge. As
Knowledge 0,008 Significant for the student’s attitude, it shows significant results also
Attitude 0,0001 Significant with a value of p = 0,0001 (<α). There was an increase
Environmet 0,004 Significant in attitude change from 51 respondents (82.2%) to 59
Third Month respondents (95.1%) or increased by 12.9%. Whereas in
Knowledge 0,996 not significant the environmental variable the results show that there
Attitude 0,144 not significant is a significant change between before and a myriad of
Environmet 0,851 not significant activities with a value of p = 0.004 (<α). The significance
of this change is due to an increase in the supporting
*p-value (<0,05)
environment, from the initial 59 respondents (95.1%)
Table 2 using the Wilcoxon test. Based on the table who had a positive environment to 61 respondents
it is known that the activities in the first month showed (98.3%). In the results of this second month, it can
significant results between before the implementation of be concluded that intervention activities can improve
the Fund Clinic with after the implementation of the Dana knowledge to be better, change attitudes that are still
Clinic with a value of p = 0,0001 (<α) for knowledge negative to be positive with significant test results and
so that the results showed a significant change. This from environments that do not support being supportive
increase in knowledge is due to the fact that previously of marriage at the ideal age.
students did not know about the genre program and the
impact of early marriage became aware of these things. Table 2 shows that activities in the third month showed
Through the Clinic program this Fund will be delivered insignificant results before before the implementation
in relation to the genre program and matters relating to of the Fund Clinic with after the implementation of the
early marriage. So the students who became respondents Dana Clinic with p = 0.996 (<α) for knowledge so that
became more aware of this. the results showed no significant changes. This is due
to an increase in the number of female students whose
The results showed that the attitude of students good knowledge is not too much, namely from 53
between before the implementation of the Dana Clinic female students (85.4%) to 55 respondents (88.7%) or
and after the implementation of the Dana Clinic showed an increase in knowledge as much as 3.3%. So that the
significant results with a value of p = 0.047 (<α). Based increase in student knowledge does not look significant.
on preliminary data there are 17.8% who still have The student’s attitude showed a non-significant result
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 193
with p = 0.144 (<α). Changes in student attitudes after ideal age, which is equal to 52 respondents (83.9%).
the Fund Clinic activities in the Third Month did not Environment is one of the factors associated with the
change drastically, ie from 59 respondents (95.1%) to incidence of early marriage. According to Puspitasari
62 respondents (100%). The environment shows that (2006), adding that the traditional factor of early age
there is no significant change between before and after marriage is due to parents’ fear of gossip from close
the activity with a value of p = 0.851 (<α). Changes neighbors, parents feel afraid that their children are
that occur are not significant, namely from the initial 61 said to be spinsters. Early marriage behavior is an
respondents (98.3%) who have a positive environment to operant behavior that is learned by adolescents from
62 respondents (100%). In the results of this third month the environment where the individual lives. This is
all variables did not experience significant changes. This related to early marriage behavior which is influenced
is because the knowledge, attitude, and environment of by the surrounding environment. The environmental
the respondents who have improved after intervention in influences referred to in this study are the existence of
the first and second months4. values and norms that develop in the community related
to the existence of a young woman and the concept
3. Final Results After Intervention for 3 Months of marriage. The influence of the environment in this
Table 3. Knowledge, Attitude and Environment study was calculated through the level of adolescent’s
After 3 Months of Intervention confidence in the norms and developing values7.

Category Frequency (Person) Percentage (%) 4. Difference Test Analysis

Knowledge Table 5. The Differences of Knowledge, Atittude,
a. Less 7 11,3 and Enviroment (before and after intervention)
b. Well 55 88,7
Attitude Variable P-Value
a. Negatif 0 0 Knowledge 0,001
b. Positif 62 100 Attitude 0,0001
Environment Environment 0,009
a. Not Support 0 0
Table 4 using the Wilcoxon test. Based on the
b. Support 62 100
information, it is known that from the first, the results
Based on table 3, it is known that the knowledge of the activity that have significant results before the
of adolescent students who become respondents is activity and after counseling with a value of p = 0.001
mostly good, that is equal to 55 respondents (88.7%). (<α) for knowledge so that the results show there are
Good knowledge will shape and influence a person’s significant changes . The student’s attitude shows
mindset, then the mindset will form a positive attitude. significant results also with a value of p = 0,0001 (<α).
The impact caused by early marriage is generally more In the environment variable shows the results that there
experienced by women5. The results showed that the is a significant change between before and after the
majority of respondents had a positive attitude towards activity with a value of p = 0.009 (<α).
early marriage in the amount of 62 respondents (100%).
Besides knowledge, another factor that is also related to Conclusions
the incidence of early marriage is the attitude towards The knowledge of teenagers who become
early marriage. According to Azwar (2009) the factors respondents is still largely lacking, amounting to
that influence attitudes are personal experiences where 45 respondents (72.6%). Most of the respondents
what has been and is being experienced will shape and had neutral attitudes towards early marriage, which
influence one’s appreciation of social stimulus and then amounted to 51 respondents (82.2%). The knowledge
form positive or negative attitudes. Other factors that variable shows that there is a significant change between
influence the formation of attitudes are emotional. In before and after the activity with a value of p = 0.001.
addition there are mass media factors that can influence The attitude variable shows significant results between
the formation of attitudes6. the first month to the third month with a value of p =
0,0001 (<α). In the environment variable shows the
Based on table 3, it is known that most respondents
results that there is a significant change between before
have an environment that supports the marriage of the
and after the activity with a value of p = 0.009 (<α).
194 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Ethical Clearance: This study has received ethical 2. Nootoatmojo, Public Helath: Science and art.
approval from the Research Ethics Committee of the Jakarta: Rineka Cipta, 2007
Faculty of Medicine, Lambung Mangkurat University, 3. Kemenkes, RI. Basic Health Research. Jakarta.
Banjarmasin, Indonesia. In this study, we used guidelines Health Research and Development Agency RI,
from the Public Health Ethics Committee, including title 2010.
research, informed consent, research objectives, data
4. Priharwanti A, Eka F, Nurul B.Health promotion
rights obtained and also the signature of researchers and
strategy in an effort to reduce Maternal Mortality
respondents. chairman.
Rate (MMR) in Pekalongan City. Journal of
Source Funding: This research was carried out Research and Mining in Pekalongan City, 2017.
by the Faculty of Medicine at Lambung Mangkurat 5. BKKBN, Guidelines for managing Youth/ Student
University, Banjarmasin, Indonesia through a grant in Information and Counseling Centers (Youth/
the context of faculty superior development research. Student PIK), National Population and Family
Planning Board, Jakarta, 2012.
Conflict of Interest: The authors declare that they
6. N. Utami, Decision making for early marriage in
have no confict interest.
young women in Umbulharjo District. Guidance
References and Counseling Journal, 2015:1-10.
7. Audina A, dkk. The relationship of perceptions of
1. Hardinsyah. Maternal employment status and
the application of family function to early marriage
income in relation to nutritional quality of family
in women of childbearing age in Pracimantoro
food in urban areas. Family Nutrition Media. 2016;
District, Wonogiri Regency in 2016. Journal of
20(2): 86-9l
Public Health (e-Journal)2017; 5(4): 172-179.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 195

Patterns and Determinants of Utilization of

Healthcarein Urban Field Practice Area of a
Tertiary Care Institute, Hyderabad

Moniza Maheen1, Fawwad M. Shaikh2, Vaseem Anjum2, A. Chandrasekhar3

1Postgraduate, 2Assistantprofessor, 3Professor & Head, Department of Community Medicine,
Deccan College of Medical Sciences, Hyderabad, Telangana, India

Abstract
Introduction: It is estimated that 68% of the World’s population shall live in urban areas by 2050; India
will have added 416 million to the urban population. With rapid increase in population, the healthcare
needs also increase. In 2016, 63% of the deaths were due to non-communicable diseases and 26% due to
communicable diseases. India is a country with high level of morbidity. Communicable diseases contribute
to the morbidity more than the non-communicable diseases. Despite the increasing public and private
expenditure on healthcare, utilization of health services still remain low. The utilization of public health
services in India range from 10-30%.

Aim and Objective: To study the Patterns and Determinants of Utilization of Healthcare.

Materials and Method: A cross-sectional study was conducted among 256 attendees of a health camp
conducted in urban field practice area, using a predesigned and pretested questionnaire. Data entered into
Microsoft excel and analysed using SPSS 20.

Results: The overall population of the area was 7634, 2256 were attended the camp giving a 30% utilisation.
Out of 256 patients 40.6% were males and 59.4% were females. 25.7% Respiratory, 12.9% musculoskeletal
and 11.7% gastrointestinal problems were common. It was found that the behavioural determinants
of subjects utilising healthcare facilities both in public and private sector showed that free services was
observed as main factor for approaching public healthcare against reliability. Whereas less waiting time was
the principal factor compared to cleanliness for visiting private healthcare.

Conclusion: In the study population, Respiratory problems were found to be highest, private healthcare
facility was preferred.

Keywords: Utilization, determinants, urban Healthcare.

Introduction added 416 million to the urban population1. With

rapid increase in population, the healthcare needs also
It is estimated that 68% of the World’s population
increase. Indian scenario in 2016, 63% of the deaths
shalllive in urban areas by 2050 and India will have
were due to non-communicable diseases and 26% due
to communicable diseases2. India is a country with high
level of morbidity. Communicable diseases contribute
Corresponding Author: to the morbidity more than the non-communicable
Dr. Fawwad M. Shaikh diseases. With the concept of universal health coverage
9-11-414/7, Jinsi Bazaar, Golconda, Hyderabad, at every sector, there seems to be a changein the burden
Telanagana, 5000008 of healthcare cost with utilization3. The twelfth five year
e-mail: [email protected] plan document noted disparities in access to healthcare
196 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
services in urban setup4. Health being a highly personal illness, reasons and duration of illness for approaching
responsibility and major public concern takes a backseat healthcare, expenditure on healthcare, awareness
when it comes to approaching it, spending from one’s regarding local healthcare facilities and schemes. A
own pocket, in a country like India where resources sample size of 256 was calculated using the formula
are limited5. With increasing population and rapid 4pq/d2(p=20%, q=80%, absolute error of 5%). Persons
urbanisation it is of importance that the private sector more than 18 years of age, co-operative, who gave
alongside public sector provides healthcare facilities consent, were included in the study. Data was entered in
to the expanding population6. At the end, out of pocket Microsoft Excel and was analysed using SPSS version
expenditure elimination happens to be a corner stone to 20 and presented as frequency tables and graphs,
achieving urban health care. This may seem possible appropriate tests of significance were applied.
through camp approach to increase coverage and
awareness7. Results
Despite the increasing public and private expenditure The overall population of the area was 7634,
on healthcare, utilization of health services still remain from which 2256 attended the camp, resulting in 30%
low. The utilization of public health services in India utilization of healthcare. Data was collected from about
range from 10-30%.Bare provision of primary healthcare 10% of the attendees who were interviewed and adjusted
facility, its utilization is a major concern added to its to meet the sample size which was equal to the estimate
access. Doorstep provision of services in the form of population given by the formula. It is seen that the most
Mega Health camps, also suffer some component of common age group is 18-45 years which constituted
underutilization. This needs to be further studied as to 49.6%. Among the study participants 41% were non
understand the factors responsible for the behavioural educated, majority (45.4%) were females. Most of them
pattern and scepticism prevalent among the community. belonged to class III socio-economic status. Alcohol
There also is variability in the community with regard consumption was seen in 5.5%, any form of tobacco
to demands of basic healthcare services which needs consumption was found in 35.9%.
to be addressed at the time of planning stage. Against As seen in Table 1, top three common illnesses
this backdrop and dearth of knowledge, the study was were Respiratory (25.8%), followed by musculoskeletal
conducted with the aim of studying the Patterns and (12.9%) and lastly gastrointestinal (11.7%). These were
Determinants of Utilization of Healthcare in this area. more found among the females as compared to the
males. This pattern may be due to the availability of the
Materials and Method population during the services provided to them.
A Cross-sectional study was conducted in the
urban field practice area of a tertiary care institute in As in Table 2 it was found that the behavioural
Hyderabad, Telangana during period from August- determinants of subjects utilising healthcare facilities
September 2018. Participants were selected from the both in public and private sector showed that free services
attendees of camp by simple random sampling. Study was observed as main factor for approaching public
tool consisted of predesigned, pretested questionnaire healthcare against reliability. Whereas less waiting time
administered through personal interviews. A clinical was the principal factor compared to cleanliness for
examination of the individuals was done and appropriate visiting private healthcare. Odds ratio of the above two
treatment was provided to the needful. Questionnaire scenarios was found to be statistically significant.
consisted of socio-demographic details, present and past

Table 1: Disease pattern among the subjects

Diseases Male n=104(40.6%) Female n=152(59.4%) Total N=256 (100%)

Diabetes 3(2.9) 19(12.5) 22 (8.6)
Hypertension 6 (5.8) 13 (8.6) 19 (7.4)
Respiratory 33 (31.7) 33 (21.7) 66 (25.8)
Musculoskeletal 8 (7.7) 25 (16.4) 33 (12.9)
Skin 8 (7.7) 10 (6.6) 18 (7)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 197

Diseases Male n=104(40.6%) Female n=152(59.4%) Total N=256 (100%)

Ocular 16 (15.4) 7 (4.6) 23 (9)
ENT 10 (9.6) 15 (9.9) 25 (9.8)
Genitourinary 2 (1.9) 18 (11.8) 20 (7.8)
Gastrointestinal 18 (17.3) 12 (7.9) 30 (11.7)

Table 2: Behavioural determinants of subjects for utilising healthcare facilities

Variable# Male (n=104) 40.6% Female (n=152) 59.4% Total (N=256) 100% Odds ratio (95% CI)
Public Healthcare 34 (32.7) 36 (23.7) 70 (27.3)
Free Services* 28 (82.3) 19 (52.8) 47 (67.1)
4.4 (1.06–18.49)
Reliability 3 (8.8) 9 (25) 14 (20)
1
Availability of Doctors 2 (6) 5 (13.9) 5 (7.1)
Others 1 (2.9) 3 (8.3) 4 (5.7)
Private Healthcare 58 (55.8) 93 (61.2) 151 (59)
Cleanliness 16 (27.6) 11 (11.8) 27 (17.9)
1
Less Waiting Time* 21 (36.2) 42 (45.2) 63 (41.7)
2.9 (1.15 -7.37)
Near to Residence 14 (24.1) 28 (30.1) 42 (27.8)
Others 7 (12.1) 12 (12.9) 19 (12.6)
Both 12 (11.5) 23 (15.1) 35 (13.7)

# Multiple response to variables * p value < 0.05 were taken as significant

Discussion Respiratory illness, diabetes and hypertension were

found to be 38%, 22.5% and 23.5% in a study done
The distribution of study population was similar to
by Patil et al compared to our study it was found to be
studies conducted across India4-7 where 49.6% were in
25.8%, 8.6% and 7.4% respectively10.
the age group 18-45 years. As compared with literacy
status our study showed a high illiterate population In another study done by Datta et al, majority of the
which was similarly found by other investigators in illnesses was contributed by respiratory, musculoskeletal
their studies3-7. In our study 56.2% belonged to class and non-communicable diseases, which were 31.1%,
III socioeconomic status, whereas Gaiki et al found 17.8% and 13.7% respectively compared to our study it
it to be 19.07%3. In a study by Mihir et al 50.6% of was found to be 25.8%, 12.9% and 16% respectively11.
men consumed tobacco in various forms which was
found similar to our study 51.6%, however 7.39% men 67.15% visited private health facility by Shukla et
consumed alcohol when compared to our study it was al, whereas 59% utilised only private health facility and
found to be almost double(13.5%). Similarly 23.5% of 13.7% utilised both public and private healthcare facility
the females used tobacco (various forms) compared to in the present study5.
our study, it was found to be 25%, alcohol consumption
In a study done by Kumar et al, 40.25% of men and
was found to be 0.8% in females, and in our study none
46.34% of female utilised public health facility, 59.5%
of the females had the habit of alcohol consumption8.
men and 53.66% females utilised private healthcare
Common diseases which were found in our study facility, whereas in our study 32.7% of men and 23.7%
coincided with other studies such as done by Shaikh et of female utilised only public health facility, 55.8%
al genitourinary diseases (16%) and digestive diseases men and 61.2% females utilised only private healthcare
(12%) were found in males and genitourinary diseases facility12.
18% and digestive diseases (12%) in females9. Whereas
Overall 59.15% utilised private healthcare and
in our study genitourinary diseases (2%) and digestive
33.8% utilised public healthcare in a study done by
diseases (17.3%) was seen in males and genitourinary
Kumar et al which was found similar to our study 59%
diseases (11.8%) and digestive diseases (7.9%) was seen
utilised private healthcare and 27.3% utilised public
in females.
healthcare13.
198 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
In a study done by Shukla et al free services 4. Rushender R, Balaji R, Parasuraman G. A study
(64.79%) was found to be the major reason for opting on effective utilization of health care services
public health facility in rural areas which was found provided by primary health centre, and sub-centres
similar (67.1%) to urban setup of our study6. in rural Tamilnadu, India. International Journal
of Community Medicine And Public Health.
Reliability (31.5%) and availability of staff 2016;3(5):1054-1060.
(12.75%) influenced utilisation of public healthcare
5. Shukla V, Agarwal M, Idiris MZ, Ahmed N, Gupta
facilities according to a study done by Patil et al whereas
P. International Journal of Community Medicine
our study found reliability (20%) and availability (7.1%)
And Public Health. 2018;5(5):1835-1838.
contribution to availing public healthcare facilities10.
6. Shukla V, Gupta P. International Journal of
The main factors behind non utilization of Community Medicine And Public Health.
public health care in urban setup were waiting time 2018;5(5):1766-1770.
(56.6%),cleanliness (7.14%) and distance (27.2%) 7. Sriram S. Critical evaluation of two approaches
according to a study done by Shukla et al which was to achieve universal health coverage in India.
found to be similar to our study, 41.7%, 17.9% and International Journal of Community Medicine And
27.8% respectively5. Public Health. 2018;5(8):3159-3163.

Conclusion 8. Mihir G, Geeta K. Socio-demographic and

morbidity profile of slum area in ahmedabad,
This study therefore concludes that when facilities India. National Journal of Community Medicine.
are provided for their effective utilization one must 2010;1(2):106-110.
keep in mind the cleanliness and waiting time and the
9. Shaikh M, Peters SAE, Woodward M, Norton R,
management of the crowd in a desirable manner. Not-
Jha V. Sex differences in utilisation of hospital care
withstanding the services must also be affordable/free to
in a state-sponsored health insurance programme
them for them to be effectively utilized.
providing access to free services in South India.
Conflict of Interest: The authors would like declare BMJ Global Health. 2018;3(3):e000859–e000859.
no conflicts of interest. 10. Patil SP, Parbhankar SS, Seema S, Gokhe B,
Shelke PS, Singh RD. Study of health seeking
Source of Funding: The study was self-funded behavior and its determinants among attendees
Ethical Clearance: Prior ethical clearance was of urban health center, Dharavi, Mumbai, India.
taken from the institutional ethics committee International Journal of Community Medicine and
Public Health. 2016;3(7):1856-1861.
References 11. Datta A, Kaushik N, Karmakar N, Datta S. A
study to assess common morbidity pattern of an
1. United Nations, Department of Economic and Social
urban population of Tripura. International Journal
Affairs Population Division. News [internet] New
of Community Medicine and Public Health. 2017
York: 2018 May [Cited 2019 April 4] Available
Dec;4(12):4613-4616.
from: www.un.org/development/desa/en/news/
population/2018-revision-of-world-urbanization- 12. Kumar S and Mishra N. A study of morbidity
prospects.html. pattern and health seeking behaviour in urban slum
population of Varanasi, India. International Journal
2. Park K. Park’s Textbook of Preventive and Social
of Advanced Research. 2017;5(9):1204-1210.
Medicine M/S BanarsidasBhanot Jabalpur 25th
edition 2019. 13. Kumar A, Dasgupta A, Das S, Sahoo SK, Biswas
D, Preeti PS. A study on morbidity pattern,
3. Gaiki VV, Khardekar M, Kokiwar P, Katkuri S,
health care utilization and Health expenditure in
ZareVR. Patterns and determinants of healthcare
a urban community of Kolkata. Medico Research
spending in denizens of urban slums from peri-
Chronicles. 2015;2(3):353-358.
indusrtial area of Hyderabad. International Journal
of Community Medicine And Public Health.
2017;4(11):4137-4140.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 199

Awareness & Practice of Road Safety Measures among

Under Graduate Medical Students of a Medical College in
Bengaluru, Karnataka

Shyam A.C.1, Mubarak Nadeer2

1Professor,
Department of Community Medicine, Rajarajeswari Medical College & Hospital, Bengaluru,
2
Junior Resident, Department of Community Medicine, Rajarajeswari Medical College & Hospital, Bengaluru

Abstract
Background: Road traffic accidents are considered as one of the important public health problems around
the world. Data from India showed that more than 1.3 lakh people died on Indian roads, giving India the
dubious honor of topping the global list of fatalities from road crashes. Rapid urbanization, motorization,
lack of appropriate road engineering, poor awareness levels, nonexistent injury prevention programmes, and
poor enforcement of traffic laws has exacerbated the situation.

Method: This cross sectional study was conducted among the undergraduate medical students from 1st to 9th
term. Data was collected using a semi structured questionnaire by interview method. Convenient sampling
was done. A sample size of 260 was calculated assuming the awareness levels among medical students as
50%, a relative precision of 6% and confidence level of 95%.

Results: The overall awareness levels among the study participants regarding road safety measures are good.
More than 90% students were aware of the basic safety measures like regular use of seat belts, distraction
caused by loud music and speed limitations. In the present study only 4 students (1.5%) have admitted being
involved in drunken driving.

Keywords: Road traffic accidents, awareness, medical students, cross sectional studies.

Introduction The UN general assembly has declared 2011-2020

as the “Decade of Action for Road Safety”.1
A road traffic accident (RTA) is any injury due to
crashes originating from, terminating with or involving a The declaration holds significance because road
vehicle partially or fully on a public road. It is projected traffic accidents (RTAs) have become a major cause of
that road traffic injuries will move up to the third position morbidity and mortality, especially among the adults and
by the year 2020 among leading causes of the global middle aged individuals who constitute economically
disease burden. They are considerable economic losses most productive age groups of society.1
to victims, their families, and to countries as a whole.2
Road traffic accidents (RTAs) are considered as
one of the important public health problems around the
world.

Data from India showed that more than 1.3 lakh

Corresponding Author:
people died on Indian roads, giving India the dubious
Dr. Mubarak Nadeer Kutty
honor of topping the global list of fatalities from road
Junior Resident, Department of Community Medicine,
crashes.2
Rajarajeswari Medical College & Hospital, Bengaluru
e-mail: [email protected] Rather than mechanical, its human factor that
200 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
contribute significantly to increasing number of road An alarming finding is the lack of knowledge on
accidents in India.2 lane discipline taking into consideration the fact that
all participants were valid driving license holders. 49
According to a report published by Ministry of students (18.8%) did not know the correct lane that
Road Transport and Highways, 56 accidents occur every should be followed while driving/riding in India.
hour on Indian roads and at least 14 people are killed in
these accidents. Prevention of RTAs thus, becomes very 48 students (18.5%) did not know the correct lane
crucial in order to improve the longevity and the quality for overtaking. We must keep in mind that a majority
of life of the individuals’ concerned.1 of accidents happen as a result of improper overtaking
maneuvers.
Simple measures like being aware of various traffic
rules & regulations and practice of road safety measures Table 1. Awareness levels among participants (who
can effectively reduce the impact of RTAs. There were responded in affirmative) regarding road safety
few studies in relation to road safety measures among measures
young adults across India and abroad.
Sl.No. Road Safety Measures Total in%
Objectives: Driving after consuming alcohol is
1 99.3
dangerous
1. To assess the awareness among undergraduate
2 Cautious driving near schools 99.6
students regarding road safety measures.
Safe time to read maps is when your
3 98.5
2. To measure the road safety practices of the students. vehicle is parked
Seat belts should be worn by everyone
4 91.6
Methodology in the car
Loud music in the car can distract the
This cross sectional study was conducted among the 5 87.0
driver
undergraduate medical students from 1st to 9th term over
6 One should drive in the left lane 81.2
a period of 2 months (August 2018-September 2018).
One should overtake from the right
Data was collected using a semi structured questionnaire 7
hand lane only
81.5
by interview method. Convenient sampling was done. One should pull over when it is safe to
A sample size of 260 was calculated assuming the 8 99.2
give way to an ambulance
awareness levels among medical students as 50%, a Safest way to use mobile phone while
9 97.3
relative precision of 6% and confidence level of 95%. driving is hands free device
Ethical clearance was obtained from the institutional One should wait patiently if pedestrians
ethical committee. The students with a valid driving 10 are taking too much time at zebra 89.2
crossings
license who gave consent were included in the study.
Correct knowledge about speed limits
11 98.5
is essential
Results
Mean age group of the study participants was 19.9 Practice of Road Safety Measures:
years with a standard deviation of 1.52.

Majority of the participants were females–155

(59.6%) and males were 105 (40.4%).

Awareness of Road Safety Measures: Majority

of the participants were aware of the fact that drunken
driving is dangerous (99.3%) and 4 students have
admitted being involved in drunken driving (Fig 1).
Fig 1. Pie chart showing that majority of students
Most of the participants were aware of the safe use of avoid drunken driving
newer technological assistance systems like navigation
& Bluetooth hands free devices.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 201
More than 90% students were aware of the basic
safety measures like regular use of seat belts, distraction
caused by loud music and speed limitations.

In the present study only 4 students (1.5%) have

admitted been involved in drunken driving which is in
contrast to the study done by Kulkarni et al in 2012 in
which 54 students (25.4%) have admitted being involved
Fig 2. Pie chart showing use of mobile phones while in drunken driving.1
driving/riding
This is a positive finding and throws light on the fact
Even though 98.5% of students were aware that that more and more people are aware of risky behaviors
knowledge of speed limits is essential, 36.5% of on the road & are consciously avoiding the same.
participants have admitted to exceeding the same on
roads. Conclusion
It is also of concern that 14.7% that is, 33 students In our efforts to curb the epidemic of road traffic
have admitted using mobile phones while driving/riding accidents, undertaking proper road safety measures
including texting, which is a very dangerous behavior are the best available interventions. The present study
(Fig 2). 15% of participants never use helmets regularly revealed good awareness and practice, but there are
& 13.5% use helmets only because of the fear of being areas where these should improve and it should be our
fined by the authorities. unending efforts to ensure 100% awareness and practice
of road safety measures.

The efforts of increasing road safety measures

through sign boards, posters & mass media should be
strengthened to reduce the morbidity & mortality in
relation to road traffic accidents.

Recommendations:
• Improve the pre-licensure training. Licensing should
Fig 3. Pie chart showing regular seat belt use among
be made stricter.
the study participants
• Frequent re-enforcement of traffic rules through
Wearing a seat belt may at times be the only mass media and trainings at educational institutions.
difference between life & death during an RTA. 78.5%
of participants are regular seat belt users & 91.6% of • Traffic rule violations should be dealt with more
them are aware that seat belts must be worn by every seriously and people should be made aware of all
occupant in a vehicle (Fig.3). punishable offences.
Conflict of Interests: None
Discussion
Source of Funding: None
The overall awareness levels among the study
participants regarding road safety measures is good
References
which is in contrast to a study done by Kulkarni et al in
2012, which revealed very low awareness levels among 1. Kulkarni V, Kanchan T, Palanivel C, Papanna MK,
medical students.1 Kumar N, Unnikrishnan B. Awareness and practice
of road safety measures among undergraduate
This difference may be due to the fact that there has medical students in a South Indian state. J Forensic
been an increase in use of social media since the past few Leg Med. 2013 May;20(4):226–9.
years which might have contributed to better awareness
2. Road Traffic Accidents | National Health Portal
of students regarding road safety measures.
of India [Internet]. [cited 2018 Sep 25]. Available
202 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
from: https://www.nhp.gov.in/road-traffic- [Internet]. The Indian Express. 2017 [cited 2018
accidents_pg Sep 25]. Available from: http://indianexpress.
3. Road accidents in India, 2016: 17 deaths on roads com/article/india/road-accidents-in-india-2016-
every hour, Chennai and Delhi most dangerous 17-deaths-on-roads-every-hour-chennai-and-delhi-
most-dangerous-4837832/
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 203

The Effect of Eye-Hand Coordination Device on

Coordination in Subjects with in-Coordination

MuzahidKadir Sheikh1, Suraj B. Kanase2

1Post-Graduate Student, 2Associate Professor, Department of Physiotherapy

Abstract
Coordination or coordinated movement is the ability to execute smooth, accurate, controlled motor responses.
The ability to produce these motor responses is a complex process dependent on a fully intact neuromuscular
system. Nowadays there are Fewer Devices Which can help in Gaining Eye-Hand Coordination. Objectives:
To compare the effect of eye-hand coordination device and conventional Physiotherapy in eye-hand
coordination for subjects with in-coordination. Materials and Method: The subjects in Krishna University
campus were screened and 44 subjects were divided into 2 groups i.e Group A subjects were given
Conventional Physiotherapy for coordination training and Group Eye-Hand Coordination Device along with
given Conventional Physiotherapy for coordination training. The interpretation of the study was done on the
basis of comparing pre-test and post-test assessment of NCT grading and FMA-UE.

Result: Intra group comparison results showed that NCT grading and FMA-UE scale were statistically
significant in both the groups (p<0.0001). Whereas the intergroup comparison results showed that Eye-Hand
Coordination The device along with Conventional physiotherapy was statistically significant in improving
NCT score (p=0.0021) and FMA-UE score (p=0.0001) than only Conventional Physiotherapy alone for
Eye-hand In-coordination.

Conclusion: The Eye-Hand Coordination Device was Significantly effective when Given With Conventional
Physiotherapy For treating In-coordination and improvement in coordination. Conventional Physiotherapy
is also effective in treating in-coordination, but after certain duration of treatment, the patient starts getting
adapted and chances of achieving the plateau phase

Keywords: Eye-Hand Coordination, coordination device, In-coordination, NCT Grading, FMA-UE.

Introduction and muscular tension. Coordination assessments provide

physical therapists with information related to motor
Coordination or coordinated movement is the
performance. They help in identifying the source of
ability to execute accurate, smooth and controlled motor
motor deficits. A variety of observational coordination
responses. It is a complex process dependent on a fully
tests have been presented and researched about the
intact neuromuscular system. Coordinated movements
same(1,2).
are characterized by speed, distance, direction, timing,
Eye-hand coordination has been studied as different
as the movement of solid objects such as archery,
Corresponding Author: sporting performance, blocks, computer gaming, copy-
Suraj B. Kanase typing, and even tea-making. It is part of the mechanisms
Associate professor, Faculty of Physiotherapy, Krishna of performing daily tasks; in its absence, most people
Institute of Medical Sciences Deemed to be University, would not be able to carry out even the simplest of
Karad, Maharashtra, India actions such as picking up a book from a table and
e-mail: [email protected] playing a video game. While it is recognized by the
Contact No.: 9881577676 term hand-eye coordination, without exception medical
204 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
sources, and most psychological sources refer to the eye- • Dribbling
hand coordination etc(3) We use hand-eye coordination
• Wall ball bounce
whenever we write. As you start making lines, our eyes
send information to the brain to tell it where the hand • Target practice (5)
is placed and if your handwriting is legible With this Eye-hand coordination device is a device which can
information, the brain form instructions for how the be used to increase in patients eye-hand coordination by
hand has to move in order to create appropriate shapes asking the patients to perform certain activity a number
and lines, resulting in alphabets. Visual feedback also of times which creates a better performance in eye-hand
helps correct letters generated by the previous motor coordination. The device can be used for many other
instructions. It is a sequence of precise motor actions purposes as a diagnosing tool as well as for treatment.
that require a certain amount of skill and training.(4) Nowadays there is a paucity of instruments or devices to
• A similar sequence takes place when we type on improve eye-hand coordination. Furthermore, the patient
a keyboard. The type of movements are different, is not able to receive biofeedback much in the other
but we still use visual information to tell the brain treatment so we can motivate him further by using this
how to guide the hand or if a mistake needs to be handheld instrument as we can make new levels in the
corrected. instrument. Further, this is a new innovative technique
which we can add up in our treatment protocol.
• When you drive, you are constantly using hand-
eye coordination because you have to use the Material and Method
visual information to move your hands on the
Approval for the study was obtained from the
wheel, keeping the car in the middle of the lane and
Protocol committee and institutional Ethical Committee
avoiding accidents.
of Krishna Institute of Medical Sciences Deemed To be
• Almost every sport requires the use of hand-eye University. The subjects in Krishna Institute of Medical
coordination to coordinate what you see with your Sciences Deemed To be University campus were
eyes with the movement if your body. Depending screened and those fulfilling the inclusion and exclusion
on the sport, the hand-eye coordination (tennis, criteria were involved. Participants were informed about
basketball, baseball, etc.) Or foot-eye coordination the study and consent was taken. Pre-test assessment
(soccer, track, etc.) Will be more used. In any the was taken by using Non-Equilibrium Coordination Test,
sport, you can count on the fact that the eyes will be Non-Equilibrium Coordination Test Grading and FMA-
coordinating with some part of the body, so a more UE to assess the patient. 44 subjects were divided into
appropriate term for this type of coordination may 2 groups, Group A and Group B based on the inclusion
simply be called motor coordination. and exclusion criteria. The treatment was started the first
• Putting a key in a lock also uses hand-eye day when the subject came for consultation. Group A
coordination. Similar examples would be when you subjects were given Conventional Physiotherapy and
insert a debit card in a chip reader, or when a child Group B subjects were given Eye-Hand Coordination
plays with toys with various shapes that they have to Device Along with conventional Physiotherapy. The
fit into a certain hole.(4) post-test assessment was taken by using NCT Grading
and FMA-UE to assess the patient. The interpretation of
Conventionally coordination training is mainly the study was done on the basis of comparing pre-test and
object based i.e training is given with the help of Balls post-test assessment of Non-Equilibrium Coordination
of various sizes, various drills, and agility training. Test Grading and FMA-UE.
Various types of exercises like: Group A: Conventional Physiotherapy For
• Frenkels Exercises improving Coordination:

• Ballon tossing • Frenkels Exercises

• Juggling • Ballon tossing
• Small ball tosing • Juggling
• Target practice • Small ball tosing
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 205
• Target practise • For starting we have asked the patient to perform
the procedure on a wire which will be a straight line
• Dribbling
which is the basic level.
• Wall ball bounce
• The levels will be made difficult by making the wire
• Target practise into many different shapes.
Group B: Eye-Hand Coordination Device -Patient • Once the patient gains confidence that he can
should be in sitting position, patient will be asked to hold perform the procedure easily he can go to the next
the hand piece which is of diameter 5cm, 4cm, 3cm, 2cm level.
and 1cm accordingly.
Findings: Statistical analysis was done manually
• First the therapist will demonstrate the activity. and by using the statistics software’s INSTAT so as
to verify the results derived. The statistical analysis of
• The patient will be handed the hand piece and ask
non-parametric data was done by Wilcoxon matched
to move the hand piece from starting position to
pairs test and Man-Whitney test. Wilcoxon matched
ending position and then again reach the starting
pairs test was used for statistical analysis of pre and post
point without much shaking of hand piece and with
intervention within the group. Man-Whitney test will be
steadiness
used for between groups statistical analysis of Group A
• If the patient touches the wire then a buzzer will be and Group B (pre-pre and post-post intervention).
on and light will blow and that will a biofeedback
that means that the patient has to go to the starting
point again for

Table 1: Data of NCT

Non-Equilibrium Coordination Test Grading

p valve
Pre-test Post-test Inference
(Pre-Post)
Mean SD Mean SD
Group A 1.545 0.8579 2.636 0.7267 <0.0001 Extremely significant
Group B 1.545 0.5096 3.227 0.4289 <0.0001 Extremely significant
p value (Pre-Pre) and (Post-Post) >0.9999 0.0021
Inference Not Significant Extremely Significant

Table 2: Data of FMA-UE

FMA-UE
p value
Pre-test Post-test Inference
(Pre-Post)
Mean SD Mean SD
Group A 33.591 5.413 43.455 5.878 <0.0001 Extremely significant
Group B 34.682 6.105 50.727 5.496 <0.0001 Extremely significant
p value (Pre-Pre) and (Post-Post) 0.5340 0.0001
Inference Not Significant Extremely Significant

Discussion injury, and developmental disorder leads to considerable

degeneration in productivity and quality of life. Normal
Eye-hand coordination is central to so many human
eye-hand coordination involves the synergistic function
activities –the tool used eating, sports and work, to name
of several sensory-motor systems including visual,
few as to be defining characteristics of typical human life,
vestibular system proprioception and the eye heads
conversely, its disruption following the stroke, disease,
and arm control systems, plus aspects of cognition-
206 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
like attention and, memory(6). Eye-Hand Coordination participated in the paper. These students were randomly
Plays an important role in daily activities of living divided into two groups as control and experimental
Eg-Eating Food, Drinking Water, Writing Activities, groups. An exercise program was applied to the
Turning a page etc. In Neurological impaired subjects experiment and control groups for approximately 3 days
during Rehabilitation usually, eye-hand coordination in 8 weeks, for about 45 to 60 minutes. Additionally, a
mostly gets un-noticed. The objectives of this study 20-minute modified proprioceptive balance program was
were to find the effect of eye-hand coordination device applied to the experimental group only. Paired sample
on coordination in subjects with in-coordination. To tests were used. As a result, significant differences were
find the effect of eye hand coordination device along found in the performance, reaction time and hand-eye
with conventional physiotherapy in improving eye- coordination performances of the experiment group,
hand coordination. To compare the effect of Eye-hand pretest, and posttest (p<0,05). Significant differences
coordination device and conventional physiotherapy were found in dominant hand visual reaction time and
in improving eye-hand coordination.The study was hand-eye coordination performances of the control
conducted with 44 subjects. Subjects were divided group, pretest, and posttest (p<0,05). In conclusion, it is
into two groups. Eye-Hand Coordination device along seen that proprioceptive training affect CAT performance
with Conventional physiotherapy (Group A) and and reaction time performances in a positive way.(8)
Conventional Physiotherapy (Group B). Prior consent
was taken. The treatment protocol was carried out for Conclusion
6 days per week for 5 weeks. The outcome measures The present study provided evidence to support
for this study were Non-equilibrium coordination test the use of eye –hand coordination device along with
grading and Fugl-Meyer Assessment-Upper Extremity conventional physiotherapy in improving NCT and
scoring system. The results of this study showed that FMA-UE scores in Subjects with in coordination.
there was a significant improvement in Coordination,
improving quality of life and reducing rehabilitation Conflict of Interest: The authors declare that there
time after 5 weeks of intervention in both the group A are no conflicts of interest concerning the content of the
and group B in Subjects with incoordination. Wilcoxon present study.
matched pairs test was used to analyze the effect eye-
hand coordination device and showed that there was Source of Funding: This study was funded by
extremely significant improving coordination in NCT Krishna institute of medical sciences Deemed to be
Grading score (p=0.0021) and FMT-UE (p=0.0001). University.

Researches have proved that there is improvement Ethical Clearance: The study was approved by the
hand pointing accuracy. A Study Done and they showed Institutional ethics committee of Krishna institute of
that the accuracy of pointing motion of the hand, directed medical sciences Deemed to be University, Karad.
at visual acuity 10° to 40° from the centre, was measured
in normal subjects. No visual feedback from the moving
References
hand was available to the participants. The head could 1. Vidoni, E. D.; McCarley, J. S.; Edwards, J. D.;
be either maintained still (head-fixed condition) or Boyd, L. A. (2009). “Manual and oculomotor
free to move (head-free condition) during the pointing performance develop contemporaneously but
movements. It was found that the error in pointing was independently during continuous tracking”.
reduced for all targets in the head-free condition. This Experimental Brain Research. 195 (4): 611–620.
reduction was more important for the more eccentric Doi: 10.1007/s00221-009-1833-2.
target (40°). Improvement in accuracy was observed 2. A review of five tests to identify motor coordination
without any significant change in either the latency difficulties in young adults by Research in
or the duration of eye, head or hand movements(7). developmental disabilities 41-42C:40-51 • June
Another Study showed that Examining the Effects of 2015
Proprioceptive Training on Coincidence Anticipation
3. Hand-eye coordination by b Ball, Morven F.
Timing, Reaction Time and Hand-Eye Coordination The
Developmental Coordination Disorder: Hints and
study stated that the effects of proprioceptive training
Tips for the Activities of Daily Living. Philadelphia:
on coinciding anticipation timing (CAT), reaction
Jessica Kingsley Publishers, 2002.
time and hand-eye coordination. 42 volunteer students
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 207
4. Acquired Brain InjuryAn Integrative Neuro- 13. Vision Therapy for Children and Adults, Dr.
RehabilitationApproach Jean Elbaum Deborah M. Michael Gallaway
Benson 14. Lee KY, Hui-Chan CW, Tsang WW.The effects
5. Physical Rehabilitation 5thEdition, Susan B. of practicing sitting Tai Chi on balance control
O’Sullivan, PT, EdD, Thomas J. Schmitz, PT, PhD and eye-hand coordination in the older adults: a
6. J.D Crawford, W.P Medendrop and JJ marotta randomized controlled trial. 2015;37(9):790-4.
Spatial transformation for eye hand coordinatiuon doi: 10.3109/09638288.2014.942003. Epub 2014
Journal of neurophysiology 92;10-19,2014;10.1152/ Jul 25.
jn. 00117.2004. 15. A review of five tests to identify motor coordination
7. B. Biguer, C. Prablanc, M. Jeannerod The difficulties in young adults by Research in
contribution of coordinated eye and head developmental disabilities 41-42C:40-51 June 2015
movements in hand pointing accuracy July 1984, 16. Bahill AT, Clark MR (1975) Glissades: eye
Volume 55, Issue 3, pp 462–469 movements generated by mismatched components
8. Halil İbrahim Ceylan and OzcanSaygin,Examining of the saccadic motoneuronal control signal. Math
the Effects of Proprioceptive Training on Biosci 26:303–318.
Coincidence Anticipation Timing, Reaction Time 17. Jenmalm P, Johansson RS (1997) Visual and
and Hand-Eye Coordination somatosensory information about object shape
9. Michael F. Land conducted a study on Eye control manipulative finger tip forces. J Neurosci
movements and the control of actions in everyday 17:4486–4499.
lifedoi: 10.3109/09638288.2014.942003. Epub 18. Liversedge SP, Findlay JM (2000) Saccadic eye
2014 Jul 25. movements and cognition. Trends Cognit Sci 4:
10. Jerry L. Griffith, Patricia Voloschin, Gerald 6‑14.
D. Gibb,On Differences In Eye-Hand Motor 19. Vickers JN (1992) Gaze control in putting.
Coordination Of Video-Game Users And Non- Perception 21:117–132.
Users 20. Smeets JB, Hayhoe MM, Ballard DH (1996)
11. Gomi, H. (2008). “Implicit online corrections Goal-directed arm movements change eye-head
in reaching movements”. Current Opinion in coordination. Exp Brain Res 109:434–440
Neurobiology. 18 (6): 558–564. doi:10.1016/j. 21. Land MF (1992) Predictable eye-head coordination
conb.2008.11.002 during driving. Nature 359:318–320
12. Optic Ataxia: A Specific Disorder in Visuomotor
Coordination Chapter • January 1983 with 10
Reads DOI: 10.1007/978-1-4612-5488-1_17.
208 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Prevalence of Depressive Symptoms among

Incognizant Patients Visiting a Hospital

A. Vinita Mary1, N. Manikandan2, K. Pavithra2, M. Nathiya2, R. Kesavan3

1AssociateProfessor, Department of Public Health Dentistry, 2Junior Resident, 3Associate Professor,
Department of Public Health Dentistry, Thai Moogambigai Dental College and Hospital

Abstract
This article depicts about depressive symptoms among patients visiting a hospital. Depression is the most
common mental illness among people in many parts of the world. A person who suffers from depression
experiences many symptoms which affects their day to day life to study the contributing factors associated
with various levels of depression, a survey was conducted among patients visiting a private dental college
at Chennai, Tamil Nadu. Convenience sampling technique was used for the survey. The patients were
categorised according to their age, gender, education and employment status. Socio-economic status of
the family head was also assessed in the survey. Marital status of an individual and any medical problems
presented was also interviewed in the questionnaire. A list of PHQ-9 questionnaire was used to assess the
associating factors among various level of depression.

Keywords: Depression, patients, socio-economic status, prevalence, mental health.

Introduction by members of the family and well-wishers at an

early stage, particularly mild to moderate depression,
World health organization quoted that more than
is often challenging[1]. The person with depression
322 million people are suffering from depression[1]. In
will experience loss of interest, less energy, poor
India, it has been reported that 57% million people i.e.
concentration, disturbed sleep and appetite. According
18% of global estimate, are affected by depression[1].
to the severity of depression, it is categorized as mild,
Depression is the most common and significant mental
moderate and severe[3]. Depression leads to increased
health disorder[2].
irritability, less activity,less attentiveness and fewer
Depending upon the age and sociocultural facial expressions. The most serious effect of depression
system, depression manifests in different ways and is a suicide attempt or completion [4]. Depressed patient
varied presentation. Due to this varied presentation of usually requires 4-9 months of regular psychiatric
subjects with depression, the recognition of depression consultation and antidepressant therapy.

Thus, considerable attention must be raised

regarding detection of depression, as this can limit the
impact of depression on the population. The assessment
Corresponding Author: of severity of depression is additionally necessary for
Dr. A. Vinita Mary proper guidance and treatment planning.[6] There are
Associate Professor, Department of Public Health many approaches to detect depression, one of them is
Dentistry, Thai Moogambigai Dental College and using a questionnaire like Generalized Anxiety Disorder
Hospital 7-item (GAD-7), Patient health questionnaire 2-items
Address: Thai Moogambigai Dental College (PHQ-2) and Patient health questionnaire 15-items
and hospital, Golden George Nagar, Mugappair, (PHQ-15) [8]. Patients health questionnaire (PHQ 9)
Chennai-600107 depression Screener was derived from the Diagnostic
e-mail: [email protected] and Statistical Manual of Mental Disorders, 4th Edition
Phone Number: +919486135017 (DSM IV) [9]. PHQ -9 questionnaires have been widely
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 209
used among various populations e. g. in a study by Zakiya There was a relation between the severity of
Al-Busaidi et al [9] it’s been used by Oman university for depression and the socioeconomic status. Five of the
Prevalence of Depressive Symptoms among university upper-class participants scored above 11 whereas 1 of
students,and also by Roger Muñoz-Navarro et al [8], in a them scored above 20. In the upper middle class, 3 scored
Spanish primary care Centre to identify major depressive more than 20. Sixteen of the middle-class participants
disorder in adult patients. scored more than 11, but none of them scored more than
20. On the other hand, none of the lower middle class
Within the above-mentioned background, studies participants scored more than 11. In lower class patients
are needed to explore the significance and the associated only one of them scored more than 20. The average
factors contributing to emotional disorder among the depression score was found to be 5.7(SD=4.3) and the
population. The aim of this study was to explore whether median score was 5.0. thus, the severity of depression
depression is endorsed among patients visiting a dental was related to the socioeconomic status of the patient.
college for dental problems. The study also aimed to
explore the association between depression,gender and Table 1: Characteristics of the Patients
socioeconomic status.
Patient Characteristics Percentage%
Materials and Method Mean Age ± SD 34 ± 11
Male 45%
A cross sectional study was conducted among Gender
Female 55%
patients visiting a private dental college at Chennai,
Single 29%
Tamil Nadu for two months; from October to November
Marital Status Married 69%
2018. The questionnaire asked focused on the attitude
Divorced 1.2%
and behaviour of the participants towards the activities
Illiterate 7%
that they normally performed over the past couple of
days. Convenience sampling technique was used and Primary school 9%
consecutive patients were interviewed. Individuals who Middle school 10%
refused to participate were excluded. The purpose and Education High school 11%
need of the study were explained and informed consent Higher secondary 12%
was obtained from the participants. A total of 500 Graduate 47%
individuals were interviewed. The collected data was Post graduate 4%
kept confidential. No diagnosed
90%
medical conditions
Statistical Analysis: The collected data was Asthma 0.8%
analyzed using SPSS version 21.0. For comparing Medical Conditions Diabetics 2.2%
percentages of demographic variables, Pearson’s Chi Hypertension 6%
square test was used. Thyroid 0.8%
Psoriasis 0.2%
Results
Present 12.4%
Habits of Smoking
A total of 500 patients (226 males and 274 females) Absent 87.6%
participated in the study. The average age of the patients Present 21%
Habits of Alcohol
was 34 ± 11 years. Nearly a quarter of the participants Absent 79%
were single,147 and the rest,347 were married (Table 1). Socioeconomic Status
The prevalence of depression by severity according to Class I 4.4%
demographic characteristics of the participants is given Class II 38.4%
in Table 2. Among the study population, 433 individuals Class III 34.2%
scored <10 and the rest, 67 individuals had a depression Class IV 21.6%
score of >11.
CLASS V 1.4%
Among the genders, 10% of males and 16% of
The frequency and percentage of patients responding
females had various levels of depression and it was
to each question regarding depressive symptoms
statistically insignificant. (p-value =0.079).
experienced in the last two weeks were measured using
210 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
PHQ-9. Final consideration of depression scored that difficult to taking care of things at home. It was somewhat
only 5(1.0%) of the patients had experienced extreme difficult for 47(9.4%) of patients. Four hundred thirty-
difficulty in getting along with other people and take three (86.6%) of patients did not experience any
care of things and 15(3.0%) patients had found it very difficulties from depression.

Table 2: Prevalence of depression by severity according to demographic characteristics of the patients

Severe Moderate Mild Normal

Total
Demographics Depresson Depression Depression Depression p- Value
Frequency
(Score ≥20) (%) (16-19) (%) (11-15) (%) (Score≤10) (%)
Male 3(1%) 7(3%) 13(6%) 203(89%) 226
Gender 0.079
Female 2(1%) 8(3%) 34(12%) 230(84%) 274
Class I 1(5%) 2(9%) 3(14%) 16(73%) 22
Socio- Class II 3(2%) 7(4%) 15(8%) 167(87%) 192
Economic Class III 0(0%) 4(2%) 12(7%) 155(91%) 171 0.000
Status Class IV 0(0%) 1(1%) 15(14%) 92(85%) 108
Class V 1(14%) 1(14%) 2(29%) 3(43%) 7
Illiterate 1(3%) 1(3%) 6(18%) 25(76%) 33
Primary School 0(0%) 1(2%) 4(9%) 38(88%) 43
Middle School 0(0%) 0(0%) 2(4%) 49(96%) 51
High School 0(0%) 0(0%) 5(9%) 48(91%) 53
Education 0.122
Higher Secondary
0(0%) 3(5%) 11(18%) 47(77%) 61
School
Graduate 3(1%) 8(3%) 18(8%) 207(88%) 236
Post Graduate 1(4%) 2(9%) 1(4%) 19(82%) 23
Single 2(1%) 7(5%) 16(1%) 122(83%) 147
Marital
Married 2(1%) 7(2%) 31(9%) 307(88%) 347 0.001
Status
Divorced 1(17%) 1(17%) 0(0%) 4(66%) 6
Total 5 15 47 433 500

It was seen that, socio-economic status had experience trouble concentrating on television and
statistically significant association with depression as in newspaper. Eighty-two (16.2%) of patients reported
class V.57% had various levels of depression. The level suicidal thought and 13(2.6%) have experienced it on
of education did not have any significant association with nearly daily. It was seen that only 31.4% never felt
levels of depression. Marital status of population had down or depressed or hopeless while at rest 75.8% felt
statistically significant association level of depression these symptoms at various period of time. Also 63% had
with 34% among the divorced being depressed in various troubled sleep patterns and felt tired. And 3.8% of the
levels (Table 2). study population, felt bad about themselves or felt they
were a failure and had let their family down. About a
The frequency and percentage of patients’ response quarter 23.8% had suicidal thoughts. When the subjects
to PHQ-9 and their experience of depressive symptoms were asked about the effect of depression on their day to
in the last two weeks was compared. It was observed day activity, it was seen that it was somewhat difficult
that 160(32%) of patient reported the symptoms of for 45.2%: very difficult for 9.8% and extremely difficult
little interest in doing things. 262(52.4%) felt down and for 3.2% of the study population.
203(40.6%) reported trouble falling or staying asleep
or sleeping too much several days a week. Feeling bad Discussion
about failure and letting their family down was the most
common symptom reported on nearly daily basis by Depression is common disorder among all ages,
19(3. 8%). On nearly daily basis, 12(2.4%) of patients gender and different socioeconomic groups.[1] In India,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 211
the lifetime prevalence of depression among individuals Conclusion
is 5.25%[1] for individuals of and above 18 years. In
This is the first study to assess the PHQ-9 to
the present study,for adults, a PHQ-9 score of 10 or
obtain the optimal cut-off values for screening patients
higher was used to identify patients with depression [3].
with depression visiting private dental hospital. The
According to Laura et al[5] patients who score more than
findings presented in this study indicate that the PHQ-
11 can be considered to be depressed.
9 is a valuable tool to help to identify suspected cases
Four hundred thirty three individuals scored <10 and of depression among patients. Based on our results, in
were graded as without depression and 67 individuals this population we recommend using a cut-off value of
had a depression score of >11 and were graded as having 11 instead of the most common cut-off value of 10. We
mild to severe depression. In the present study, 16% of also found that depression is common in patients visiting
females suffered from depression which is similar to the dental hospital with preponderance among females.
study done by Giora Kaplan et al (2010).
Ethical Clearance: Not Applicable.
Fifty seven percent of study population who have
Source of Funding: Self.
Class V Socio-economic status i.e. low socio-economic
class had with various levels of depression which is Conflict of Interest: Nil.
similar to the study by Zimmerman FJ, et al (2005).
Low financial support and poor nutrition might have References
been the origin of depression in those people. About one
1. Depression and Other Common Mental Disorders:
third 34%, who were divorced suffered from various
Global Health Estimates. Geneva: World Health
level of depression which is also reported by Jang SN,
Organization; 2017. Licence: CC BY-NC-SA 3.0
et al (2009). Dissolution in the marriage life caused
IGO.
loneliness, betrayal of trust and loss of moral support
which resulted in depression in one’s life. Also 63% of 2. Kaplan G, Glasser S, Murad H, Atamna A, Alpert
subjects had troubled sleep patterns was also analysed by G, Goldbourt U, Kalter-Leibovici O. Depression
Lund HG, et al (2010). People who were over thinking among Arabs and Jews in Israel: a population-
and anxious about day - to - day life experienced trouble based study. Social Psychiatry and Psychiatric
in sleeping. This over thinking sometimes leads to Epidemiology. 2010 Oct 1;45(10):931-9.
nightmares which affected the sleeping pattern. Around 3. Keller MB, Kocsis JH, Thase ME, Gelenberg
3.8% of study population felt that they were a failure AJ, Rush AJ, Koran L, Schatzberg A, Russell
nearly every day which is also discussed by Bennet DS, J, Hirschfeld R, Klein D, McCullough JP.
et al (2005). Insecurities in one’s life posed a negative Maintenance phase efficacy of sertraline for chronic
feeling about themselves and made them to think they depression: a randomized controlled trial. Jama.
were a failure almost every day of their life. 1998 Nov 18;280(19):1665-72.
4. Löwe B, Unützer J, Callahan CM, Perkins AJ,
Among the study population, 23.8% reported that
Kroenke K. Monitoring depression treatment
they have suicidal thoughts which is similar to study
outcomes with the patient health questionnaire-9.
done by Hawton K, et al (2012). Loneliness, the pain
Medical care. 2004 Dec 1:1194-201.
of existence became unbearable to the people who were
in depression. Thus people had a thought of harming 5. Richardson LP, McCauley E, Grossman DC,
themselves. McCarty CA, Richards J, Russo JE, Rockhill
C, Katon W. Evaluation of the Patient Health
Among the study population, 63% of people felt Questionnaire-9 Item for detecting major depression
tiredness or little energy at various period of time which among adolescents. Pediatrics. 2010 Oct 26: peds-
is discussed by Balsis S, et al (2008). Fatigue can affect 2010.
people emotionally and physically. Depressed people 6. Kroenke K, Spitzer RL, Williams JB. The PHQ‐9:
felt tiredness or less energy because their body is battling validity of a brief depression severity measure.
against them both physically and psychologically. Journal of general internal medicine. 2001
Sep;16(9):606-13.
212 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
7. Spitzer RL, Kroenke K, Williams JB, Patient 12. Zimmerman FJ, Katon W. Socioeconomic status,
Health Questionnaire Primary Care Study Group. depression disparities, and financial strain: what
Validation and utility of a self-report version of lies behind the income‐depression relationship?
PRIME-MD: the PHQ primary care study. Jama. Health economics. 2005 Dec;14(12):1197-215.
1999 Nov 10;282(18):1737-44. 13. Jang SN, Kawachi I, Chang J, Boo K, Shin HG, Lee
8. Muñoz-Navarro R, Cano-Vindel A, Medrano LA, H, Cho SI. Marital status, gender, and depression:
Schmitz F, Ruiz-Rodríguez P, Abellán-Maeso analysis of the baseline survey of the Korean
C, Font-Payeras MA, Hermosilla-Pasamar AM. Longitudinal Study of Ageing (KLoSA). Social
Utility of the PHQ-9 to identify major depressive science & medicine. 2009 Dec 1;69(11):1608-15.
disorder in adult patients in Spanish primary care 14. Lund HG, Reider BD, Whiting AB, Prichard JR.
centres. BMC psychiatry. 2017 Dec;17(1):291. Sleep patterns and predictors of disturbed sleep in
9. Al-Busaidi Z, Bhargava K, Al-Ismaily A, Al- a large population of college students. Journal of
Lawati H, Al-Kindi R, Al-Shafaee M, Al-Maniri adolescent health. 2010 Feb 1;46(2):124-32.
A. Prevalence of depressive symptoms among 15. Hawton K, Saunders KE, O’Connor RC. Self-harm
university students in Oman. Oman medical and suicide in adolescents. The Lancet. 2012 Jun
journal. 2011 Jul;26(4):235. 23;379(9834):2373-82.
10. Al-Ghafri G, Al-Sinawi H, Al-Muniri A, Dorvlo 16. Bennett DS, Ambrosini PJ, Kudes D, Metz C,
AS, Al-Farsi YM, Armstrong K, Al-Adawi S. Rabinovich H. Gender differences in adolescent
Prevalence of depressive symptoms as elicited depression: do symptoms differ for boys and girls?.
by Patient Health Questionnaire (PHQ-9) among Journal of affective disorders. 2005 Dec 1;89(1‑3):
medical trainees in Oman. Asian journal of 35-44.
psychiatry. 2014 Apr 1;8:59-62.
17. Balsis S, Cully JA. Comparing depression diagnostic
11. Mackenzie S, Wiegel JR, Mundt M, Brown D, symptoms across younger and older adults. Aging
Saewyc E, Heiligenstein E, Harahan B, Fleming and mental health. 2008 Nov 1;12(6):800-6.
M. Depression and suicide ideation among students
accessing campus health care. American journal of
orthopsychiatry. 2011 Jan;81(1):101-7.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 213

Intelligent System for Physically Challenged Person in

Virtual Prototype Environment

N. Prabhakaran1, N.D. Bobby2, M. Munireddy3, G.S. Sivapriya3

1Asst. Professor, 2Professor, 3Asst Professor, Department of ECE, Vel tech High Tech Dr. Rangarajan
Dr. Sakunthala Engineering College, Avadi, Chennai, India

Abstract
In this paper, a framework is fabricated to authorize the physically tested individual device for controlling
the needed thing like lighting the room, electrical gadgets with small power application used in an indoor
environment. The indoor application controls the wheelchair utilizing only a couple of fingers to do the
work effectively. The MEMS-based accelerometers sensor is designed without any pressure and makes the
device highly favorable to a physically challenged person. The accelerometers are the small gadget equipped
for distinguishing the quickening of the article to which they are appended in which the accelerometers are
connected to the fingers for a particular application. The individual, to whom the accelerometers are attached,
can assign the control gadget using the straight forward development tool of the fingers like tapping them
on the surface to do one particular application in indoor environment. So the novel system is designed and
implement for physically challenged person to operate both in indoor and outdoor environment.

Keyword: Wheelchair, Physically handicapped, MEMS, Gesture control.

Introduction innovation. The clinical aptitudes of restorative experts

depend entirely on the feeling of touch, joined with
Haptics is a late improvement to practical situations
anatomical and analytic learning [2]. Haptic environment
permitting clients to “touch” and “feel” the reproduced
produced perceptional properties and human haptic
objects with which they communicate. Haptics is the
recognition as a valuable tool to restorative examination.
investigation of touch. The word from the Greek word
The characterization of haptic data, and how it can
haptikos which signify “having the capacity to come into
see, is essential to understand how medicinal experts
contact with”. The investigation of haptics rose up out of
accomplish the haptics to empower learning and achieve
advances in virtual reality. Virtual the truth is a type of
the abnormal amount of execution of man power. Papers
human-PC connection (rather than console, mouse, and
which investigate haptic models of the patient, and
screen) giving a virtual situation that one can investigate
additionally perceptual or behavioral parts of the haptic
through direct cooperation with our faculties. They can
methodology are pertinent to therapeutic examinations
cooperate with a domain, and there must be criticism.
and strategies, are requested. Haptic frameworks and
For instance, the client ought to have the ability to
the role of haptics in preparing and assessing clinical
touch a practical question and feel a reaction from it.
abilities: Haptic test systems address a developing
This kind of criticism is called haptic input. In human-
requirement for successfully developing and assessment
PC collaboration, haptic criticism implies both material
of clinical attitudes [3]. Such test systems can connect a
and power feedback [1]. Haptics connects to an extensive
wide range assortment of restorative callings and ordering
variety of gadgets. In compelling the accuracy, surgical
the identity, including the surgery part, interventional
test system use haptics to give sensible power which
radiology for monitoring, are the new abilities. Papers
imitates the vibe range of proper therapeutic strategy
that location test system advancement and assessment
method. In forcing for the size of the input power, the
from these points of view are requested[4].
gamers can counter the authentification. Furthermore,
the first demonstration of the telephone is vibrating Background Work: MEMS are comprised of
when a call is important and straightforward type of segments between 1 to 100 micrometers in size (i.e.
214 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
0.001 to 0.1 mm), and MEMS gadgets covers a broad environment. The proposed block diagram consists of
range in size from 20 micrometers (20 millionths of two parts; the first part consists of transmitter section in
a meter) to a millimeter (i.e. 0.02 to 1.0 mm). This is which the information transmitted through a particular
often to comprise a focal unit which procedures the distance with MEMS sensor (micro electronics
information on microchip and a few segments that mechanical system). The mem sensor is controlled by
associate with all surroundings, for example, small-scale microcontroller through various action of disabled
sensors. At these size scales, the standard develops of person the output section is controlled. The information
established material science are not generally helpful[5]. is transmitted with antenna through only a small distance
Index finger course based robot is a machine that is the position of antenna alignment is controlled with a
controlled by a MEMS sensor through Radio recurrence particular frequency. The same frequency is controlled
innovation. The sensor which put on our index finger by receiver and demodulates the signal according to the
works when the heading of the finger changes. Limited input through which it takes the time delay and propagates
component investigations utilizing human finger model in the receiving end through which led buzzer and led
amid element touch demonstrated that spatial data of maintained. The relay is maintained o make the signal
the textured surface identified the transient recurrence low enough and characteristics signal is maintained
changes at the position of material receptors in the finger according to the input. So the wheel chair car controlled
print interface [6]. In touch sensor exercises, the people in the receiving end also. The proposed block diagram
can evaluate one by one by means of relative hand speed explains about the interferences which is mem sensor
between the surface texture and in the investigating both in the transmitting end and receiving end. Further
finger, of spatial period of the surface can be seen by mode the device is completely implement with low cost
integrating the transient recurrence of the vibration dynamic system and it takes advantages of reducing the
in sensor mode [7]. So that f=v/p printed on the sensor entire size of the hardware with low power dissipation
mode .In counterfeit touch it propagate the signal, factor. This system can be easy to carry anywhere both
while considering innovative methodologies in which indoor and outdoor environment to do particular work
mechanical detecting components inserted on skin-like and implement in any part of the world for physically
structure elastomeric grid on the surface that copy human handicapped person. The above-shown data are the block
skin penetration, such as vibrations analysis sought to diagram implemented in this paper. The entire system
be evoked by boost skin interface which releases the divided into two modules; they are the human interface
effect, by this movement elements are controlled, and by module and the robot interface module. Each one of this
contact mechanics the effect is evoked, and afterwards module s described below. The MEMS connected to
assembling and detecting the units are situated under the the microcontroller unit which given as a PDA to the
protecting material [8]. Stimuli are the responses, when physically challenged person. The MEMS placed on the
connected in mean level heads against the surface of the person for the gesture movements which converts the
skin tissue -like material of the clusters cells, which may signal level with respect to mean value. Each position
brought about a huge compelling noise of the sensor of the person holds the MEMS sensor for individual
node component with a unique mark sort surface than gesture analysis specified. When the person specifies his
that with a smooth surface [9]. A. MEMS Sensor Micro hand forward or backward or in any direction, that signal
electro mechanical frameworks (MEMS) (additionally received by the microcontroller and sent to the antenna.
composed as miniaturized scale electro-mechanical, The robot unit receives the signal obtained from the
Micro Electro Mechanical or microelectronic and antenna. This robot unit is nothing but a wheelchair
smaller scale electromechanical frameworks) is the unit. Two relays placed on two wheels which receive the
innovation of little gadgets; it converges at the Nano- input from the microcontroller. The microcontroller will
scale into Nano electromechanical structures (NEMS) give the direction to control the motors to move. This
and nanotechnology. MEMS likewise alluded to as micro direction purely based on the muscle movement of the
machines (in Japan), or Microsystems innovation–MST person which is indeed received by the MEMS placed
(in Europe) [10]. in them. At the point when the digit on the surface, the
movement of the finger identifies the accurate analysis
Material and Method and the same is utilized as a trigger sign to turn an
The figure 1 shows the proposed block diagram for electrical gadget on or off.
a physically challenged person both indoor and outdoor
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 215

Figure 1 Block Diagram of the Interface Controller for human system

The human machine interface provides a highly can be utilized to control besides gadgets. Subsequently,
visual device with low cost, comprehensive and intuitive the accelerometers are appended to the fingers of a man
design with low power and allow the system to operate which can use as a virtual keypad to control any device in
efficiently has designed by the designer. For outdoor indoor environment. Furthermore, the entire framework
environment that are very expensive and difficult to can be made smaller which gave to remote control
observe all the parameters visually. So the proposed gadgets for assembling on a separate sheet. However,
system is designed with low cost and low power system this framework can go about as a straightforward and
device. hazel free guide for the physically debilitated.

Result and Discussions

The figure 2 and figure 3 is implemented with mem
based accelerometer is proposed both in the transmitter
and receiver end and circuit diagram is also proposed.
The hardware device consists of power supply block,
microcontroller block, mems sensor and a camera to
visualize the entire object both in indoor and outdoor
environment. The power supply gives moderate 12.5v
to microcontroller mem sensor and camera. The
microcontroller revises the voltage and controls the
mem sensor and camera to operate the wheel chair
car for a physically handicap person. The device can
be applicable and implemented all types of physically
challenged person

The same trigger sign can use for controlling a

wheel seat’s development: a microcontroller unit and a
drive circuit used for controlling the gadgets. Numerous
fingers can use for some such particular reactions
from which various devices can control the internal
environment. Further, if the individual can control the
power of tapping the distinctive intensities of tapping Figure 2. Hardware for Proposed Circuit
216 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Figure 3: Circuit diagram for the proposed system

Conclusion International Journal of Systemics, Cybernetics,

and Informatics, vol. 49, pp. 64- 69, Apr2008
The intelligent assisting device designed and
implemented to assist the physically challenged people in 3. J. W. Morley, A. W. Goodwin and I. Darian-Smith,
satisfying their basic needs using MEMS accelerometer “Tactile Discrimination of Gratings,” Exp. Brain
sensor. This is accomplished using the physically Res., vol. 49, pp. 291- 299, 1983
challenged people who do not depend on others and they 4. L. A. Jones, and S. J. Lederman, “Tactile Sensing
are trained by themselves and 60% of their work aligned in Human Hand Function”, New York: Oxford
or motivated using self performance. In future, the same University Press, pp. 44-74, 2006
system can e developed in such a way that the height 5. A. Prevost, J. Scheibert, and G. Debregeas, “Effect
movements of the wheelchair can be adjusted. of fingerprint orientation on skin vibrations
during tactile exploration of textured surfaces”,
Conflict of Interest: There is no conflict of interest
Communicative & Integrative Biology, vol. 2, pp.
assigned in this research paper
1-3, Sept.-Oct.2009
Source of Funding: Self 6. C.M. Oddo, L. Beccai, M. Felder, F. Giovacchini,
and M. C.Carrozza, “Artificial Roughness Encoding
Ethical Clearance: The research work proves in
with a Bio-inspired MEMS Tactile Sensor Array
the novelty of the proposed action.
Sensors”, vol. 9, pp. 3161-3183, Apr. 2009
Reference 7. Calogero M. Oddo, Lucia Beccai, Giovanni
G Muscolo and Maria Chiara Carrozza, “A
1. Grigore C Burdea, “Haptic Issues in Virtual Biomimetic MEMS-based Tactile Sensor Array
Environment”, Proceedings of Computer Graphics with fingerprints integrated into a Robotic Fingertip
International2000, Geneva, Switzerland, pp. 295- Artificial Roughness Encoding”, Proceedings of
302, 19-24 Jun 2000 the IEEE International Conference on Robotics and
2. C. S Bagewadi and G M Lingaraju, “Manix3D: Biomimetics, pp 894-900, Dec.19-23, 2009
A3D tracking device with tactile feedback”,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 217
8. V. Maheshwari and R. F. Saraf, “Tactile devices o Conference on Robotics and Automation,
sense touch on apart with a human finger,” Angew Barcelona, pp. 2565-2570, 2005.
Chem. Int. Edit., vol. 47, pp. 7808–7826, 2008\ 10. J. Scheibert, S. Laurent, A. Prevost and G.
9. Y. Mukaibo, H. Shirado, M. Konyo and T Maeno, Debregeas, “The role of fingerprints in the coding
“Development of a texture sensor emulating the of tactile information probed with a biometric
tissue structure and perceptual mechanism of sensor,” Science, vol. 323, pp. 1503-1506, Jan.
human fingers,” In Proc. of the IEEE International 2009
218 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Health Insurance Utilisation Pattern in

Two Districts of Karnataka

Nagaraj Shet1, Ghulam Jeelani Qadiri2, Sunita Saldanha3, Gayathri Kanalli S.4, Prajna Sharma5
1Assistant
Medical Superintendent and Assistant Professor, 2Professor, 3Professor and HOD, Department of
Hospital Administration, Yenepoya Medical College Hospital, Deralakatte, Mangaluru, 4MBBS, 5Assistant
Professor, Department of Community Medicine, Kanachur Institute of Medical Sciences, Deralakatte, Mangaluru,
Karnataka, India

Abstract
Introduction: Health insurance is a widely recognized and preferable mechanism to finance the health care
expenditure of the individuals. It is an important mechanism in the modern world to save the individuals
from the huge health shock but only a small percentage of people even from educated higher income groups
are covered under any health insurance policy. This study was undertaken to know the pattern of health
insurance utilization in Uttar Kannada and Udupi districts of Karnataka.

Material and Methodology: A descriptive study was conducted among 550 household of Uttar Kannada
and Udupi districts. Household were selected using multistage sampling technique.

Results: Of the 550 study participants, 348 (63.27%) were aware and also subscribed for any type of the
health insurance and of these only 89 (25.57%) utilized them. 190 (34.55%) had availed Rashtriya Swasthya
Bima Yojana, 42 (7.64%) for Yashasvini, 6 (1.09%) for ESI, 12 (2.18%) for Sampoorna Suraksha and 15
(27.27%) had private insurances. Reasons for not availing health insurances other than being unaware were
complicated process 85 (42.08%) and provides only partial coverage 49 (24.26%). The main reasons for
not using the health insurance were non availability of empanelled hospital 84 (74.34%), disease not being
under the scope of scheme 60(23.17%) and 32 (12.36%) were unaware about the process of availing.

Conclusion: Health insurances being are the best way to help people reduce their financial burden has to be
made aware and the drawbacks have to be addressed.

Keywords: Health insurance, utilization, Udupi, Uttar Kannada.

Introduction ability to lead a socially and economically productive

life’ as defined by World Health Organisation (WHO).
Health is multi-dimensional and is ‘a state of
An understanding of health is the basis of all health
complete physical mental and social wellbeing and
care.1 In many countries health is a fundamental human
not merely an absence of disease or infirmity and the
right.2 The glaring contrast in the state of health between
the developed and developing countries, between rural
and urban areas and between the rich and poor have
attracted worldwide criticism as ‘social injustice’.
Corresponding Author:
The commitment of all countries, under the banner of
Dr. Prajna Sharma
WHO, is to wipe out the inequalities in distribution of
Department of Community Medicine, Kanachur health resources and services, and attain Sustainable
institute of Medical Science, Mangalore-575018, Development Goals.1
Karnataka, India
e-mail: [email protected] Socio-Economic development and health of
Phone: +91-8762907545 community cannot be achieved in isolation as they are
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 219
related with each other.3
Despite large improvements This study was undertaken to know the pattern of
in recent years, life expectancy in India still remains health insurance utilization in Uttar Kannada and Udupi
below than other countries following a similar pattern districts of Karnataka.
of development.2
Materials and Methodology
Health outcomes and service provision vary
significantly across different states, with only a few A community based descriptive study was
providing access to comprehensive basic healthcare conducted from June 2016 to August 2018 among 310
services to all.2 Various studies reveal that in India more study participants from Uttar Kannada and 240 study
than 80 percent of health care financing is mainly in the participants from Udupi, a total of 550 households.
form of out-of-pocket (OOP)3 often posing an enormous Households were selected randomly and those houses
burden on underprivileged households. The costs are which were locked at the time of visit and those who
frequently high enough that households are unable to did not give consent to participate in the study were
recuperate them from existing resources.4 excluded Multistage sampling technique used to collect
the sample for the study.
Human life is unpredictable and in case of
emergency health situations, health insurance can make The pre-designed and pre-tested proforma was used
it safe and secure from bearing huge financial loss and to collect information on socio-demographic profile and
decreasing economic burden on the family members.5 health insurance utilization of the study participants. Data
Health insurance is a widely recognized and preferable collected were entered in Microsoft Excel and analysis
mechanism to finance the health care expenditure of the was carried out with the help of Statistical Package for
individuals.3 Social Sciences–20.0.1 (SPSS Statistics–20.0.1). Data
was presented using proportions and percentages.
The International Labour Organization defines
health insurance as “the reduction or elimination of the Results
uncertain risk of loss for the individual or household The study was conducted in few selected villages
by combining a larger number of similarly exposed in Uttar Kannada and Udupi districts. Of the 550 study
individuals or households who are included in a common participants, 310 were from Uttar Kannada and 240 were
fund that makes good the loss caused to any one from Udupi.
member”.5 Health insurance policy is a contract between
an insurance company and an individual and comes in Health insurance (HI) was availed by 185 (59.68%)
handy in case of severe emergencies.(6) These insurance in Uttar Kannada and by 163 (67.92%) in Udupi. Table
system works on the basic principle of ‘pooling of risks II and III shows the district wise distribution of study
of unexpected costs of persons falling ill and needing participants those who subscribed for health insurance
hospitalization by charging premium from a wider and those who used the health insurance respectively.
population base of the same community’.7

Table I: Distribution of study participants based on their awareness regarding health insurance.

Awareness Uttar Kannada, n (%) Udupi, n (%) Total, N (%)

Yes and subscribed for HI, 348 Utilized 42 (2.90) 47 (18.33) 89 (25.57)
(63.27%) Not utilised 143 (17.42) 116 (13.75) 259 (74.43)
Yes and not subscribed 71 (2.90) 44 (18.33) 115 (20.91)
No 54 (17.42) 33 (13.75) 87 (15.82)
Total 310 240 550
220 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table II: District wise distribution of study participants based on health insurance subscribed.

Health Insurances Availed Uttar Kannada, n (%) Udupi, n (%) Total, N (%)
RSBY 107 (57.84) 83 (50.92) 190 (54.59)
Yashasvini 23 (12.43) 19 (11.66) 42 (12.07)
ESI 2 (1.08) 4 (2.45) 6 (1.72)
Sampoornasuraksha 7 (3.78) 5 (3.07) 12 (3.45)
RSBY, Yashaswini 22 (11.89) 17 (10.43) 39 (11.21)
RSBY, ESI 1 (0.54) 6 (3.68) 7 (2.01)
Yashaswini, ESI 5 (2.7) 3 (1.84) 8 (2.3)
RSBY, Yashaswini, Sampoornasuraksha 6 (3.24) 4 (2.45) 10 (2.87)
Yashaswini, Sampoornasuraksha 1 (0.54) 2 (1.23) 3 (0.86)
RSBY, Sampoornasuraksha 1 (0.54) 12 (7.36) 13 (3.74)
Private insurances 7 (3.78) 8 (4.91) 15 (4.31)
Yashaswini, Private insurances 3 (1.62) 0 3 (0.86)
Total 185 163 348

Of the 185 study participants from Uttar Kannada premium payment in all the card holders was annually.
who availed health insurance, 162 (87.57%) paid a Whole family was covered in all those who had health
premium of less than Rs 500, 13 (7.03%) paid Rs 500- insurance. A coverage of Rs 25001-50000 was provided
1000 and 10 (5.40%) of them paid more than Rs 2000. In to 119 (64.32%) from Uttar Kannada and 104 (63.8%)
Udupi 142 (87.11%) paid <Rs 500, 13 (7.98%) paid Rs from Udupi and 66 (35.68%) from Uttar Kannada and 59
500-1000 and 8 (4.91%) paid > Rs 2000. Frequency of (36.2%) from Udupi were covered for more than 1 lakh.

Table III: Distribution of study participants based on the health insurance utilized.

Health insurance utilised Uttar Kannada, n (%) Udupi, n (%) Total, N (%)
RSBY 10 (23.81) 8 (17.02) 18 (20.22)
Yashasvini 15 (35.71) 9 (19.15) 24 (26.97)
ESI 5 (11.90) 6 (12.77) 11 (12.36)
Sampoornasuraksha 3 (7.14) 9 (19.15) 12 (13.48)
RSBY, Yashaswini 1 (2.38) 2 (4.26) 3 (3.37)
RSBY, ESI - - -
Yashaswini, ESI 2 (4.76) 2 (4.26) 4 (4.49)
RSBY, Yashaswini, Sampoornasuraksha - - -
Yashaswini, Sampoornasuraksha 1 (2.38) 1 (2.13) 2 (2.25)
RSBY, Sampoornasuraksha - 4 (8.51) 4 (4.49)
Private insurances 3 (7.14) 6 (12.77) 9 (10.11)
Yashaswini, Private insurances 2 (4.76) - 2 (2.25)
Total 42 47 89

Table IV: Reasons for not subscribing for HI and not utilizing the HI they availed.

Reasons for not availing (n=202)* Uttar Kannada, (n=125) (%) Udupi, (n=77) (%) Total, (N=202) (%)
Not aware 54 (43.2) 33 (42.86) 87 (43.07)
Process is complicated 51 (40.8) 25 (32.47) 85 (42.08)
Not interested as I can afford The cost of treatment 17 (5.6) 13 (16.88) 30 (14.85)
Most of the Health Insurance provides partial
30 (24) 19 (24.67) 49 (24.26)
coverage
It is not cashless 36 (28.8) 15 (19.48) 51 (25.24)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 221

Reasons for not using HI* Uttar Kannada, (n=143) (%) Udupi, (n=116) (%) Total, (N=257) (%)
Unaware about the process of availing 12 (8.39) 20 (17.24) 32 (12.45)
Lack of required documents 6 (4.19) 0 6 (2.33)
Maintained good health 5 (3.49) 32 (27.58) 37 (14.39)
Non availability of empanelled hospital 43 (30.07) 41 (35.34) 84 (32.68)
Health assurance scheme covered the expenses 13 (9.09) 12 (10.34) 25 (9.73)
Disease was not under the scope of scheme 29 (20.28) 31 (26.72) 60 (23.35)
Financial coverage limit of card was drained 0 2 (1.72) 2 (0.780)

*Multiple answers were given.

Two (1.23%) of them who had subscribed for and emergency services. Among the inpatient services
health insurance did not renew even after its validity most 190 (54.6%) of the health insurance covered only
was expired and the reason was high premium in both medical treatment and 114 (32.76%) of them covered
the cases. Facilities provided by the health insurance both medical and surgical treatment. Only 13 (3.74%)
is described in table V. Most 252 (72.41%) of the were free to choose the health care institution of their
health insurances provided inpatient services and travel choice.
allowance. Only few 21 (6.03%) provided outpatient

Table V: Distribution of study participants based on the facilities provided by the health insurance.

Facilities Uttar Kannada, n=185 (%) Udupi, n= 163 (%) Total, N= 348 (%)
In Patient Services 37 (20) 38 (23.31) 75 (21.55)
In Patient Services and travel allowance 140 (75.68) 112 (68.71) 252 (72.41)
Emergency Service, In Patient Services, Travel
8 (4.32) 13 (7.978) 21 (6.03)
allowance and daily allowance
IP Facilities
Medical Treatment 107 (57.84) 83 (50.92) 190 (54.6)
Medical Treatment, Surgery, Implants, Preventive
Measures, Ambulance service, Maternity/Delivery 56 (30.27) 58 (35.58) 114 (32.76)
services
Surgery, Implants, Preventive Measures,
22 (11.89) 22 (13.5) 44 (12.64)
Ambulance service, Maternity/Delivery services
Freedom to select health care institution
Yes 5 (2.70) 8 (4.91) 13 (3.74)
No 180 (97.3) 155 (95.09) 335 (96.26)

Most 34 (38.2%) them who had utilized health benefit. It was either partial coverage or reimbursement.
insurance utilized it only once. Five (11.91%) of them It can be seen that the health insurance which provided
from Uttar Kannada and 2 (4.26%) from Udupi utilized cashless benefits were utilized more.
it 5 times. Six of them who utilized never had cashless

Table VI: Distribution of study participants based on health insurance utilization and cash benefit.

Number of times heath insurance utilized Uttar Kannada, n=42 (%) Udupi, n=47 (%) Total, N=89(%)
1 17 (40.48) 17 (236.17) 34 (38.20)
2 15 (35.71) 14 (29.78) 29 (32.58)
3 4 (9.52) 12 (25.53) 16 (17.98)
4 1 (2.38) 2 (4.26) 3 (3.37)
5 5 (11.91) 2 (4.26) 7 (7.86)
222 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Number of times cashless method was provided

0 3 (7.14) 3 (6.38) 6 (6.74)
1 19 (42.24) 18 (38.30) 37 (41.57)
2 10 (23.81) 10 (21.28) 20 (22.47)
3 4 (9.52) 12 (25.53) 16 (17.98)
4 1 (2.38) 2 (4.26) 3 (3.37)
5 5 (11.91) 2 (4.26) 7 (7.87)
Number of times reimbursed
0 38(90.48) 45(95.74) 83 (93.26)
1 2 (4.76) 0 2 (2.25)
2 2 (4.76) 2 (4.26) 4 (4.94)

Discussion Conclusion
This cross sectional study was conducted among Even though more than half the study participants
550 households in Uttar Kannada and Udupi districts subscribed for health insurance, only quarter of those
to know their health insurance utilization pattern. This who subscribed utilized it. Major reason for this was
study showed that 20.91% of them did not avail for any not being aware about health insurances or the process
health insurance even if they were aware of it and also for utilization. This shows the gap in communication
only 25.57% of them who had health insurance utilized between the health personals and the general population.
it. This shows the deficiencies in the health insurances There are few more who even if they were aware did not
available. avail for any health insurance. The reasons being non
availability of empanelled hospital, limit of financial
In the present study health insurance was availed by coverage, the disease not covered and high premium.
59.68% in Uttar Kannada and by 67.92% in Udupi. In These drawbacks in the health insurances that are
another similar study done in rural areas of Bangalore available should be addressed as health insurances are
in 2015 among 399 study participants, 66.9% had health the best way to help people reduce their financial burden.
insurance coverage.8 A study done in St.John’s Medical
College, Bangalore in 2007 among 200 households Hence it is very important to educate the community
to study the awareness, prevalence and utilization of regarding the best health insurance available so that they
Health Insurance services it was seen that 47.5% of the can take the maximum benefits from it.
individuals were aware of health insurance, 42.5% had
availed for health insurance, of them 32.9% had utilized Declaration:
health insurance.9 Conflict of Interest: No
In the present study, 34.55% had availed Rashtriya Source of Funding: No
Swasthya Bima Yojana, 7.64% for Yashasvini, 1.09%
for ESI, 2.18% for Sampoorna Suraksha and 27.27% had Ethical Clearance: Taken from institutional ethical
private insurances. In a study in rural Bangalore 92.6% committee.
of the study participants were covered by Government
health insurance schemes and 7.4% had private health References
insurance schemes.2 In a another study conducted 1. Park J E. Park textbook of Preventive and Social
by Public Health Foundation of India, it was reported medicine. 25th ed. Jabalpur. M/s Banarsidas Bhanot;
that coverage of health insurance by Vajpayee Arogya 2019.
Shree scheme was 0.95 million families in Karnataka,
2. Gowda S, Chaitra M, Deepa K. Determinants
Rashtriya Swasthya Bhima Yojana covered 22.7 million
of health insurance in rural population of South
families across India, 55 million individuals were
India. Indian J Forensic and Community Med
covered by Yeshaswini scheme in Karnataka and 14.3
2015;2(3):172-5.
million families were covered by ESI scheme.10
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 223
3. Bawa SK, Ruchita. Awareness and Willingness to Nutrition and Population, The World Bank. 2001:
Pay for Health Insurance: An Empirical Study with 1-32.
Reference to Punjab India. International Journal of 8. Indumathi K, Hajira SI, Gopi A, Subramanian M.
Humanities and Social Science. 2011;1(7) : 100-8. Awareness of health insurance in a rural population
4. Mondal S, Kanjilal B, Peters DH, Lucas H. of Bangalore, India. Int J Med Sci Public Health
Catastrophic out-of-pocket payment for health 2016;5(11):1-6.
care and its impact on households: Experience 9. Goud BR Mangeshkar AJ, Soreng S, Prathima,
from West Bengal, India. Future Health Systems: Varghese NM, Deepthi R, Kumar MS et al.
Innovations for equity’. 2010: 1-21. Prevalence and factors affecting the utilisation
5. Ghosh M. Awareness and Willingness to Pay for of health insurance among families of rural
Health Insurance: A Study of Darjeeling District. Karnataka, India. Int J Curr Res Academic Rev
IOSR Journal Of Humanities And Social Science 2014;2(8):132‑7.
(IOSR-JHSS). 2013; 12(1): 41-47. 10. Reddy KS, Selvaraj S, Rao KD, Chokshi M, Kumar
6. Gowda S, Manjunath C, Krishna D. Awareness P, Arora V et al.et al. A critical assessment of the
about health insurance in rural population of existing health insurance models in India. Public
South India. Int J Community Med Public Health. health foundation of India. 2011: 26-28. Available
2015 Nov; 2(4):648-650. DOI: http://dx.doi. from: http://www.planningcommission.nic.in/
org/10.18203/2394-6040.ijcmph20151064 reports/sereport/ser/ser_heal1305.pdf. [Accessed
7. Gumber A. Hedging The Health of The Poor The on 19th September 2016].
Case for Community Financing in India. Health
224 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Study of Knowledge, Attitude and Practise (KAP) Regarding

Swachh Bharat Mission Among High School Students in
Field Practise Area of Medical College in
Dakshina Kannada, Karnataka

Nanjesh Kumar S.1, Jithin2, Harshitha2, Rashmi Kundapur3, Sanjeev Badiger4, Pavan Kumar5
1Associate
Professor, 2Postgraduate, 3Professor, 4Professor and HOD, 5Assistant Professor, Department of
Community Medicine, K.S. Hegde Medical Academy, NITTE Deemed to be University, Mangalore, Karnataka

Abstract
Background: India generates about 60 million tonnes of garbage every day, of this around 45 to 50 million
tonnes is left untreated. Wastes are thrown on the streets. Open defecation is still a problem in rural India.
All these actions cause health hazards among population.

Objective: To assess the knowledge, attitude and practices regarding Swachh Bharat among 8th to 10th
standard students.

Methodology: This cross-sectional study was carried out in seven government high schools in the field
practice area of a medical college in Mangalore. A total of 441 government high school students from 8th to
10th standard were included in the study. Collection of data was done by interview method using pretested
semi structured questionnaire.

Results: Total of 441 students were included in the study. 55.32% were boys and 44.68% were girls.
According to scoring done for students, 84.35% had good knowledge, 95.23% had good attitude but only
50.34% had good practice about environmental cleanliness and personal hygiene.

Conclusion: To improve the good practice various health educations and practical demonstrations about the
cleanliness and benefits of practicing them can be conducted as school-based initiatives to create awareness
among students.

Keywords: Knowledge, School students, Environment, Sanitation, Awareness, India.

Introduction 10 million tonnes waste daily. India’s sewage system is

among the poorest in the world. Wastes are thrown on
India generates about 60 million tonnes of garbage
the streets. Open defecation is still a problem in rural
every day, of this around 45 to 50 million tonnes is left
India. All these actions cause illness, makes the country
untreated. In 2040, Urban India alone would generate
sicker 1.

Government of India initiated the Central Rural

Sanitation Programme (CRSP) in 1986 primarily with
Correspondence Address: the objective of improving the quality of life of the
Dr. Nanjesh Kumar S. rural people and also to provide privacy and dignity to
Associate Professor, Flat G3, Sai-Paradise, Chilimbi, women. From 1999, a “demand driven” approach under
Urwa Store, Ashokanagara post, Mangalore575006, the “Total Sanitation Campaign” (TSC) emphasized
Karnataka, India more on Information, Education and Communication
e-mail: [email protected] (IEC), Human Resource Development (HRD), Capacity
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 225
Development activities to increase awareness among was considered as poor knowledge, 2-5 considered as
the rural masses and generation of demand for sanitary average knowledge and >5 as good knowledge. Attitude
facilities. Later “Nirmal Bharat Abhiyan” (NBA) was also scored, +1 was awarded for positive attitude
was launched on 1.4.2012 to accelerate the sanitation and 0 was awarded for negative attitude. Score less than
coverage in the rural areas. Under NBA, the incentives 0-2 was termed as poor attitude, 2-5 as average and
for IHHLs were increased and further focused support more than 5 was taken as good attitude. Practice was
was obtained from MNREGA. However, there were also scored the similar way. Inclusion criteria: All the
implementation difficulties in convergence of NBA with students between 8th to 10th standard who were willing
MNREGA as funding from different sources created to participate in the study were included. Exclusion
delays at the implementation mechanism. To accelerate criteria: Students who were absent during the time of
the efforts to achieve universal sanitation coverage and to study, were excluded from the study
put focus on sanitation, the Prime Minister of India Shri
Narendra Modi launched the Swachh Bharat Mission Results
on 2nd October, 2014. The Mission shall remove the Table 1: Socio-demographic distribution of the
difficulties that were hindering the progress, including study subjects (N=441)
partial funding for Individual Household Latrines from
MNREGS, and focusing on critical issues affecting Age No. of Students Percentage
outcomes. 2 13 133 30.3%
14 137 31.2%
Shri Narendra Modi urged people to denote 100
15 171 38.5%
hours every year towards cleanliness. Union Ministry of
Place of School
Rural Development and Drinking Water and Sanitation
Sashitulu 48 10.8%
announced 20 lakhs to be given to every village per year
Faringepete 48 10.8%
to achieve the goal of Swachh Bharat. 3
Hejmady 29 6.5%
School provides an excellent opportunity for Subramanya 65 14.7%
children to learn about healthy hygienic practices and Nitte 121 27.4%
also identified as powerful channel of communicating Bailur 100 22.6%
sanitation messages to homes and communities. Through Natekal 30 6.8%
our study we aim to assess the knowledge, attitude and Standard
practices of students about Swachh Bharat and educate 8th 128 29.04%
them in this regard. 9th 115 26.07%

METHODOLOGY: - This cross-sectional study 10th 198 44.89%

was carried out in seven government high schools in Sex
the field practice area of a medical college, in Dakshina Boys 244 55.32%
Kannada district, Karnataka. The study subjects were Girls 197 44.68%
selected by Cluster sampling method. A total of 441
Table 1 shows that majority of students were belongs
government high school students from 8th to 10th standard
to age 15. Boys (55.32%) were more than the Girls
were included in the study. The purpose of the study and
(44.68%). More students were belonging to Government
procedure were explained to the students in the local
high school (27.4%) of Nitte village.
language and oral informed consent was obtained from
them. Collection of data was done by interview method Table No.2 Knowledge and Attitude about Swachh
using pretested semi structured questionnaire which had Bharat Abhayan among study subjects
questions to assess the Knowledge, attitude and practice
amongst the students on Swachh Bharath Mission. Yes No
Do we require separate toilet for Boys
100% 0
Statistical analysis was done using SPSS software. and Girls in school
Data was expressed in tables and graphs. Knowledge Solid waste disposal should be taught in
87.98% 12.02%
was scored, +1 was given for the correct answer and 0 school
for the incorrect answer. Scoring was done. Score 0-2 Proper waste removal and disposal is
97.95% 2.05%
important
226 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Any member of household has heard from toilet mainly to drain pit (87.52%) followed by
90.02% 9.98%
about Swachh Bharat open drain (11.3%) and to river (1.2%).
Do you feel street should be clean and
94.78% 5.22% Table No 4 Scoring of the Study Subjects Under
free of solid waste
Does improper waste removal and Knowledge, Attitude And Practice in Swachh
90.02% 9.98%
disposal affect environment Bharat Abhayan
Is water made available for use in toilets 87.98% 12.02%
Poor Average Good
Soap is available in school toilets for Knowledge
57.59% 42.41% 0 69(15.64%) 372(84.35%)
washing hands
Does your household have a toilet 97.27 2.73% Poor Average Good
Attitude
Did any member of the household 0 21(4.76%) 420(95.23%)
defecate in the open in the last three 14.06% 85.94 Poor Average Good
months or after gaining access to toilet Practice
0 219(49.65%) 222(50.34%)
Is there any garbage or litter piled up
or dumped within 10 feet perimeter of Table four knowledge score was good in 84.35%
41.04% 58.96%
the house, outside the premises of the
and average among 15.64% of study subjects. Attitude
household being canvassed
was good in 95.23% and average among 4.76% of the
Does anyone go out and defecate in open
20.1% 79.9% study subjects. Practice was good in 50.34% and average
in your village
among 49.65% of study subjects responding to Swachh
In table two 57.59% of students told that soap Bharath Abhiyan.
was present in school toilet for washing hand. 41.04%
students told that Garbage disposal near the houses still Discussion
persist in their village. 20.1% students told open air
Total of 441 students were included in the study.
defection was still present in their village.
In that 55.32% were boys and 44.68% were girls with
Table No. 3 Practice of Swachh Bharat 30.3%, 31.2% and 38.5% belonging to age group of 13,
Abhayanamong study subjects 14 and 15 years respectively.

Yes No 97.27% said their household had a toilet but only

Washing hands with 87.98% had water available in the toilet due to limited
80.72% 19.28% supply of water with majority of them stating that human
soap after defecation
Use of dustbin at school waste was disposed in drain pits rather than river or
89.56% 10.44%
for dumping waste open drain indicating unsanitary practices and they were
Use of Toilet in the
97.27 2.73%
educated regarding proper waste disposal. All of them
household agreed that the schools had separate toilets for boys and
Availability of the water girl which were kept clean.
92.06 7.94%
in/for the toilet
Do the family members In the present study 80.72% of the subjects use
segregation of waste as 53.96% 46.04% soap for washing hands after defecation and97.27% of
dry waste and wet waste
subjects use toilet for defection. Study done by Swain
Place of dumping the Dustbin Compost Other P et al showed that only 54% of the individuals were
food waste at school 71.42% 28.11% 0.47% defecating in the toilets and 8% of the respondents didn’t
Drain pit River
Open wash their hands after defecation.4
Site of human waste Drain
disposal from the toilet
87.52% 1.2% 11.3% Hand washing after defecation with soap was
practiced by 80.72% of students which was way higher
In table three 80.72% of the subjects use soap for than a study conducted by Shrestha A et al among
washing hands after defecation and 89.56% of subjects primary school going children of urban Karnataka.5
use dustbin to dumping waste in school. 97.27% of
subjects use toilet for defection. 53.96% of subjects 20.1% students noticed that residents from their area
told that the family segregate the waste into dry and wet practiced open defecation and most of them had family
separately. 71.42% subjects dump the food waste in dust member who still continues the same even after gaining
bin and 28.11% into composting. Human waste disposal access to toilet because of their developed as routine
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 227
and unawareness about its effect on their health and environmental or personal and benefits of practicing
environment. them can be conducted as school-based initiatives to
create awareness among students.
Majority of them thought proper waste disposal
is important in the house but only 53.96% practiced Conflict of Interest: Nil
segregation of waste as they had lack of knowledge and
87.98% asked for education on the subject in schools. Source Of Funding: Nil
For general waste disposal, 89.56% of them used dustbin Ethical Clearance: Taken
in school for dumping and only 28.11% used compost
for food waste and we educated them the benefits of References
compost over dustbins.
1. Pradhan P. Swachh Bharat Abhiyan and the
Almost all of them (99.3%) have good perception Indian Media. Journal of Content, Community &
of the cleanliness of their school compound but 41.05% Communication Amity School of Communication.
noticed garbage near their houses and opinionated that 2017;(5),2395-7514.
it should be cleaned as improper waste disposal affects 2. De, Singh LC, Suman Thapa DR and Gurun. Swachh
the environment. This shows their knowledge towards Bharat Abhiyan-an overview. International Journal
Swachh Bharat and their willingness to take initiatives of Information Research and Review 2016;11(3):
for the same. Study conducted by Tiwari S K showed 3066-73.
that all students were aware of the mission Swachh
3. Chaudary A. Swachh Bharat Mission-Need,
Bharat: Swachh Vidyalaya and the level of awareness of
Objective and Impact. International Journal for
the students from public school and private schools was
research in Management and Pharmacy. 2017;6,
equally good.6
2320-0901.
Knowledge about the Swachh Bharat Abhayan in 4. Swain P, Pathela S. Status of sanitation and
the household of these students was about 90.02% which hygiene practices in the context of “Swachh Bharat
shows the effectiveness of various means promoting Abhiyan” in two districts of India. International
this mission. According to scoring done for students, Journal of Community Medicine and Public Health
84.35% had good knowledge, 95.23% had good attitude 2016 Nov; 3(11):3140-3146
but only 50.34% had good practice about environmental 5. Shrestha A, Angolkar M. Impact of Health Education
cleanliness and personal hygiene which was either due to on the Knowledge and Practice Regarding Personal
their acclimatization to existing old habits and mindset. Hygiene among Primary School Children in Urban
Area of Karnataka, India. IOSR J Dental and
Conclusion Medical Sciences. 2014;13(4):86-9.
The study conducted showed that study subjects 6. Tiwari SK. To study awareness of a national
had good knowledge and good attitude towards mission: Swachh Bharat: Swachh Vidyalaya in the
Swachh Bharat Abhayan but a lack of practice was middle school students of private and public schools.
seen among them. So, various health educations and Indian Journal of Research 2014 Dec;3(12):23-24.
practical demonstrations about the cleanliness whether
228 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Association of Personality Traits, Life Satisfaction, Subjective

Happiness and Oral Health Status in
School Teachers of Vikarabad

N. Sindhu Reddy1, M. Monica2, T. Abhinav Nithin3,

P. Parthasarathi Reddy4, Irram Abbas Hameed5, B. Prathibha5
1Post
Graduate, 2Professor, 3Senior Lecturer, 4Professor and Head, 5Reader,
Department of Public Health Dentistry, Sri Sai College of Dental Surgery, Vikarabad

Abstract
Background: To determine the association between personality traits, life satisfaction, subjective happiness
and oral health status in school teachers of Vikarabad.

Material and Method: A cross sectional study was conducted among 400 private and government
school teachers of Vikarabad. A validated questionnaire was used (BFI)-10 to measure personality traits,
life satisfaction and subjective happiness. Clinical examination was done to measure DMFT and OHI-S.
Collected data was subjected to statistical analysis. Spearman’s Correlation and multiple regression analysis
was done.

Results: Among the teachers 13% were males and 87% were females and their mean age was 30 years. 57%
had high and 43% had low levels of extraversion, 55% had high and 45% had low levels of agreeableness in
their personality. The mean DMFT score was 1.12 ± 1.41 and mean OHI-S score was 1.71 ± 1.06.

Conclusion: A significant association was observed between personality traits and satisfaction in life
of teachers with their oral health. Satisfaction with life will improve the quality of life and wellbeing of
individuals.

Keywords: Personality traits, School teachers, subjective happiness, life satisfaction, dental caries, oral
hygiene.

Introduction term “well-being” is frequently used in literature to

mean happiness. However, well being is commonly
Oral diseases are a significant public health burden
used in relation to physical factors and happiness
in India as well as across the globe. The consequences of
used in relation to mental factors.[3] Happiness is a
widespread poor oral health can be seen at the personal,
multidimensional construct comprising both emotional
population, and health systems level.[1] According to
and cognitive domains, and has been defined as ‘the
previous research,good oral health is independently
degree to which an individual judges the overall
associated with greater subjective well-being.[2] The
quality of his or her life favorably as a whole’.Several
factors which affect happiness of a person like income,
job satisfaction, community values, health, family
experience, education, sleep habits, personality based
Corresponding Author:
traits and life satisfaction[4]
Dr. Navari. Sindhu Reddy
Plot No. 93, Street No. 6, Sri Venkateshwara Enclave, Life Satisfaction (LS) has been conceptualized
Upperpally, Hyderabad, Rangareddy-500028 as a cognitive constituent of subjective well-being.
e-mail: [email protected] High satisfaction suggests that the quality of life, in
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 229
the population concerned, is good. Low satisfaction included. Teachers who have migrated to work place
on the other hand marks serious shortcomings of some from other population were excluded. Questionnaire
kind. Research has suggested that stress, depression recorded socio-demographic factors and questions about
and ineffective coping may contribute to development sleep quality, smoking status, physical activity and
of periodontal diseases and dental caries. Dental caries self reporting of their general health status. Standard
and periodontal diseases are the two major oral diseases, questionnaires were used for measuring the personality
which are universal in distribution and constitute the traits (BFI-10)[11], Life Satisfaction Scale (LSS)[12], and
primary reason for tooth mortality. Particular personality Subjective Happiness Scale (SHS)[13]. Both Telugu and
types of people are more prone to ineffective coping with English questionnaires were used in the present study.
stress, depression and hence may affect their carious The content validity and the internal consistency was
experience. Personality Traits (PT) of an individual found to be good (Cronbach‟s alpha = 0.78).The oral
reflect people’s characteristic patterns of thoughts, health status of the subjects was recorded using WHO
feelings, and behaviors. People with different PT tend to Oral Health Proforma 1997 [14] for recording the dentition
experience different degrees of subjective well-being.[5,6] status and Oral Hygiene Index Simplified (OHI-S).
Collected data was subjected to statistical analysis using
Meshram et al[8] suggest that there exists no co- SPSS version 20. Outcome variables DMFT and OHI-S
relation between various personality traits and associated were associated with the independent variables like PT,
oral health status. Tuchtenhagenet al [4] concluded LS and SH. Spearman’s correlation and linear regression
that oral conditions like dental caries is influenced by analysis was done to know the overall association of the
happiness of school children. In a study conducted outcome variables on all the independent variables.
by Dumitrescu et al[10] life satisfaction and subjective
happiness indicators seemed to be associated with self- Results
reported oral health status and behavior.
In this study total male teachers were 13% and
In today’s global world, workers like public and females were 87% with a mean age of 35.11±10.21. 48%
private school teachers are put under a lot of stress were government and 52% were private school teachers.
which influences their psychological well-being. They 20% of teachers had trouble in night sleeping and 80%
feel burned-out, unhappy, dull, or unsatisfied because of of teachers were satisfied with their night sleep. About,
factors such as high teacher-student ratio, inconvenient 35% had regular daily physical activity. 88% of subjects
or inefficient physical school conditions and low reported their general health was satisfactory. 57% of
salaries.[11] There exists, no literature about oral health teachers were subjectively happy. 70% were satisfied
and its association with factors like PT, Subjective in their life, 7% were neutral and 23% were dissatisfied
Happiness (ST) and LS in this population. Hence, with their life.
the present study was carried out with an objective to
determine the association of the personality traits, life Table 1 shows, mean DMFT score was 1.12 ± 1.41.
satisfaction and happiness with oral health among school Mean OHI-S score was 1.71 ± 1.06. Table 2 shows
teachers of Vikarabad district. among PT 57% had high and 43% had low levels of
extraversion (E), 55% had high and 45% had low levels
Methodology of agreeableness (A), 59% had high and 41% had low
levels of conscientiousness (C), 51% had high and 49%
A cross sectional epidemiological study was had low levels of neuroticism (N), 63% of teachers had
conducted among school teachers in various government high and 37% had low levels of openness (O). Table 3,
and private schools in Vikarabad District, Telangana. shows PT like extraversion, agreeableness, neuroticism,
India. A pilot study was carried out to test the feasibility openness and SH was weak and positively correlated
of the study and understanding of the questionnaire. With DMFT score. C and LS is negatively correlated with the
an estimation of 80% power of study, alpha error of 5%, DMFT score.
and assuming the prevalence of dental diseases as 50%,
sample size was estimated at 384,which was rounded Table 4, 5 shows sleep quality determining the
to 400. Permissionto conduct the study was obtained trouble in falling asleep (p= 0.003*), general health
from DEO of district. School principals who granted status (p= 0.028*), physical activity (p= 0.022*), PT
permission and teachers willing to participate were like neuroticism (p= 0.047*), openness (p= 0.007*),
230 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
LS (p= 0.016*) and subjective happiness (p= 0.032*) Respondents
showed significant association with the DMFT scores. Factor Categories
n %
Gender (p=0.001*), marital status (p=0.013*), type of Good 187 47%
school (p=0.038*) and extraversion (p=0.021*) showed OHI-S Score Fair 184 46%
significant association with the OHI-S scores in multiple
Poor 29 7%
regression analysis.
Table 2: Distribution of personality traits among the
Table 1: Distribution of oral health status among
study subjects
the study subjects
Personality Traits High Low
Respondents
Factor Categories Extraversion 57% 43%
n %
Agreeableness 55% 45%
0 191 48%
Conscientiousness 59% 41%
DMFT Score 1-3 179 41%
Neuroticism 51% 49%
≥4 42 11%
Openness 63% 47%

Table 3: Showing correlations between Personality traits, Life satisfaction, Subjective happiness with the
oral health factors DMFT and OHI-S

DMFT E A C N O LSS SHS

(r) 1 .002 .037 -.097 .112* .083 -.143** .093
DMFT
Sig. (2-tailed) .964 .463 .053 .025 .098 .004 .063
(r) 1 .009 -.011 .006 .036 .036 -.111* .035
OHI-S Sig. (2-tailed) .850 .821 .901 .478 .476 .027 .484
N 400 400 400 400 400 400 400 400

**.Correlation is significant at the 0.01 level (2-tailed)., *.Correlation is significant at the 0.05 level (2-tailed).
Table 4: Linear regression model of outcome variable DMFT

Dependent Variable: Unstandardized Coefficients Standardized Coefficients

P value
DMFT B Std. Error Beta
(Constant) -1.110 .990 .263
Age .012 .007 .090 .075
Gender .175 .157 .057 .266
Type of School .012 .164 .004 .941
Education -.290 .163 -.095 .076
Maritalstatus -.005 .169 -.001 .977
Sleep Quality -.549 .183 -.163 .003*
Sleep trouble -.029 .186 -.008 .874
Physical activity .348 .152 .118 .022*
General health .154 .070 .115 .028*
Extraversion .073 .047 .080 .120
Agreeableness .029 .039 .037 .456
Conscientiousness -.021 .044 -.025 .630
Neuroticism .076 .038 .105 .047*
Openness .121 .045 .134 .007*
LSS -.113 .047 -.129 .016*
SHS .149 .069 .109 .032*
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 231
Table : 5 Linear regression model of outcome variable OHI-S

Dependent variable: Un standardized Coefficients Standardized Coefficients P Value

OHIS B Std. Error Beta
(Constant) 3.077 0.769 0
Age 0.007 0.005 0.068 0.19
Gender -0.406 0.122 -0.174 0.001*
Marital status -0.329 0.132 -0.131 0.013*
Schooling -0.264 0.127 -0.114 0.038*
Education -0.157 0.127 -0.069 0.215
Sleep quality 0.109 0.142 0.043 0.443
Sleep trouble -0.22 0.144 -0.083 0.129
Physical activity 0.097 0.118 0.044 0.41
General health 0.05 0.054 0.05 0.354
Extraversion -0.084 0.036 -0.123 0.021*
Agreeableness 0.019 0.03 0.033 0.523
conscientiousness 0.038 0.034 0.058 0.267
Neuroticism -0.005 0.03 -0.009 0.874
Openness -0.002 0.035 -0.002 0.962
LSS -0.024 0.036 -0.037 0.501
SHS 0.024 0.054 0.023 0.662

Discussion had good oral hygiene. It is in contrast to the study

conducted by Mesharam et al [8], which suggested that
Good health and happiness represent critical aspects
there exists no correlation between various personality
of individual welfare, and their pursuit as a worthy end
traits and oral hygiene.
of one’s living has been a subject of countless treatises.
Personality traits imply consistency and stability. Trait Conscientiousness implies a desire to do a task
psychology rests on the idea that people differ from well. They tend to be efficient and organized as opposed
one another in terms of where they stand on a set of to easy-goingand disorderly. Conscientiousness and
basic trait dimensions that persist over time and across DMFT were not significantly but weak and negatively
situations. The most widely used system of traits is correlated (r = -.097). Conscientiousness people are
called the Five-Factor Model. This system includes five more likely to make and keep medical appointments,
broad traits Openness, Conscientiousness, Extraversion, and they might notice sooner when something is wrong
Agreeableness, and Neuroticism. in their oral health. In spite of this lack of time in these
personalities may be the reason for poor oral hygiene.
Extraversion indicates how outgoing and social
a person is. In the present study, highly extraversive A person who is high in neuroticism has a tendency
teachers were relatively happier than introversive, and to easily experience negative emotions. Teachers high
had increased prevalence of oral diseases. Teachers in neuroticism were constantly worrying for small
who were friendly, participate actively in social events things showing negative emotions. In the present
and may not spare time to take care of their oral study, neuroticism, was significant and positively co
health. Agreeableness is the tendency to be friendly, related (r =.112, r = 0.036) with DMFT values and
compassionate and cooperative with others. In the OHI-S. As teachers fail to cope with the stress levels
present study, agreeableness was not significant but it causes poor oral health in them. It is similar to the
weak and positively correlated (r= 0.037) to DMFT study conducted by Takeshita et al,[7] where neurotic
scores. Teachers with high levels of agreeableness had individuals consistently report worse self perceived
high caries which could be due to lack of time and self health. Personality trait openness, indicates the extent of
assessment in them. Teachers with high agreeableness open-mindedness in a person. A person with a high level
232 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
of openness to experience in a personality test enjoys Source of Funding: Self
trying new things. Dental caries and high plaque and
calculus scores doesn’t cause any symptoms initially, Conflict of Interest: No conflict of interest
leading to negligence towards oral health.
References
Life satisfaction is the way people show their 1. Gambhir RS, Gupta T. Need for oral health policy
emotions and feelings (moods) and how they feel in India. Annals of medical and health sciences
about their directions and options for the future. Life research. 2016;6(1):50-5.
satisfaction when correlated with DMFT and OHI-S
2. Ayo-Yusuf OA, Motloba P, Ayo-Yusuf IJ.
showed significant and negative correlation (r= -.104, r=
Oral health and subjective psychological well-
-.111) with DMFT. Those teachers who are satisfied in
being among South African Adults: Findings
life had less dental caries. This might be attributed to the
from a national household survey. S Afr Dent J.
fact that they maintain a healthy lifestyle and take care
2015;70(10):436-41.
of their oral health
3. Mehrdadi A, Sadeghian S, Direkvand-Moghadam
Oral health outcomes have the potential to influence A, Hashemian A. Factors affecting happiness:
happiness. Yoon et al[9] found a significant relationship a cross-sectional study in the Iranian youth. J
between oral health related factors and happiness among ClinDiagn Res: JCDR. 2016;10(5):VC01.
an elderly Korean sample. In the present study, DMFT 4. Tuchtenhagen S, Bresolin CR, Tomazoni F, da
was weakly but positively correlated with happiness, Rosa GN, Del Fabro JP, Mendes FM, Antunes
though it was not statistically significant. This shows JL, Ardenghi TM. The influence of normative and
poor awareness and negligent attitude towards oral subjective oral health status on schoolchildren’s
health among school teachers. In a recent study of happiness. BMC oral health. 2015;15(1):15.
Romanian medical students, researchers noticed a strong
5. DeNeve, K. M., & Cooper, H. (1998). The happy
correlation between gum health and participants’ reports
personality: A meta-analysis of 137 personality
of overall life satisfaction. The present study has certain
traits and subjective well-being. Psychological
limitations. As there was self reporting of the general
Bulletin, 124, 197-229.
health and subjective happiness it might have created
improper opinions owing to inhibitions in them. Oral 6. Steel, P., Schmidt, J., & Shultz, J. (2008).Refining
hygiene behaviors like brushing habits of the teachers the relationship between personality and subjective
were not recorded which might have provided the major well-being. Psycholgoical Bulletin, 134, 138-161.
clue in estimating their oral health status. 7. Takeshita H, Ikebe K, Kagawa R, Okada T,
Gondo Y, Nakagawa T, Ishioka Y, Inomata C,
14% of the variation in DMFT was explained Tada S, Matsuda KI, Kurushima Y. Association of
by all the various predictor variables. With respect to personality traits with oral health-related quality of
OHI-S 9% of the variation was explained by all the life independently of objective oral health status:
variables. Evidence shows that individual thoughts, a study of community-dwelling elderly Japanese. J
perceptions have an influence on general and oral health. Dent. 2015;43(3):342-9.8. Mesharam S, Gattani
Longitudinal research has to be conducted as personality D, Shewale A, Bodele S, Association of personality
traits are genetic and they may change over time. traits with oral health status: A Cross-Sectional
Study, Int J Indian Psychol, 2017;95(2)
Conclusion
9. Yoon HS, Kim HY, Patton LL, Chun JH, Bae KH,
There exists a significant association between Lee MO. Happiness, subjective and objective oral
personality traits and satisfaction in life of teachers health status, and oral health behaviors among
with their oral health. Personality traits act as indirect Korean elders. Community dent oral epidemiol
modulators of the state of oral health. Satisfaction with 2013 Oct;41(5):459-65.
life will improve the quality of life and wellbeing of
10. Dumitrescu AL, Kawamura M, Dogaru BC,
individuals.
Dogaru CD. Relation of achievement motives,
Ethical Clearance: Institutional Review Board of satisfaction with life, happiness and oral health in
Sri Sai College of Dental Surgery. Romanian university students. Oral health Prev
Dent. 2010;8(1).
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 233
11. Ilgan A, Ozu-Cengiz O, Ata A, Akram M. The 16. Mangal A, Kumar V, Panesar S, Talwar R, Raut
relationship between teachers’ psychological D, Singh S. Updated BG Prasad socioeconomic
well-being and their quality of school work life. J classification, 2014: A commentary. Indian J.
Happiness Well-Being. 2015;3(2):159-81. public. health. 2015;59(1):42.
12. Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, 17. Lizica D, Kawamura M, Carmen B, Dinu C,
S. (1985). The Satisfaction with Life Scale. J. Per. Relation of Achievement Motives, Satisfaction
Assess.49, 71-75. with Life, Happiness and Oral Health in Romanian
13. McCrae, R. R., & Costa. P. T. Jr. (1999). A five- University, Oral Health Prev Dent 2010;8:15-22.
factor theory of personality. In L. A. Pervin, & O. 18. Yagaval P, Singla H, Prevalence of dental caries
P. John (Eds.), Handbook of personality: Theory based on personality types of 35-44 years old
and research. New York: Guilford Press. residents in Davangere city. J Oral BiolCraniofac
14. Lyubomirsky S, Lepper HS. A measure of Res, 2017;7: 32-35
subjective happiness: Preliminary reliability and 19. Montero J, Gomez-polo C Association between
construct validation. Social indicators research. Personality traits and oral health quality of life : a
1999 Feb 1;46(2):137-55. cross-sectional study, Int J Prosthodont, 2017;30(5).
15. WHO Oral health surveys; basic method. 4thed,
1997; 47-51,63-64
234 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Effect of Structured Exercise Programme on Pulmonary

Function and Physical Performance in Geriatric Population

Gaurav S. Chandolkar1, Javid H. Sagar2, Govindhan Vardharajulu3

1MPTh Student, 2Professor, 3Dean, Professor, Krishna Institute of Medical Sciences,
Faculty of Physiotherapy, Karad, Satara, Maharashtra

Abstract
Objectives: The objective was to evaluate the effect of structured exercise programme on pulmonary
function and physical performance in geriatric population.

Methodology: Ethical clearance was obtained from the Institutional Ethical Committee, KIMSDU, Karad.
A total of 61 subjects between 60-80 years of age, who were able to ambulate independently and able to
understand instructions, who did not suffer from any musculoskeletal, neurological or cardiopulmonary
disease were given structured exercise programme which consisted of warmup and cool down period along
with resisted training, treadmill walking and static cycling for 4 weeks duration (5times/week). The subjects
were assessed using Pulmonary function test (PFT), six minute walk test (6MWT) and Short Form 36 (SF-
36) Health- related quality of life questionnaire before and after intervention.

Results: Statistical analysis was performed using Paired t- test. The results showed significant difference in
all three measures that is PFT Values (FVC, FEV1 and FEV1/FVC ratio), 6MWT with p value of <0.0001 and
SF-36 questionnaire with the p value of <0.0005 when compared between pre and post intervention results.

Conclusion: It can be concluded that structure exercise programme on physical performance and pulmonary
function along with health-related quality of life in geriatric population has shown significant improvement
when assessed with 6 MWT, PFT and SF-36 questionnaire.

Keywords: Pulmonary function, physical performance, structured exercise programme.

Introduction in to three subgroups people between 65-74 years are

termed as young elderly, people between 75-84 years are
Aging is characterized by the progressive organ
classed as Old elderly, and above 85 are Old elderly3.
system and tissue degeneration. It is mainly determined
Healthy ageing has been defined as the ability to lead
by genetic and influenced by a variety of environmental
a healthy, socially acceptable lifestyle relatively free
factor such as diet, physical exercises, micro-organism
from illness or disability, and this is more seen in those
exposure, pollutants and harmful ionizing radiation.1
actively engaging in activities to improve their health
The Indian geriatric population is currently the second
and wellbeing4. The aging causes reduction in overall
largest in the world2. The elderly population is divided
physical fitness i.e strength, endurance, agility and
flexibility resulting in limitations in ADL and normal
functioning in elderly.
Corresponding Author:
Javid H. Sagar Physiological Changes Due to Aging: Sarcopenia
Professor, Krishna Institute of Medical Sciences, is defined as the loss of muscle strength and muscle mass
Faculty of Physiotherapy, Karad, Satara, leading to functional impairment that occurs with aging5.
Maharashtra-415110 Sarcopenia results from decreased physical activity
e-mail: [email protected] with aging appears to be the key factor6. Osteoporosis
Contact: +919860285859 is the skeletal disorder which causes decrease in
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 235
bone mass leading to mechanical failure of skelet al. were given a set of structured exercise programme for
Hormonal factors play important role in development 4 weeks, 5 times/week for 60 minutes including rest
of osteoporosis and it affects women more than male periods.
due to menopause7. Physical activity contribution to
good physical and psychological health at all ages8. All The Warm-up and cool down exercises included:-
this again results in decreased physical performance in Static stretching: Static stretching was given for major
elderly population. muscle group mainly for pectoralis, Biceps, Triceps,
hamstrings and quadriceps muscles. The warm-up
The functional residual capacity also increases exercise was done for 5 minutes and cool down exercise
with age but is opposed by increased stiffness of the for 5 minutes. Dynamic stretching: Front leg swings,
chest wall9. Around 50 years of age, there in increase hug into chest expansion, arm push back, March and
in diameter of alveolar ducts due to degeneration of reach. Strength training: strength training was given with
elastic fibers around them. This causes closure of small theraband exercises, squats, wall pushup. This exercises
airways during breathing, hyperinflation hence senile were given for major muscle groups of upper limb and
emphysema. With ageing there is change in the surface lower limb at 40-80% of this strength. Aerobic training:
area which causes decline in diffusion capacity of lung. Static Bicycle the subject cycled for 7 minutes with no
Due to loss of surface area along with decrease in resistance added to cycling. Rest is given if needed by
pulmonary capillary blood volume there is decrease in participants. Treadmill walking:- subject walked at their
ventilation to perfusion ratio in elders10. own pace staring at 0.1km/hr till maximum speed till
end of 7 minutes. If subject wanted rest in between 1
World health organization (WHO) has published min rest was given. All vitals were measured before and
certain guidelines on what are the benefits of physical after exercises.
activity in geriatric population. Based on this guidelines,
exercise is an efficient and cost effective way of Outcome Measures: Six minute walk test (6MWT)-
improving older people’s functional capacity. Strength intergroup comparison (within group) using paired t-test
training, balance training and flexibility exercises are the
most effective in preventing falls in elderly populations11. Table 1 showed the comparison of mean and
standard deviation of pre and post values within group
Method In this present study pre-interventional six minute
The Present study was experimental which was walk distance showed the Mean of 313.6±86.26
conducted on 61 geriatric subjects with the age group which was improved post-interventional to mean of
between 60-80 years out of which 41 were male and 352.65±96.54. The p value by paired t-test was found to
20 were female. Before commencement of this study be <0.0001 which was extremely significant.
Ethical Clearance was obtained from Institutional
Ethical Committee of KIMSDU, Karad. The subjects Pulmonary Function Test (PFT) – intergroup
who fulfilled the inclusion. Both gender, Age group comparison (within group) using paired t test
between 60-80 years, Subjects willing to participate, Forced vital capacity: Table 1 FVC showed the
Decreased PFT values considered normal for their age, Mean 1.98±0.61 pre-intervention which was increased
Reduced air entry and chest wall mobility and exclusion and post-interventional to mean of 2.16±0.62. The intra-
criteria Subjects with neurological disorder, Subjects group analysis was done using paired ‘t’ test within the
with hearing and vision impairment, Subjects with any group. The post-test interventional analysis considered
vessel disease, Subjects with previous history surgery very significant difference within the group with P value
within one year, Uncooperative patients were included 0.0015.
in this study through consecutive sampling method. This
study was carried out in the time period between July FEV1: Pre-interventional Forced Expiratory
2018- February 2019 Subjects were explained about the volume in 1sec showed the mean of 1.43±0.50 and
procedure of the study in detail and informed consent post-interventional FEV1 showed improvement with
were obtained from them. The subjects were assessed mean of 1.59±0.52. The intra-group analysis was done
for physical performance and pulmonary function using using paired ’t’ test within the group. The post-test
six minute walk test, pulmonary function test and SF- interventional analysis showed extremely significant
36 questionnaire pre and post intervention. The subjects difference within the group with P value 0.0009
236 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
FEV1/FVC: Pre-interventional Forced expiratory SF-36 QUESTIONNAIRE (SF-36): Table 3 Pre-
volume in 1sec/Forced vital capacity showed the mean interventional SF- 36 questionnaire showed the mean of
of 70.3±11.4 and post-interventional FEV1/FVC showed 0.52±0.11 and post-interventional SF 36 questionnaire
improvement with the mean of 75.3±7.75 The intra- showed the mean of 0.66±0.11 The intra-group analysis
group analysis was done using paired’t’ test within the was done using paired’t’ test within the group. The post-
group. The post-test interventional analysis showed test interventional analysis showed extremely significant
extremely significant difference within the group with P difference within the group with P value < 0.0005
value < 0.0005.

Table 1: Comparison of six minute walk test (Distance Covered)

6MWT (Distance covered) Pre-intervention Post-intervention P value Inference

Mean ± SD 313.65±86.26 352.6± 96.54 <0.0001 Extremely significant

Table 2: Comparison of PFT values pre and post intervention

Mean ± SD
Pulmonary function test P value Inference
Pre-interventional Post-interventional
FVC 1.98±0.61 2.16± 0.622 0.0015 Very significant
FEV1 1.43±0.50 1.59±0.52 0.0009 Extremely significant
FEV1/FVC 70.39±11.45 75.32±7.75 0.0005 Extremely significant

Table 3: Comparison of PFT values pre and post intervention

SF-36 questionnaire Pre-interventional Post- interventional P values Inference

Mean ± SD 0.52±0.11 0.66±0.11 <0.0001 Extremely significant

Discussion programme by the participants. The intra-group analysis

was done using Paired ‘t’ test with the p value <0.0001
Ageing is a phenomenon and not a disease that causes
which was considered extremely significant. The finding
general decline in function which leads to inactivity and
of this study correlates with the study of Santakumar
risk of developing disease12. As aging progress, there
Haripriyal et al who stated that multicomponent exercise
is measurable decline in the physiological function of
program causes significant improvement in 6 MWT
respiratory system like reduced forced vital capacity and
values16. In their study the outcome measures used were
forced expiratory volume in one second, with increase in
8-foot up and go test for functional mobility, 6 MWT
residual volume and functional residual capacity13
for exercise capacity and SF-36 questionnaire for health
A structured exercise programme involves multiple related quality of life and in this study instead of 8-foot
component which includes strength training, exercise up and go test PFT were used to assess Pulmonary
to improve cardio-vascular endurance14. Structured function. Their study duration was 10 weeks which was
exercise are recommended by American college of sports long than this study which was only 4 weeks.
medicine for optimal aging, minimizing the adverse effect
Aging negatively correlates with pulmonary
of aging, reducing risk of disease. In this study strength
function17. Pulmonary function has also show to
training was given through theraband for major muscle
decline with aging, in this study pulmonary function
groups, wall-pushups. Aerobic exercises including
was examined prior to the intervention through forced
treadmill walking and static cycling along with warm-up
vital capacity, forced expiratory volume in one sec
and cool-down exercises. There was a study done which
and forced expiratory volume in one sec/forced vital
state that 6 MWT helps to evaluate the exercise capacity
capacity ratio. There was significant improvement in
in elderly people15. In this study Six minute walk test
FEV1 with the p value <0.0009, FCV with the p value
was performed before the administration of exercise
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 237
<0.0015 and FEV1/FVC ratio with the P value <0.0005 6. Morley JE, Baumgartner RN, Roubenoff R, Mayer
after the intervention of 4 weeks which correlates with J Sarcopenia J. Lab. Clin. Med.2001; 137, 231-243
the study of Mahtab Moazamil & Samaneh Farahati who 7. Knight J, Nigam Y. Anatomy and physiology of
concluded that there was improvement in PFT values ageing 5 : the nervous system. Nursing times 113
after aerobic training in postmenopausal women13 (6);55-58 2017.
Health-related quality of life was assessed using SF- 8. Bog JaJeoung, Yang Chool Lee. A study
36 questionnaire which showed significant improvement of relationship between fraity and physical
after exercise programme with P value <0.0001 this performance in elderly women. Journal of exercise
findings correlates with the study of Dhanesh K who rehabilitation 2015;11(4)215-219.
stated that 10 week multi-component exercise program 9. Johnson BD, Reddan WG, Pegelow DF, Seow
which compromised aerobic, resistance, balance and KC, Dempsey JA. Flow limitation and regulation
functional training significantly improved that the health of functional residual capacity during exercise in a
related quality of life16. physically active aging population. Am Rev Respir
Dis. 1991; 143(1): 960-967.
Conclusion 10. PruthiN, Multani N.K. Influence of Lung Function
The present study provided evidence to support Test. Journal of exercise science and physiotherapy,
the use of structure exercise programme for improving Volume 8; 1-6, 2012.
physical performance and pulmonary function along 11. Jan C, Veronika T, Milan S, Helmut K, Winfried M,
with health-related quality of life in geriatric population. Dusan H. Physical activity in elderly Eur J Transl
Myol- Basic ApplMyol 2015; 25 (4): 249-252
Acknowledgement: We acknowledge the constant
support and guidance of Dr. G Varadharajulu Dean, 12. Caruso LB. Silliman RA. Geriatric Medicine In
Professor, Dr. Javid Sagar Professor and Dr. SV Kakade Harrison’s Principles of internal medicine, vol
for statistical help. II,(17)2008 53-59
13. Mahtab Moazamil, Samaneh Farahati . The effect
Conflicts of Interest: The authors declare no of aerobic training on pulmonary function in
conflicts of interest postmenopausal women. 2013 Intl. j. Sport stdvol
3(2): 169-174.
Funding: This research received no external
funding. 14. Robert S Mazzeo, Peter Cavanagh. Exercise and
physical activity for older adults. Med. Sci. Sports..,
Reference Vol. 30, No. 6, pp. 992-1008, 1998.

1. Yamni Nigam, John Knight, Sharmila Bhattacharya, 15. Gopi P.M, Vinod B, Akshata A, Sai K46. Combined
Antony Bayer. Physiological Changes Associated effect of PNF stretching with chest mobility exercise
with Aging and Immobility. Journal of Aging on chest expansion and pulmonary function for
Research Volume 2012. 2pages. elderly. Int J Physother 2015;2 (3) 563-571

2. The World Health Organization. Mental Health. 16. Santhakumar Haripriyal, Dhanesh Kumar et al.
Available from: http://www.who.org. Last assessed Effect of a multi- component exercise program on
on 2015 may 14 functional Mobility, exercise capacity and quality
of life in older. J. Clini and Diagnostic Research
3. Demographics of Aging. Tansgenerational.org.
2018 Jul, Vol-12(7).
Retrieved 2016. April 04
17. R.K. Dharl, mrityunjay Gupta. Evaluation of
4. Jamie S. McPhee. Physical activity in older
pulmonary function test in elderly population;
age: perspectives for healthy aging and frailty:
International Journal of med science and public
Biogerontology (2016)17: 567-580.
health 2017; vol 6.
5. Baumgartner RN, Waters DL, Gallagher D, Morley
JE. Predictors of skeletal muscle mass in elderly
men and women. Mech. Ageing Dev. 107, 123‑136.
238 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Comparative Evaluation of Depth of Cure of Bulk-fill

Composite Resin and Alkasite Restorative Material by
Vicker’s Hardness Test

Gowrish Bhat1, Namrata Khanna2, Mithra Nidarsh Hegde3, Vandana Sadananda4

1Reader, 2Post Graduate Student, 3Professor and Head of Department, 4Lecturer, Department of Conservative
Dentistry and Endodontics, AB Shetty Memorial Institute of Dental Sciences, Mangaluru, Karnataka, India

Abstract
Background: This study evaluates depth of cure (hardness ratio) of a bulk-fill resin composite and an
alkasite material in self cure and dual cure mode and compares and evaluates the Vicker’s hardness and
depth of cure of a bulk-fill resin composite and an alkasite material in self cure and dual cure mode.

Materials and Method: A dual-cure alkasite material and a bulk-fill composite resin were divided into
three parts: Group A- bulk-fill resin composite, Group B- self-cured alkasite material and Group C- light-
cured alkasite material. The samples were prepared in a stainless steel split mould of 6mm height and 4mm
diameter. Vicker’s hardness testing was performed to evaluate depth of cure of 4mm at three levels of 0mm,
2mm and 4mm.

Results: The statistics were analyzed using SPSS Software and One- way ANOVA and Post Hoc tests. The
data obtained revealed that Cention N showed the greatest depth of cure in dual cure mode.

Conclusion: Most dual cure restorative materials exhibit better strength post light-curing compared to only
the self-cure mode.

Keywords: Alkasite, bulk-fill resin, composite, depth of cure, Vicker’s hardness.

Introduction bonding, and the gold standard thickness of each

increment of 2 mm. However, deeper preparations with
The rationale of this study was to compare and
2-mm increments are time consuming and relatively
evaluate the claimed depth of cure of 4mm of bulk-fill
technique sensitive. The validation for this incremental
restorative materials; an alkasite cement cured by itself
technique is to warrant the penetration of the curing light
and dually, with a bulk-fill composite resin.
deeply enough to initiate and complete the curing of the
Resin based composites require isolation, necessary resin, apart from reducing the shrinkage and shrinkage-
steps for enamel and dentin etching, priming, and induced stress associated with polymerization of resin
based composites. Recently, the introduction of resin-
based bulk-fill composites claim to fill cavities up to 4–6
mm immediately.
Corresponding Author:
Dr. Namrata Khanna Dental bulk-fill resins are increasing in demand,
Post Graduate Student, Department of Conservative but the clinicians doubt that the in-depth cure may
Dentistry and Endodontics, AB Shetty Memorial be insufficient. An alternative is possible through
Institute of Dental Sciences, Mangaluru, Karnataka, newer dual-cured resin based composites that not only
India save critical clinical time but also provide bioactive
e-mail: [email protected] properties. Apart from new photo-initiators1, the given
Phone Number: 9049738815 techniques improve the depth in light-cured bulk-fill
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 239
resin based composites by reducing the filler–matrix index of alkaline fillers when compared to regular
interface by enlarging the filler size2 and decreasing silicate glass fillers may alter the filler/resin refractive
the amount of pigments. Apart from fast curing and index match that is crucial for better light transmission
sufficient strength in large increments, modern bulk-fill for optimum depth. The result would be a more dense
resin based composites also necessitate the need for an material that is able to camouflage the oral cavity or
additional feature to make it more acceptable, namely, the tooth’s structural discolorations effectively rather
bioactivity or self-adhesiveness.3 than the one obtained through several translucent, light-
cured, bulk-fill resin based composites.
The increasing demand for a quick restorative
procedure with light-cured, bulk-fill composites raises Materials and Methodology
a doubt whether an adequate depth of cure will be
achieved.4 This factor, along with the trial to offer an A dual-cure alkasite material (Cention-N, Ivoclar
aesthetic, basic filling material has proved to be the Vivadent AG, Schaan, Liechtenstein) and a bulk-fill
motivation for the launch of several dual-cure resin based composite resin (FiltekTM Bulk-Fill Posterior Restorative
composites in the market, that are also appropriate for a material, 3MTM ESPE, St. Paul, USA) were selected for
bulk-filling procedure. The bulk fill resin materials also the study. The materials were divided into three parts:
concentrate on bioactive properties that intend to prevent Group A - bulk-fill resin composite, Group B- self-cured
tooth demineralization by releasing acid-neutralizing alkasite material and Group C - light-cured alkasite
ions and aid in remineralization. For this sole purpose, material.
one method implemented the addition of alkaline fillers A stainless steel split mold of height 6mm and
in a methacrylate resin matrix, by introducing a new diameter 4mm was used to prepare 10 Samples from
material category—the alkasites.5 each group.
Dual-curing resin based composites consists of Group A (Cention N-Self Cure) - Powder and liquid
mixing two components together, each of which, consists was dispensed onto a paper pad in the ratio of about
of a different initiator system. Currently, dual-cure resin 4.6:1, mixed for about 45-60s and condensed into the
based composites have been mainly used in modern mold. They were retrieved after 5 minutes of setting
dentistry for core build-up and cementation. However, time.
it needed to be confirmed whether the self-curing
polymerization reaction was enough not only in case of Group B (Filtek Bulk-Fill) - The samples were
impeded light transmittance, but also in the absence of condensed into the mold and cured for 20 seconds with
light. On comparing the features of resin based bulk fill blue LED Light Source.
composites that were either self-cured or dual-cured, it
was found that the impact of light irradiation depended Group C (Cention N-Dual Cure) - The powder and
on the final material ranging from no- impact to high- liquid was mixed and the cement loaded into the mold to
impact.6 Hence, the concluding factor for a newer dual- be cured. The samples were cured for 20 seconds with blue
cured alkasite cement, apart from its caries preventive LED Light Source (Kerr DemiTM Ultra Ultracapacitor-
ability, is the duration it takes to set, the adequacy of its 1200 mW/cm2) and were retrieved immediately after
mechanical properties and early strength, the degree of the curing cycle was complete. The samples were all
conversion in depth, and the impact on the properties of thermocycled (Thermocycler SD Mechatronik, GmbH
the final material with additional light-curing. Dental Research Equipment, Germany) for 5,000 cycles
at 5°C and 55°C (dwelling time: cold bath, 30 seconds;
The polymerization that is light-initiated facilitates hot bath, 30 seconds).
the curing of a material on demand, whereas the
polymerization procedure through a redox activation The Depth of cure was measured by Vicker’s
occurs slowly in comparison and may not be conducive Hardness Testing Machine (MMT- X7A, Matsuzawa
enough for a quick restorative procedure that is generally Co., Ltd., Japan).
required in modern clinics. The time required to set the
material in question should be calculated and adjusted to
Results
the required time of a regular clinical treatment, even in The statistics were analyzed using SPSS Software
the absence of light. Furthermore, the higher refractive 16.0. One- way ANOVA statistical tests were done to
240 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
compare the three groups and on achieving statistically Group C had the highest VHN value of 65.08
significant results, Post Hoc test was done. followed by Group B at 54.63 and lastly group C, at
43.87 and the surface layer of 0mm. Even at the claimed
The results obtained (Table I) showed that Group depth of 4 mm, Group C did better with the VHN value
C (Cention N- Dual Cure) had manifested the most of 49.86.
coveted results in comparison to the other two groups.
Group C showed best results at all three levels of 0mm,
2mm and 4mm.

Table I: Vicker’s Hardness Numbers of Group A, B, C at 0, 2 and 4 mm.

Group Depth Sample Size (n) Mean Standard Deviation

Group A – Cention N - Self Cure
0 mm 10 43.87 0.881
2 mm 10 39.94 0.910
4 mm 10 32.45 0.820
Group B – Filtek Bulk- Fill
0 mm 10 54.63 0.834
2 mm 10 48.23 0.824
4 mm 10 41.35 0.921
Group C – Cention N- Dual Cure
0 mm 10 65.08 0.820
2 mm 10 57.31 0.748
4 mm 10 49.86 0.625
The mean difference is significant at p<0.05.

Discussion methacrylate monomers to a high polymer network

density and may be responsible for the better depth of
Currently, bulk-fill resin based composite materials
cure.7
has gained popularity among practitioners owing to the
comparative simplicity of the procedure. A self-curing material with options for light-
curing outlook is the substance of analysis. Although
Manufacturers, with the help of advanced
the initiation rate can be very high in the light-curing
technology, relate the modifications in the filler content
mode, its significant drawback maybe the fact that the
and/or organic matrix as their claim in the main
saturation of light energy in depth is quite low. In order
advancement of bulk-fill composite materials i.e, namely
to improve this, the alkasite was modified and a redox
increased depth of cure, which probably results from
activation containing a copper salt, a peroxide and a
higher translucency, and low polymerization shrinkage
thiocarbamide was added in the powder component.7
stress
The use of restorative and viscous composite resins
Cention N contains an acyl phosphine oxide
has demonstrated that greater depth of cure up to 4
initiator (Norrish type1 initiator) which requires
mm is more effective.8,9 It has been found that filler
just one component for radical formation and the
size and content in dental composites may reduce light
photoinitiator, Ivocerin. The presence of this leads to
penetration and this, in turn, has an effect on the depth of
faster polymerization of the resin material and causes
the cure.10,11 The pigments present in shaded composite
better conversion of the monomer to polymer which may
materials have a direct impact on the depth of cure since
have lead to the results developed in this study. Cention
these are dense particles that hinder the penetration
N also contains UDMA, DCP, and an aliphatic/aromatic
of light and decrease the degree of polymerization at
UDMA; which has claimed faster cross-linking of the
greater depths while a cavity is being treated.12
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 241
Filtek Bulk-Fill claims to contain AFM (addition- preserve the feature that can not only allow them to react
fragmentation monomers) that react with the with each other but also with other reactive sites of the
methacrylate to keep the physical features of the material developing polymer. Thus the physical features of the
intact. The kind of monomers being used have an effect polymer are retained along with relief from stress.
on the Methacrylate composites as they have the ability
to shrink in varying degrees during polymerization. Conclusion
Filtek Bulk Fill Posterior Restorative consists of two Under the limitations of this study, Cention N
new methacrylate monomers; their properties have showed best depth of cure when tested by the Vicker’s
served as a catalyst to gain lower polymerization stress Hardness Test in dual cure mode. Filtek bulk fill also
that is necessary for better results. showed coveted results while maintaining a desirable
Filtek bulk fill (bulk fill viscous composite) depth of cure. In self-cure mode, Cention N may
has shown a higher degree of conversion than the not achieve enough curing and we recommend that
conventional viscous composite. Probably the reduced the alkasite material be used along with light curing
filler volume fraction is convenient compared to the less protocols.
viscous conventional composite.13 The composition of Acknowledgements: The study was a self-funded
4 high molecular weight monomers, viz. Bis-GMA, study and the authors would like to thank the associated
Bis-EMA, UDMA and procrylate in Filtek bulk fill institution for aid in conducting the research.
facilitates a higher conversion and Depth of cure . Filtek
bulk fill flow composites contain a proprietary monomer Conflicts of Interest: There are no conflicts of
equivalent to Bis-GMA and patented as Procrylat interest with this study.
resin.14 Procrylat is a high molecular weight monomer
with low viscosity similar to Bis-GMA but with a lower Ethical Clearance: This was an in vitro dental
viscosity, the lack of pendant hydroxyl groups is the material based study and did not require ethical clearance
only difference between Bis-GMA and Procrylate.15 from the ethical committee.

The decreased hydrogen bonding potential is due to References

the lack of hydroxyl group which reduces the viscosity 1. Ilie N. Comparative Effect of Self-or Dual-Curing on
of the monomer. Also Bis-EMA and UDMA are high Polymerization Kinetics and Mechanical Properties
molecular weight monomers with low viscosity so in a Novel, Dental-Resin-Based Composite with
the manufacturers adjust the proportions of the 4 high Alkaline Filler. Running Title: Resin-Composites
molecular monomers to decrease viscosity and create with Alkaline Fillers. Materials. 2018;11(1):108.
hard cross link network.16
2. Moszner N. State of the art: Photopolymerization in
The monomer aromatic dimethacrylate (AUDMA) dentistry. Ivoclar Vivadent Report. Liechtenstein:
with a high molecular weight is responsible for reducing Ivoclar Vivadent AG. 2013 Jul;19.
the number of reactive groups in the resin. Polymerization 3. Ilie N. Impact of light transmittance mode on
stress is caused mainly due to two factors – the shrinkage polymerisation kinetics in bulk-fill resin-based
in the volume and the stiffness in the developing and composites. Journal of dentistry. 2017 Aug 1;-
final polymer matrix. However, AUDMA is capable of 63:51‑9.
combating both these factors. 4. Tarle Z, Attin T, Marovic D, Andermatt L, Ristic
Another distinctive methacrylate characterizes a class M, Tauböck TT. Influence of irradiation time on
of compounds called addition-fragmentation monomers subsurface degree of conversion and microhardness
(AFM). The AFM reacts like any other methacrylate of high-viscosity bulk-fill resin composites. Clinical
by forming cross-links between the adjacent polymer Oral Investigations. 2015 May 1;19(4):831-40.
chains during the process of polymerization. The third 5. Ilie N. Comparative Effect of Self-or Dual-Curing on
reactive site of the AFM splits into fragments during Polymerization Kinetics and Mechanical Properties
polymerization. This process provides a technique to in a Novel, Dental-Resin-Based Composite with
relax the developing network that results in greater relief Alkaline Filler. Running Title: Resin-Composites
from the stress caused. The fragments, however, still with Alkaline Fillers. Materials. 2018;11(1):108.
242 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
6. Ilie N, Simon A. Effect of curing mode on the micro- 12. Garcia D, Yaman P, Dennison J, Neiva GF.
mechanical properties of dual-cured self-adhesive Polymerization shrinkage and depth of cure of bulk
resin cements. Clinical Oral Investigations. 2012 fill flowable composite resins. Operative dentistry.
Apr 1;16(2):505-12. 2014 Jul;39(4):441-8.
7. Cention N – Ivoclar Vivadent Brochure http:// 13. Zorzin J, Maier E, Harre S, Fey T, Belli R,
www.ivoclarvivadent.in/en-in/p/all/cention-n. Lohbauer U, Petschelt A, Taschner M. Bulk-fill
8. Lazarchik DA, Hammond BD, Sikes CL, Looney resin composites: polymerization properties and
SW, Rueggeberg FA. Hardness comparison of extended light curing. Dental materials. 2015 Mar
bulk-filled/transtooth and incremental-filled/ 1;31(3):293-301.
occlusally irradiated composite resins. The Journal 14. Yokesh CA, Hemalatha P, Muthalagu M, Justin
of prosthetic dentistry. 2007 Aug 1;98(2):129-40. MR. Comparative evaluation of the depth of cure
9. Jackson RD. New posterior composite materials and degree of conversion of two bulk fill flowable
improving placement efficiency. Compendium of composites. Journal of clinical and diagnostic
continuing education in dentistry (Jamesburg, NJ: research: JCDR. 2017 Aug;11(8):ZC86.
1995). 2012 Apr;33(4):292-3. 15. Elhawary AA, Elkady AS, Kamar AA.
10. DeWald JP, Ferracane JL. A comparison of four COMPARISON OF DEGREE OF
modes of evaluating depth of cure of light-activated CONVERSION AND MICROLEAKAGE IN
composites. Journal of Dental Research. 1987 BULKFILL FLOWABLE COMPOSITE AND
Mar;66(3):727-30. CONVENTIONAL FLOWABLE COMPOSITE
(AN IN VITRO STUDY). Alexandria Dental
11. Ferracane JL. Correlation between hardness and
Journal. 2016 Dec 15;41(3):336-43.
degree of conversion during the setting reaction of
unfilled dental restorative resins. Dental Materials. 16. Filtek™ Bulk Fill Flowable Restorative. 3M.
1985 Feb 1;1(1):11-4. 2012. Available at: http://multimedia.3m.com/
mws/media/792319O/filtek-bulk-fill-flowable-
restorative.pdf
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 243

Population Growth and its Impact on Public Health in India:

A Legal Analysis

Hiranmaya Nanda1, Shyamantak Misra1

1Assistant Professor, Faculty of Legal Studies, Siksha ‘O’ Anusandhan University, Bhubaneswar, Odisha, India

Abstract
In this article the author after a thorough research on population growth strives to pen down the major factors
that envelope the matter of population explosion in India only. The author beautifully states the occurrences
of change year wise through the family welfare programs planned and implemented in India along with the
consequential changes that took place because of such programs. The National Population Policy, Role of
National Commission on Population have been discussed as well followed by the impact of the same on
Public health. Most importantly the measures that were taken to control such fast growing population in
India have been individually dealt with in order to provide a in depth knowledge to the readers of this article.
However the author hopes to have dealt with the matter sensitively and in simple language as well, so as to
satisfy the needs of the reader on the mentioned topic.

Keywords: Population, public health, fertility, family welfare program.

Introduction Moreover as we see today water has already become a

matter of concern in India.1
India firstly adopted the population control policy
as a matter of national concern before 1951. The goal Development of India’s Family Welfare
of the year 1951 was that “the country was working on Programs: In the Year 1950: When India achieved
stabilizing the population at a level consistent with the independence at that time the country’s health care
needs of the national development.” The problem of services relating to hospitals were predominately
population explosion in the country is considered to be available in the Urban areas only. Rural India at that
the biggest and most fundamental problem which India stage seemed to be very underdeveloped. The general
is facing till date. Why is it that this matter of population physicians were well versed with the women and child
turns out to be the biggest problem an the other major health services. In the year 1951, India became the first
problems like poverty, environmental degradation, nation to develop a state sponsored family planning
unemployment etc are more or less overshadowed by program in the National Family Planning Program. The
this so called fundamental problem. There is no doubt main goals of this program are to lower the fertility rates
that the pace and momentum in which population growth and to slow down the population growth as a means to
is taking place today might very soon lead to disastrous drive the economic development.2
situations due to scarce of food, water and shelter etc.
This national program was based on 5 ethical goals
such as, “the community must be prepared to feel the
need for the services in order that, when provided, these
Corresponding Author: may be accepted, parents alone must decide the number
Hiranmaya Nanda of children they want and their obligations towards
Assistant Professor, Faculty of Legal Studies, Siksha them, people should be approached through the media
‘O’ Anusandhan University, Bhubaneswar-751003, they respect and their recognized and trusted leaders and
Odisha, India without off-ending their religious and moral values and
e-mail: [email protected] susceptibilities, services should be made available to the
Mob: 9861057452 people as near to their doorsteps as possible, services
244 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
have greater relevance and effectiveness if made an reduce dropouts at the primary and secondary school
integral part of medical and public health services and levels to below 20 per cent for both boys and girls; to
especially of maternal and child health programs.”3 reduce the infant mortality rate to below 30 per 1,000
live births; to reduce the maternal mortality ratio to
In the Year 1960: In the year 1960 many useful below 100 per 100,000 live births; to achieve universal
medicines which are beneficial for the prevention of six immunization of children against all vaccine preventable
childhood diseaseand for effective contraceptives for diseases; to promote delayed marriage for girls, not
birth also became available. The family welfare program earlier than age 18 and preferably after 20 years of
and various immunization programs were among the age; to achieve 80 per cent institutional deliveries and
primary programs which were added the national policy. 100 per cent deliveries by trained persons; to achieve
During this ear sterilization remained the aim of the universal access to information/counseling, and services
national family planning program. Several awareness for fertility regulation and contraception with a wide
programs and efforts were made for the promotion of basket of choices; to achieve 100 per cent registration of
vasectomy and to provide services exclusively to the births, deaths, marriages, and pregnancy; to contain the
rural peoples. spread of the Acquired Immuno-deficiency Syndrome
In the Year 1970: However in the year 1970 (AIDS) and promote greater integration between the
population explosion was though not considered as management of reproductive tract infections (RTIs) and
the chief threat to the nation but many troubles due to sexually transmitted infections (STIs) and the National
increased population were emerged. The government AIDS Control Organization; and to prevent and control
of India had given main concern to this problem. The communicable diseases.”6
parliament of India has enacted a legislation namely The National Commission on Population: On May 11,
Medical Termination of Pregnancy Act, 1971which can 2000 under the chairmanship of Prime Minister, The
check unwanted pregnancy of women and to get a safe National Commission on Population was constituted
termination of pregnancy after fulfilling the requisite along with Chief Ministers of all the states, concerned
conditions of the law. In this era it is reported a massive ministers of the related central ministries, secretaries of
sterilization drive done in the year 1976 which is near the concerned departments, distinguished physicians,
about 8 million persons.4 demographers and the representatives of the civil society
In the Year 1980:The chief thrust in the year 1980 are members of the commission. The commission has
was to implement the WHO’s “Alma Ata Declaration given the mandate such as, “to review, monitor and give
of Health for all by the year 2000 through establishing a direction for implementation of the National Population
network of health care centre’s in urban and rural areas.” Policy with the view to achieve the goals set in the
In the year 1986 a Universal Immunization Program Population Policy; to promote synergy between health,
started in 30 districts and subsequently it was extended educational environmental and developmental programs
to cover 448 districts by the end of Seventh Plan.5 so as to hasten population stabilization; to promote inter
sectoral coordination in planning and implementation
In the Year 1990: In the year 1990 with the starting of the programs through different sectors and agencies
of Eighth Plan, several efforts were made under “Safe in center and the states; to develop a vigorous peoples
Motherhood and Child Survival and the Social Safety program to support this national effort.”
Net Program” to enhance the access to motherhood and
childhood health care services. Impact on Public Health: The degree and
accentuation of a general wellbeing or public health
National Population Policy: A proficient committee program are essentially impacted by the changing
headed by M.S. Swaminathan who was appointed by the attributes of the populace it serves. Among the different
government to draft a National Population Policy and attributes of ongoing population explosion patterns,
finally it came into operation from year 2000. The said aging of the populace is a standout amongst the most
policy has set out few goals for the year 2010 such as; “to major in its bearing on national public health.
address the unmet needs for basic reproductive and child
health services, supplies, and infrastructure; to make Human health is in danger as the denser the
school education up to age 14 free and compulsory, and populace; the simpler airborne ailments can spread.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 245
The increment in overpopulation has prompted issues The Injectable Contraceptive: This type of
like urban swarming and ecological changes that have process is a threat to life and health of the acceptor which
brought about the development of numerous irresistible certainly makes the mockery of her fundamental rights.
diseases. Increment in antimicrobial obstruction turns This process affects women’s menstruation cycle and
out to be a sudden issue for illnesses, for example. may have bleeding and spotting between the periods.7 It
Tuberculosis, Malaria, Cholera, Dengue fever etc. occurs mostly during the first few months of its usage but
may also occur after the use of injectable contraceptive
The overpopulation also results in the contamination for some time. Periods and fertility may take up to a year
and pollution of water. People also die each year due to return after stopping injections, depending on the type
to contamination of water related diseases. Because the of injectable, and this may vary from woman to woman.
virus spreads faster in water than any other platform.

This population growth also explodes the number

Conclusion
of vehicles in the society. Due to vehicular use air in the After all the above discussions on population
environments degrades by toxic contents and it affects growth the author is of the opinion that if the present
easily with children and older persons. They suffer ruling government of India strives to strike down the
from various respiratory diseases like Asthma,Lung unnecessary policies and programs and go for programs
cancer, Chest pain, Congestion, Throat inflammation, which would make aware the eligible couples about the
Cardiovascular disease etc. numerous benefits of birth-control, policies that would
provide free education to the single child of a couple,
Rapid population growth has also led to affect implementing strictly the laws on preventing early
of ozone layer. The UV rays of the sun which causes marriage, arranging a vigorous training program for the
various skin problems like skin cancer and premature family welfare workers and improving the situation by
aging of skin. It also results in the eye problems like implementing all the above stated suggestions majorly
cataract and sometimes it leads to blindness. in the rural sectors of India would yield great results.
Checking Overpopulation: The government has Ethical Clearance: Not required, as the research
taken various measures to put a check on overpopulation. article is based on population explosion and its impact
Only legislation, rules and regulations cannot only put an on public health. The research is doctrinally undertaken.
end to population however medical assistance through
proper sterilization can control this problem in India. Source of Funding: Self

Therapeutic Sterilization: This type of sterilization Conflict of Interest: Nil

is performed where a person is of sound mind gives
consent to such operations. This is very common in the References
world. A medical practitioner when performed this type 1. Gupta SK, Deshpande RD. Water for India in 2050:
of sterilization with the consent of the patient having first-order assessment of available options. Current
very less chance of criminal prosecution. However if it science. 2004 May 10:1216-24.
is done without the consent of the spouse then r this may
2. Ledbetter R. Thirty years of family planning in
rise to civil liabilities. This is civil liabilities because of
India. Asian Survey. 1984 Jul 1;24(7):736-58.
the The Hindu marriage Act, 1955 which is a ground for
divorce under the purview of cruelty. 3. Banerji D. Family Planning in India: The Outlook
for 2000 AD. Economic and Political Weekly. 1974
Eugenic Sterilization: This is performed where a Nov 30:1984-9.
further procreation capacity of a mother will weaken 4. Garg S, Singh R. Need for integration of gender
physically and psychologically. There is no particular equity in family planning services. The Indian
legislation available pertaining to eugenic sterilization in journal of medical research. 2014 Nov;140(Suppl
India. In most of the states of United States of America 1):S147.
this type of legislation prescribes sterilization. However
5. Banerji D. Family planning in the nineties: More of
other modes of sterilization which controls the birth
the same?. Economic and Political Weekly. 1992
process should be made free and voluntary.
Apr 25:883-7.
246 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
6. Chopra S, Dhaliwal L. Knowledge, attitude and 7. Fraser IS, Weisberg E. A comprehensive review
practices of contraception in urban population of of injectable contraception with special emphasis
North India. Archives of gynecology and obstetrics. on depot medroxyprogesterone acetate. Medical
2010 Feb 1;281(2):273. Journal of Australia. 1981;1(1 Suppl):1-9.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 247

Evaluation of Malondialdehyde, Glutathione Peroxidase and

Defensin Levels in Patients with and without Periodontitis

J. Hemashree1, Sreedevi Dharman2, Selvaraj3

1GraduateStudent, 2Reader, Department of Oral Medicine and Radiology, 3Assistant Professor,
Department of Biochemistry,, Saveetha Dental College & Hospital, Saveetha Institute of Medical and
Technical Sciences, Chennai, India

Abstract
Aim: Aim of the study is to estimate the levels of Malondialdehyde, glutathione peroxidase and Defensin
levels on patients with and without periodontitis.

Materials and Method: The levels of Malondialdehyde and Glutathione peroxidase was estimated using
colorimetric estimation and Defensin was estimated using ELISA

Results: Levels of Defensin is increased in patients with periodontitis 9.18+-1.72 when compared to healthy
subjects 6.22+-2.73. The mean levels of MDA is increased in patients with periodontitis 2.35+-0.32 when
compared to normal patients 3.58+-0.36. The levels of Gpx is lower in patients with periodontitis 2.52+-0.58
when compared to normal patients 3.58+-0.36. The p – value was found to be significant (0.001)

Conclusion: Thus, this study reveals that Malondialdehyde, Defensin and glutathione peroxidase can be
considered as biomarkers in the periodontal diseases.

Keywords: Periodontitis, oxidative stress, inflammation, saliva, tooth.

Introduction factors predisposed to this disease.2 Periodontitis is one

of the most common causes of tooth loss in adults.3
Periodontitis is an inflammatory disease of
However this can be prevented by preventing plaque
supporting tissues of the teeth that are caused by
and calculus formation which harbours the periodontal
specific microorganisms or groups of microorganisms,
pathogens . The periodontal pathogens in the causal
which eventually results in progressive destruction of
of the disease include a vast list of organisms among
the supporting tissues of the teeth. It is also combined
which Porphyromonas gingivalis, and Aggregatibacter
with periodontal pocket formation, gingival recession
actinomycetemcomitans, which are commonly seen in
or both.1 Periodontitis is a complexive disease resulting
the biofilm. The colonization and subsequent invasion of
from interaction of bacterial infections and host response
these Gram-positive and Gram-negative microorganisms
to such bacterial infections. Environment, acquired risk
into the gingival epithelium leads to progression of the
factors and genetic susceptibility are certain modification
disease.

The severity of periodontitis could be diagnosed

on the basis of its typical clinical parameters. These
Corresponding Author: include periodontal probing depth, pocket depth, clinical
Dr. Sreedevi Dharman attachment loss and amount of gingival bleeding.
Reader, Department of Oral medicine and Radiology, Moreover,analysis of saliva as an important laboratory
Saveetha Dental College & Hospital, Saveetha Institute test for the evaluation of many salivary conditions,
of Medical and Technical Sciences, 162, Poonamalle including periodontitis, has gained attention during the
High Road, Chennai -600077 Tamil Nadu, India last few decades.4 Using saliva as a diagnostic marker
248 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
for monitoring various biological alternations in human Inclusion Criteria:
is an emerging trend worldwide. Human saliva is an
1. Presence of plaque
easily collectable biochemical fluid, which is similar
to blood in various biological aspects.It possesses 2. Presence of calculus
a simple and non-invasive collection with low-cost 3. Generalised clinical attachment loss ≥ 4 mm
storage and easily storage nature. Saliva contains both
locally and systemically derived biochemical molecules 4. Probing depth more than 5mm
with relatively important diagnostic value, which could 5. Generalised Gingival recession
be used for detecting periodontal diseases.5 It can be
used to assess both the severity of the disease as well Exclusion Criteria:
as monitoring the patient’s responses towards the 1. No history of systemic diseases
treatment. Detection of salivary biomarkers is a non-
2. Patients who have undergone periodontal therapy
invasive laboratory examination for early diagnosis of
periodontitis.6 3. No history of diabetes

Glutathione peroxidaseis a marker of oxidative stress 4. No history of hypertension

and dependent on the micro nutrient selenium (Se).7 Estimation of levels of MDA and glutathione
Periodontal diseases are associated with disturbances in peroxidase: The levels of MDA and Gpx was determined
the balance between the oxidants and antioxidants. This by the use OF chemical reagents and subjecting it to
causes an increase in Reactive oxygen species(ROS) colorimetric analysis with the help of a colorimeter.
as well as decreased antioxidant activity in saliva.8 Colorimetric analysis is a method of determining
Lipid peroxidation is a outcome of periodontitis. This the concentration of a chemical element or chemical
is caused by free radicals which leads to the production compound in a solution with the aid of a color reagent
of toxic and reactive aldehyde metabolites such as
MDA formed by the peroxidation of poly unsaturated Estimation of Defensin: This was estimated using
fatty acids.9 Defensin is an anti microbial peptide of the Enzyme Linked Immunosorbant Assay(ELISA).
human flora. In case of infection or inflammation, it
gets expressed on the surface of neutrophils. They Results
also directly stimulate antigen-presenting dendritic The data was statistically analysed. The table given
cells and memory T-cell, and thus can link innate and below shows the statistical data of the bio markers
adaptive immune responses.10,11 So, this study aims at estimated in the study.
evaluating the salivary bio markers which get expressed
in the periodontal diseases. The markers are Glutathione It is seen that the levels of Defensin is increased in
Peroxidase (Gpx), Malondialdehyde (MDA) and patients with periodontitis 9.18+-1.72 when compared
Defensin (beta-2) . to healthy subjects 6.22+-2.73(Table 1).The mean levels
of MDA is increased in patients with periodontitis
Materials and Method 2.35+-0.32 when compared to normal patients 3.58+-
0.36 (Table 2). The levels of Gpx is lower in patients
This was a case control study performed in the
with periodontitis 2.52+-0.58 when compared to normal
Department of Biochemistry, Saveetha Dental College
patients 3.58+-0.36 (Table 3). The p – value was found to
and Hospitals, Chennai. It was carried out in 20 subjects
be significant (0.001). Bar Graph 1,2,3 shows the levels
among which 10 patients had chronic periodontitis
of Defensin, Gpx, MDA respectively among patients
aged 50-70 years (group I) and 10 patients were healthy
with periodontitis and normal patients.
subjects (group II). Informed consent was obtained from
each patient before the study. Table 1: Levels of Defensin among patients with
periodontitis and normal patients
Saliva Collection: Unstimulated whole saliva
(Resting Saliva) from each participant was expectorated Subject Mean Standard Deviation p value
into sterile tubes prior to any kind of treatment. Group I 9.18 1.72
0.001
Group II 6.22 2.73
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 249
Table 2:Levels of Gpx among patients with
periodontitis and normal patients

Subject Mean Standard Deviation p value

Group I 2.52 0.58
0.001
Group II 3.58 0.36

Table 3: Levels of MDA among patients with

periodontitis and normal patients

Subject Mean Standard Deviation p value

Group I 2.35 0.32
0.001
Group II 0.94 0.58

Graph 3: Graph showing comparison of levels

of MDA among patients with and without
periodontitis.

Discussion
From the above results it is seen that the levels
of Defensin beta -2 and Malondialdehyde levels are
increased in case of periodontitis patients whereas the
level of Glutathione peroxidase is decreased when
compared to healthy subjects. The reason for the increased
levels of MDA is because, in case of periodontitis, there
is an imbalance between the oxidants and antioxidants
present in the oral cavity which ultimately leads to
the production of ROS. Therefore lipid peroxidation
occurs and there is increased MDA. For patients with
periodontitis there is increased oxidative stress occurs
Graph 1: Graph showing comparison of comparison which causes reduced antioxidant activity causing the
of levels of Defensin (beta 2). among patients with decrease of Gpx. Human defensin beta- 2 gets expressed
periodontitis and normal patients. on the surface of neutrophils which involves in innate
immunity causing phagocytosis of the bacterial flora.
Moreover it protects the undifferentiated stem cells of
the periodontium.

Several studies have shown similar results. In a

study done by Akalin et al,12 the levels of MDA was
elevated in saliva in patients with periodontitis. Lipid
peroxidation causes release of ROS which causes
the suitable host environment for resorption of bone,
degradation of connective tissue and increase in
the matrix metalloproteinase activity.13 Dhotre et al
conducted a study to find of any significant relation
between the serum and salivary levels of MDA. It was
reported that there was a significant increase in the levels
of serum MDA in patients with periodontitis. They even
concluded that this increase in the levels of MDA can
Graph 2: Graph showing Comparison levels of
be referred to the possibility of an association between
Gpx among patients with periodontitis and normal
periodontitis and cardiovascular disease. 14
Patients.
250 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
In accordance with the studies done to evaluate 3. Borrell LN, Burt BA, Taylor GW. Prevalence and
the levels of glutathione peroxidase there was varying trends in periodontitis in the USA: The [corrected]
results. In contrary to our study, A study done by Wei NHANES, 1988 to 2000. J Dent Res 2005;84:924-
et al15, showed the levels of Gpx was increased in the 30.
gingival crevicular fluid in patients with periodontitis. 4. Lima DP, Diniz DG, Moimaz SA, Sumida DH,
Not all patients demonstrated the increased level of Gpx Okamoto AC. Saliva: reflection of the body.
in periodontal diseases . For eg. A study by Brock et al16 International Journal of Infectious Diseases. 2010
reported the levels of GpX was reduced when compared Mar 1;14(3):e184-8.
to healthy subjects. This indicates that there is hampered
5. Dodds MW, Johnson DA, Yeh CK. Health benefits
antioxidant capacity in patients with periodontitis. This
of saliva: a review. Journal of dentistry. 2005 Mar
study is in accordance with the our study. The levels
1;33(3):223-33.
of Gpx might have a positive correlation between the
progression of disease.17 6. Todorovic T, Dozic I, Barrero MV, Ljuskovic B,
Pejovic J, Marjanovic M, Knezevic M. Salivary
Human Defensin beta -2 is profoundly indicative of enzymes and periodontal disease. Medicina
the antimicrobial activity occurring in the oral cavity. oral, patología oral y cirugía bucal. Ed. inglesa.
They play a major role in the adaptive and innate Immune 2006;11(2):4.
responses. They provoke efficient epithelial barrier 7. Arthur JR. The glutathione peroxidases. Cell Mol
repair to limit entry of invading bacteria.18 Related to the Life Sci. 2000;57:1825–1835.
severity of disease, some study conducted by Ertugrul et
8. Pompella A, Visvikis A, Paolicchi A, De Tata
al,19 found that significantly higher level of HBD-2 from
V, Casini AF. The changing faces of glutathione,
chronic periodontitis than gingivitis subjects (p<0.05)
a cellular protagonist. Biochem Pharmacol.
Another study by Sulijaya et al.20 reported that HBD-2
2003;66:1499–503.
protein level was higher in severe chronic periodontitis
than other patients. 9. Gupta M, Chari S, Kolte A, Chandankhede M,
Gupta M. Malondialdehyde levels in patients with
Conclusion chronic periodontitis. J Evolution Med Dent Sci.
2013;24(2):4325-8.
Thus to conclude the role of biomarkers in
10. Yang D, Chertov O, Bykovskaia SN, Chen Q, Buffo
periodontal diseases is to prevent the onset as well as
MJ, Shogan J, et al. Beta-defensins: Linking innate
the progression of the diseases. Antimicrobial peptides
and adaptive immunity through dendritic and T cell
provide multiple benefits as frontline defense molecules
CCR6. Science 1999;286:525-8.
and antioxidants can provide better integration of the
tissues. Nevertheless, therapeutic considerations for 11. Brogden KA, Heidari M, Sacco RE, Palmquist
the adjunctive use of glutathione, defensin and the D, Guthmiller JM, Johnson GK, et al. Defensin-
elimination of MDA in management of periodontitis can induced adaptive immunity in mice and its potential
limit the tissue damage and enhance the wound healing. in preventing periodontal disease. Oral Microbiol
Immunol 2003;18:95-9
Ethical Clearance: Taken from Instituitional 12. Akalin FA, Baltacioglu E, Alver A, Karabulut
Ethical Committee. E. Lipid peroxidation levels and total oxidant
Source of Funding: Self status in serum, saliva and gingival crevicular
fluid in patients with chronic periodontitis. J Clin
Conflict of Interest: Nil Periodontol 2007; 34:558-565.
13. Pendyala G, Thomas B, Suchetha K. The challenge
References of antioxidants to free radicals in periodontitis. J
1. Newman MG, Carranza FA, Takei H, Klokkevold Ind Soc Periodontology 2008 Sep-Dec; 12(3):79-
PR. Carranzas clinical Periodontology. 10th ed. 83.
Elsevier health sciences; 2006. 14. Dhotre PS, Suryakar AN, Bhogade RB.
2. Marsh PD. Dental plaque as a biofilm and microbial Oxidative stress in periodontitis: A critical link
community-implication for health and diseases. to cardiovascular disease. Biomedical Res 2011;
BMC Oral Health. 2006;6:S14. 22(2):178-182.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 251
15. Wei PF, Ho KY, Ho YP, Wu YM, Yang YH, Tsai 18. Vongsa RA, Zimmerman NP, Dwinell MB. CCR6
CC. The investigation of glutathione peroxidase, regulation of the actin cytoskeleton orchestrates
lactoferrin, myeloperoxidase and interleukin- human beta defensin-2- and CCL20-mediated
1beta in gingival crevicular fluid: implications for restitution of colonic epithelial cells. J Biol Chem
oxidative stress in human periodontal diseases. J 2009;284:10034-45.
Periodontal Res. 2004; 39:287-93. 19. Ertugrul AS, Dikilitas A, Sahin H, Alpaslan N,
16. Brock GR, Butterworth CJ, Matthews JB, Chapple Bozoglan A, Tekin Y. Gingival crevicular fluid
IL. Local and systemic total antioxidant capacity in levels of human beta‐defensins 1 and 3 in subjects
periodontitis and health. J Clin Periodontol. 2004; with periodontitis and/or type 2 diabetes mellitus:
31:515-21. a cross‐sectional study. Journal of periodontal
17. Tsai CC, Chen HS, Chen SL, Ho YP, Ho KY, Wu research. 2013 Aug;48(4):475-82.
YM, et al. Lipid peroxidation: a possible role in the 20. Sulijaya b, masulili sl, lessang r, soeroso y, auerkari
induction and progression of chronic periodontitis. ei. The human betaǧdefensinǧ1 level from smokers
J Periodontal Res. 2005; 40:378-84. with chronic periodontitis. Asian j pharm clin res.
2016;9(5):1-3.
252 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Effect of Neurodynamic Sliding Technique on

Hemiplegic Stroke Subjects with Hamstring Tightness

J. Anandhraj1, A. Kumaresan2
1MPT
(Neurology), Saveetha College of Physiotherapy, 2Assisstant Professor,
Saveetha College of Physiotherapy, Saveetha Medical Technical Sciences, Thandalam, Chennai

Abstract
Aim and Objectives: To determine the effect of Neurodynamic Sliding Technique On Hemiplegic Stroke
Subjects With Hamstring Tightness.

Methodology: Quasi Experimental study design was used in this study. Total 20 hemiplegic subjects with
hamstring tightness were selected. Then pre intervention measurements was taken using goniometer by
passive SLR test on affected side. Then all subjects underwent Neurodynamic sliding technique (NDST) for
20 repetitions and 3 sets. NDST was performed for 4 week. At the end of fourth week post test measurement
was taken. Then pre and post intervention measurements were taken using goniometer as per pre intervention
measurement. The values were tabulated and statistically analyzed.

Results: At the end of study data were analysed the mean score of Passive SLR for hamstring pre-
intervention 56.30 and post-intervention 62.55. Finally there is significant change in mean value (p & lt;
0.00).Conclusion: NDST shows minimal observable significance in hemiplegic subjects. Hence this NDST
should be practiced for long term effect.

Keywords: Neurodynamic sliding technique, hamstring flexibility, passive SLR test, Goniometer,hemiplegia.

Introduction of calf and hamstring may affect static, dynamic balance

of body and mobility3. Poor hamstring flexibility
Stroke occurs when an interrupted blood flow to
appears to be one accepted factor causes of hamstring
brain, without oxygen rich blood brain cells die. Stroke
injuries4, musculoskeletal disorders and reduction
is one of the leading causes of death and disability in
in physical performance5. Entire nervous system in
India. Incidence: 119-145/100000 based on recent
the body is a continuous structure which slides as we
population studies. Prevalence: 84-262/100000 in rural
move and the movement shows physiological processes
and 334-424/100000 in urban1. Hamstring muscles
such as blood flow to neuron. Nerve adhesions in the
have an important role in the performance of daily
hamstring may alter neurodynamics causing abnormal
activities such as controlled trunk movement, walking,
mechanosensitivity of the sciatic nerve; which could
and jumping2. Muscle tightness is one of the commonest
influence hamstring flexibility6. This mechanosensitivity
motor system factor which affect the balance. Tightness
of the neural tissue could limit hamstring length in
normal healthy individuals7. Before stroke the brain
communicated through spinal cord to the muscle
Corresponding Author: when to tighten and relax to control movement. After
Dr. J. Anandhraj stroke the affected brain is not able to understand the
Saveetha College of Physiotherapy, Saveetha Medical signals from the affected muscle. The signals has been
Technical Sciences, Thandalam, Chennai-602105 not transmitted to affected part of brain it undergo safe
e-mail: [email protected] mode. Spinal cord send its own impulse to muscle in
Contact No.: 9100230011 those limb to remain contracted or tight, so that muscle
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 253
don’t get overstretched and tight hamstring limits the Procedure: As pre-test values was noted for all 20
movement of pelvis in relation to the legs. Hamstring hemiplegic subject using goniometer measuring passive
pull the pelvis into backward tilt, rounding and putting SLR of hamstring muscle. A pair of examiners needed
strain over lower back. to measure the passive ROM of hamstring flexibility.
The subjects would be in supine lying with wedge is
Several stretching method have been used to improve placed under upper back for thorax and cervical flexion
muscle flexibility, including the static stretching, contract- also landmark identified and labelled marker: ASIS,
relax stretching, ballistic stretching and neurodynamic greater trochanter, lateral epicondyle of femur. One
sliding technique (NDST)8-10. Other conservative examiner has to perform passive SLR test by stabilising
techniques robotics to provide physical assistance, knee extension and ankle in neutral. Heavy dorsiflexion
virtual reality, extra corporeal shock wave therapy, is avoided to prevent calf muscle stiffness. Another
bilateral training or irradiational therapy, constraints- examiner has to place goniometer on axis of hip joint.
induced therapy functional electrical stimulation with The stable arm parallel to examine table and movable arm
biofeedback11. Neurodynamic is a manual method of parallel to the measuring limb by performing the passive
stretching in which force is applying to nerve structures SLR until the patient get pain over hamstrings and note
through posture and multi-joint movement, aiming down the values. All 20 subjects received neurodynamic
to produce a sliding movement of neural structures sliding techniqueand to produce the sliding movement of
relative to their adjacent tissues12. Neurodynamic is neural structures to relieve adjacent tissues. Cervical and
thought to decrease neural mechanosensitivity and thoracic spine should be in flexed position. Alternate hip
can be a beneficial technique in the management of flexion, knee flexion and dorsiflexion then hip extension,
hamstring flexibility13. Neurodynamics change in knee extension and plantar flexion was performed.
mobility of nervous system achieved through movement NDST were performed for 15 repetitions and 3 sets5
and stretching could modify such sensations. NDST days/week for 4 weeks. Post test measurement is done
interventions to decrease neural mechanosensitivity, after intervention.
this intervention could be beneficial in the hamstring
flexibility14. Decreased hamstring flexibility as Result
evidenced by limited range in the passive straight leg
raise test (SLR) could be due to altered neurodynamics The statistical analysis revealed significant
affecting the sciatic, tibial, and common fibular nerves15. difference (P<0.0001) between pretest and posttest
Altered posterior lower extremity neurodynamics could values of hamstring ROM within the group. The pretest
arguably influence resting muscle length and lead to mean value is 56.30(SD=8.84) and posttest mean value
changes in the perception of stretch or pain16. Providing 62.55(SD=8.87). This shows that hamstring ROM of test
movement or stretching could lead to changes in the in posttest values were comparatively less than pretest
neurodynamics and modification of sensation and could value- p<0.0001 and t- value is 32.8564 (Table No. 1).
help to explain the observed increase in flexibility. Table 1: Comparison of pre-test and post-test values
of Hamstring ROM
Methodology
Participants: Patients were participate in this study Hamstring Standard
Mean t-value P- value
ROM Deviation
was screened for inclusion subjects of both the gender
within the age group of 60 years or more, physically Pre test 56.30 8.84
independent, not currently engaged in a structural 32.8564 <0.0001
exercise program, Able to understand and follow simple Post test 62.55 8.87
verbal instructions, and exclusion criteria Physical or
functional impairments, Dementia, Alzheimer’s disease, Discussion
Parkinson’s disease, Any Musculoskeletal disorder
The results confirmed our initial hypothesis that
20 sample was selected using convenient sampling
an isolated neurodynamic sciatic sliding technique
technique. They were explained about safety and
would provide a greater immediate improvement in
simplicity of the procedure and informed consent was
hip flexion, assessed by passive SLR, than hamstring
obtained. This study is conducted in Saveetha College of
stretching or placebo. Very few studies have examined
physiotherapy OPD Thandalam, Chennai India.
the effect of neurodynamic interventions on hamstring
254 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
flexibility17,18. The results of this study can be seen as Ethical Consideration: The study was approved
adding further evidence for the potential role of neural by Institutional Ethics committee (017/12/2018/IEC/
tissue mechanosensitivity in limiting the SLR19. There SU on 27/12/2018) and was done in accordance with
are many approaches to treat the hamstring tightness Ethical Guidance for the Human Participants. This
in stroke like stretching, cryotherapy, Proprioceptive study protocol was approved by institutional Ethical
neuromuscular facilitation techniques are commonly committee.
provided treatments.
Conflict of Interest: Nil
While some theories explaining the therapeutic
effects of muscle stretching suggest there is alteration Sources of Funding: Self
of the viscoelastic properties of muscles, studies have
Reference
shown the importance of distinguishing between real
and apparent increases in muscle flexibility20. The 1. Jeyrajduraipandiyan, paulinsudhan; Stroke
pretest measurement of hamstring ROM of stroke epidemiology and stroke care service in India,.J
subjects were measured with the use of goniometer then Stroke. 2013 Sep; 15(3): 128–134.
NDST is performed to the patient and post measurement 2. Lumbroso D, Ziv E, Vered E, Kalichman L. The
of hamstring ROM values are noted with the help of effect of kinesio tape application on hamstring and
goniometer. In this study NDST shows hamstring gastrocnemius muscles in healthy young adults. J
flexibility in stroke patients. There is marked significant Bodyw Mov Ther. 2014; 18:130-8.
increase in mean value from pre test to post test
3. Shah, Chaitali The effect of Hamstring and
mean value. When they added a neurodynamic slider
Calf Tightness on Static, Dynamic Balance
technique they found greater mean increases of 62.55 in
and Mobility-A Correlation Study Article;
the hemiplegic SLR.
October 2013;Indian Journal of Physiotherapy &
Limitations of this study only examined immediate Occupational Therapy;Oct-Dec2013, Vol. 7 Issue
effects of a single episode and the lack of longer term 4, p17
follow-up should be considered. It is not known how long 4. Adel Rashad Ahmed and Ahmed Fathy Samhan;
the observed increase in hamstring flexibility might have Short Term Effects of Neurodynamic Stretching
lasted. Furthermore, it is not known if repetition and an and Static Stretching Techniques on Hamstring
appropriate dosage of the neurodynamic interventions Muscle Flexibility in Healthy Male Subjects;. Int J
over time might lead to longer lasting effects. Finally, we Med Res Health Sci. 2016, 5(5):-36‑41
did not conduct any long-term follow-up to determine if 5. Forman J, Geertsen L, Rogers ME. Effect of deep
the observed changes in flexibility might have resulted stripping massage alone or with eccentric resistance
in any change in incidence of hamstring injuries in on hamstring length and strength. J Body Mov
these subjects with short hamstring tightness in stroke Ther. 2014; 18:139-44.
subjects. Further recommendation of the study is long
6. Lew P C and Briggs C A. Relationship between the
term intervention in neurodynamic sliding technique.
cervical component of the slump test and change in
And also relatedly with other techniques were included
hamstring muscle tension. Manual Therapy (May).
in future study.
1997; 2(2), 98-105.
Conclusion 7. McHugh MP, Johnson CD, Morrison RH. The
role of neural tension in hamstring flexibility.
These results show that the Neuro dynamic sliding Scandinavian Journal of Medicine & Science In
is an acceptable and effective intervention for stroke to Sports Apr. 2012; 22(2), 164-169.
promote improvements in important aspects of hamstring
8. Herrington L. Effect of different neurodynamic
flexibility and Range of motion in a sample of stroke
mobilization techniques on knee extension range of
subjects. NDST shows minimal observable significance
motion in the slump position. J Man Manip Ther.
in hemiplegic subjects .Since there is marked clinical
2006; 14:101-107.
outcomes with this immediate technique, Hence this
NDST would be practiced for long term effect. Mean 9. Stephens J, Davidson J, Derosa J, Kriz M, Saltzman
value of pre test and post test. N. Lengthening the hamstring muscles without
stretching using “awareness through movement”.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 255
Phys Ther. 2006; 86:1641-50. Therapy, vol. 10, no. 12, pp. 481–487, 1989. View
10. George JW, Tunstall, AC, Tepe RE, Skaggs CD. at Google Scholar · View at Scopus
The effects of active release technique on hamstring 16. P. W. M. Marshall, A. Cashman, and B. S. Cheema,
flexibility: A pilot study. J Manipulative Physiol “A randomized controlled trial for the effect of
Ther. 2006; 29(3):224-7. passive stretching on measures of hamstring
11. Bhavana Suhas Mhatrea. Which is better method to extensibility, passive stiffness, strength, and stretch
improve perceived hamstring tightness – Exercises tolerance,” Journal of Science and Medicine in
targeting neural tissues mobility or exercises Sport, vol. 14, no. 6, pp. 535–540, 2011. View
targeting hamstring muscle extensibility. Published at Publisher · View at Google Scholar · View at
online July29 2013. Scopus
12. Kavlak Y, Uygur F. Effects of nerve mobilization 17. C. Kornberg and P. Lew, “The effect of stretching
exercise as an adjunct to the conservative treatment neural structures on grade one hamstring injuries,”
for patients with tarsal tunnel syndrome. J Journal of Orthopaedic and Sports Physical
Manipulative Physiol Ther. 2011; 34:441-448. Therapy, vol. 10, no. 12, pp. 481–487, 1989.
13. De-la-Llave-Rincon AI, Ortega-Santiago R, 18. R. Méndez-Sánchez, F. Alburquerque-Sendín,
Ambite-Quesada S, Gil-Crujera A, Puentedura EJ, C. Fernandez-de-las-Peñas et al., “Immediate
Valenza MC, Fernández-de-las-Peñas C. Response effects of adding a sciatic nerve slider technique
of pain intensity to soft tissue mobilization and on lumbar and lower quadrant mobility in soccer
neurodynamic technique: a series of 18 patients players: a pilot study,” Journal of Alternative and
with chronic carpal tunnel syndrome. Journal of Complementary Medicine, vol. 16, no. 6, pp. 669–
Manipulative and Physiological Therapeutics. 675, 2010.
2012; 35(6): 420–427. 19. B.S. Boyd, L. Wanek, A.T.Gray, and K.S. Topp,
14. Yolanda Castellote-Caballero, marie C. valenza, mechanosensitivty of the lower extremity nervous
Emilioj. Puentedura, cesarfernandez-de-las-penas, system during straight-leg raise testing in healthy
Immediate effect of neurodynamic sliding versus individuals, journal of manipulative and physiology
muscle stretching on hamstring flexibility in thereutics, vol, 35,no.6,pp.420-427,2017.
subjects with short hamstring syndrome. Journal of 20. H. Folpp, S. Deall, L. A. Harvey, and T. Gwinn,
Sports Medicine Volume 2014 (2014), Article ID “Can apparent increases in muscle extensibility with
127471, 8 pages. regular stretch be explained by changes in tolerance
15. C. Kornberg and P. Lew, “The effect of stretching to stretch?” Australian Journal of Physiotherapy,
neural structures on grade one hamstring injuries,” vol. 52, no. 1, pp. 45–50, 2006.
Journal of Orthopaedic and Sports Physical
256 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

To Compare the Flexural Properties of Three Commercially

Available Heat Cure Denture Base Resins After Water
Immersion Over a Period of Three Months: An in Vitro Study

Neha Chugh1, Pradeep Sheriger2, Dhanasekar Balakrishnan3, Aparna Ichalangod Narayan4

1Post Graduate Student, 2Additional Professor, 3Professor and Head, 4Professor, Department of
Prosthodontics and Crown and Bridge, Manipal College of Dental sciences, Manipal

Abstract
Aim: To evaluate and compare the flexural properties of three commercially available brands of PMMA heat
cure denture base resins after water immersion over a period of 3 months.

Method and Material: Commercially available heat cure denture base resins (DPI, Triplex, and Trevalon)
were used in the study. An aluminum die was fabricated according to ISO 1567. Each of the tested materials
was manipulated according to manufacturer’s instructions. Total of 60 samples were made (n=10). With
3 control (dry) groups and three experimental (water immersed) groups. The samples were subjected to
INSTRON universal testing machine.

Statistical Analysis Used: Student ‘t’ test, ANOVA and Post hoc tukey’s test.

Results: Student ‘t’ test indicated that there is significant difference in the flexural properties of the denture
base resins after long term water immersion with p<0.05 for all the three groups. ANOVA indicated that
there was no significant difference among the three groups/brands.

Conclusions: The flexural properties of heat cure denture base resins was affected by long term water
immersion. The ultimate flexural strength decreased, flexural strength at proportional limit remained same
and modulus of elasticity decreased. Thus after long term water immersion, the denture base material
becomes weaker and stiffer.

Keywords: Denture base resins; Flexural strength; tensile strength; elastic modulus; Water sorption; Water
immersion.

Introduction commonly used in the fabrication of complete & partial

dentures, various other intraoral and extraoral prostheses
Acrylic resins were acquainted to dentistry in 19371,2
and has an acceptable overall performance.
and since that time, none of the materials equaled the
appearance of the oral soft tissues with such pronounced Skinner and Cooper3 suggested that a minor lack
reliability as acrylic resin. The acrylic resins are now in dimensional stability must be accepted as one of the
short comings of acrylic resin dentures, with shrinkage
and expansion being the two unavoidable glitches.

Corresponding Author: For acrylic prostheses to thrive effectively in a

Pradeep Sheriger hostile oral environment, it should possess acceptable
Additional Professor, Room No. 5 Department of mechanical and physical properties, i.e. flexural strength,
Prosthodontics and Crown and Bridge, Manipal hardness, water sorption, solubility.4,5 Physical and
College of Dental Sciences, Manipal mechanical properties may vary among different groups
e-mail: [email protected] of acrylic resins, which is a result of differences in their
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 257
chemical structure and the cycle of polymerization
process.6-9 In addition to distortions which may occur
due to thermal softening or release of internal stresses
other mechanism such as water sorption may also
contribute to dimensional instability as well10.

A usual weakness of the denture base polymers with

respect to fatigue is the flexural strength, which limits its
use in demanding clinical situations.11,12 Studies13 have
been conducted to evaluate the relationship between
the flexural strength and the period of water immersion
showing a significant decrease in the flexural strength at
proportional limit for the denture reline materials when Figure 1
the duration of water immersion was increased from Aliminum die
1 to 30 days. Further studies14 also exhibited flexural
strength at proportional limit remained constant after Selection and Manipulation of denture base
water immersion. materials: Three commonly used Denture Base
Materials were used for the study. The materials were
Other studies also showed that the ultimate flexural divided into three groups of 20 samples each, with a total
strengths and flexural moduli of dry specimens of acrylic of 60 samples (figure 2).
resin composites had decreased after 48 weeks of water
immersion15 and fiber reinforced composites after 10
years of water immersion16.

Some studies have been done investigating the

relationship between the mechanical properties of
denture polymers and the water immersion period13, 15-17
however, to best of our knowledge, there is insufficient
information to systemically evaluate the effect on the
flexural properties of denture immersed in water over a
longer period.

In this context, the purpose of this study was to

investigate the flexural properties of three brands of
commercially available denture base resins subjected to
water immersion over a period of three months. Figure 2

Subjects and Method Acrylic Samples:

The study was directed to evaluate and compare Group I: PMMA pink heat cure resin (Dental
the flexural properties of three commercial brands of Products of India, Mumbai)
Poly methylmethacrylate (PMMA) heat cure denture
base resins after water immersion over a period of three Group II: PMMA pink heat cure resin (SR Triplex
months. Efforts were made to select and utilize standard Hot, IVOCLAR VIVADENT AG)
method and materials. Group III: PMMA pink heat cure resin (Trevalon,
Preparation of the Master Die: Aluminum Dentsply India Private Limited. Gurgaon Haryana)
Master Die of dimension 65×10×3 mm3 (figure 1) Preparation of samples:-The heat cure denture
was fabricated using a Milling Machine in accordance base materials were dispensed and mixed following
with ISO 1567:1999, International Organization for manufacturer’s instructions. When the mix reached the
Standardization, Geneva, Switzerland, 1999 for Denture dough stage, the die was packed and a cellophane sheet
Base Polymers.18 was used as separating medium between the die and the
258 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
resin mix. After packing, the die was placed in a Kavo F: Load at fracture, L: Span length that was 50mm,
clamp which was subsequently placed in a hydraulic b: Width of the Specimen,h: thickness of the specimen.
press at 2000 psi for 5 mins. Overnight bench curing was
allowed and then the samples were placed in an acrylizer Calculation of Flexural Strength at Proportional
for long curing, bench cooled overnight and samples Limit:-FPL = 3F1L/2bh2
were removed from the die and finished with 100, 200, F1: Load at Proportional limit. The load at
400 and 600grit of sandpaper, followed by polishing proportional limit was determined from each load
with pumice deflection graph that was plotted for every specimen,L:
Storage in water: The samples were divided into Span length that was 50 mm,b: Width of the specimen,
six sub groups, three sub groups Ia, IIa, IIIa were used h: Thickness of the specimen.
as control. The other three sub groups Ib, IIb, IIIb were Calculation of Elastic Modulus: MOE=F2L3/4bh3d
weighed and stored in distilled water at 37⁰C and the
specimens were then subjected to flexural testing. F2: Load at any point on the straight line of the load/
deflection graph,L: Span length 50mm,b: width of the
Test for flexural properties: The specimens were specimen,h: Thickness of the specimen,d: Deflection
tested for ultimate flexural strength (MPa), flexural corresponding to F2.
strength at the proportional limit (MPa) and the elastic
modulus (MPa). Height and width of each specimen was Statistical Analysis: Data was analyzed using
recorded before testing. Dry specimens (control group) Statistical Package for Social Sciences (SPSS), version
were tested soon after they were prepared. For water 18.0 (SPSS Inc. Chicago IL). Mean (X) and Standard
immersed specimens, each specimen was taken out one Deviation (SD) was calculated for ultimate flexural
by one from water storage and placed on a 50 mm-long strength, flexural strength at proportional limit and
support for three point flexural testing. A vertical load modulus of elasticity.
was then applied at the mid-point of the specimen at a
crosshead speed of 5 mm/min on a load testing machine. For all the tests a p-value of <0.05 was considered
Load was applied until failure, and fracture load was statistically significant. Comparison of mean values
recorded in Newtons (N) (figure 3). was done using ANOVA with post-hoc Tukey’s test.
Comparison of mean before and after values were done
using student t test.

Results
Mean ultimate flexural strength (UFS) for group
Ia, Ib; IIa, IIb; IIIa, IIIb were compared using student
t test. There were significant differences in the values
of ultimate flexural strength among the dry and the wet
samples of each group/brands. (Table 1)

Mean flexural strength at proportional limit (FPL)

for Ia (dry) (34.89±4.36), Ib (wet) (37.92±5.65), IIa
(dry) (32.87±3.58), IIb (wet) (35.16±4.25), IIIa (dry)
(37.04±5.48), IIIb (wet) (35.50±6.98) compared with
Figure 3 student t test. There was no significant difference in the
values of flexural strength at proportional limit among
Testing using Instron machine: All the tests were the dry and the wet samples of each group/brands.
performed under uniform atmospheric conditions of
23.0 ± 1⁰C and 50 ± 1% relative humidity and calculated Mean modulus of elasticity (MOE) for group Ia,
using formulas. Ib; IIa, IIb; IIIa, IIIb were compared using student t
test. There was significant difference in the values of
Calculation of ultimate flexural strength: UFS = modulus of elasticity among the dry and the wet samples
3FL/2bh2 of each group/brands. (Table 2) MOE increased after
water immersion.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 259
When compared among the three brands the flexural properties were similar to each other and there was no
significant difference.

Table 1: Comparison of ultimate flexural strength (UFS) of dry and wet samples of each group/brands.

Dry (a) Wet (b)

UFS p-value
Mean SD Mean SD
Group I 93.51 6.55 79.62** 10.17 0.002; Sig
Group II 92.65 5.93 72.92** 8.03 <0.001; Sig
Group III 91.66 8.65 79.88** 8.37 0.008; Sig

Table 2: Comparison of modulus of elasticity (MOE) of dry and wet samples of each group/brands.

Dry (a) Wet (b)

MOE (Ƞ) p-value
Mean SD Mean SD
Group I 2588.33 195.11 2724.60 194.54* 0.031; Sig
Group II 2472.16 126.52 2738.57 218.19** <0.001; Sig
Group III 2488.11 123.32 2803.24 170.38** <0.001; Sig

* (P < 0.05) ** (P <0.001)

Discussion The second parameter evaluated in this study was

the flexural strength at proportional limit (FPL). Denture
The ultimate flexural strength of a material reflects
base plastics typically exhibit considerable plastic
its potential to resist catastrophic failure under a flexural
deformation before fracture. The plastic deformation
load. High flexural strength is crucial to denture wearing
beyond its proportional limit permanently alters the
success, as alveolar resorption is a gradual, irregular
dimensions of a denture and is not clinically acceptable.
process that leaves tissue-borne prostheses unevenly
Hence, in this study, the flexural strength at the
supported. As a foundation, the acrylic resin materials
proportional limit was also evaluated. The proportional
should exhibit a high proportional limit to resist plastic
limit of each sample was calculated using the load
deformation and also exhibit fatigue resistance to endure
deflection graph. The values of mean flexural strength at
repeated masticatory loads.19 The prime and most
proportional limit (FPL) showed that the flexural strength
frequent site of fracture in the upper denture is in the
at proportional limit (FPL) did not show any significant
medial line. During chewing, denture base material is
difference after water immersion over a period of three
subjected to flexural deformation.20 An acrylic resin
months. These results were in accordance with the
capable of sustaining higher flexure in combination
previous studies done by Takahashi17, 21 et al in 1999,
with high resistance to cyclic loading may be less prone
and in 2013, and Sasaki14 et al in 2016.
to clinical failure.19 In the present study, INSTRON
three point bend test was used to calculate the flexural The third parameter used in the study was modulus
properties, including the measurement of ultimate of elasticity (MOE). As modulus of elasticity increases,
flexural strength, modulus of elasticity and flexural the material becomes more rigid. A denture base material
strength at proportional limit. with a high elastic modulus can withstand permanent
mastication-induced deformation.22 The present study
The results of this study revealed that, the ultimate
showed decrease in the modulus of elasticity after long
flexural strength of three groups/brands of heat cure
term water immersion for all the groups. These results
denture base resins reduced significantly after long
are consistent with the previous studies conducted by
term water immersion. These results were similar to
Vallittu15, 16 et al in 1998 and 2007 and Sasaki13 et al in
the results as shown by previous studies conducted by
the 2016. The results varied from the study conducted by
Vallittu et al in 1998 for 48 weeks15 of water immersion
Takahashi et al in 2103 where the Modulus of elasticity
and in 2000 for 10 years16 of water immersion.
increased after water immersion.21 This variation in
260 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
results may be due to difference in control groups. In Source of Funding: Self
the present study the controls were dry samples, while in
study done by Takahashi21 et al the control samples were Conflict of Interest: Nil
immersed in water.
References
Thus, the strength of a denture polymer at a given 1. Sear VH. Developments in denture field during the
time after water immersion is affected by the relative past half century. J Prosthet Dent 1958; 8:61-7.
number of those molecules present17. Similarly, in this
2. Peyton FA. History of resins in dentistry. Dent Clin
study, the outward leakage of the soluble constituents
North Am 1975; 19:211-22.
affected the flexural properties and it appeared that
the ultimate flexural strengths and the elastic modulus 3. Skinner EW, Cooper EN. Physical properties of
decreased. As a result, the denture base resins became denture resins: part I. Curing shrinkage and water
weak and less stiff after long term water immersion. sorption. J Am Dent Assoc 1943; 30:1845-52.
From these results, it appears that denture base resins 4. Krunić N, Kostić M, Anđelković M. Acrylic resins
generally trend toward decreasing the elastic modulus - still irreplaceable materials in prosthetic dentistry.
after water immersion over a period of three months. Acta Stomatol Naissi 2007; 23: 747-52.
5. Uzun G, Hersek N. Comparison of the fracture
To summarize, water immersion over a period of
resistance of six denture base acrylic resins. J
three months generally decreased the ultimate flexural
Biomater Appl 2002; 17: 19-29.
strength and did not change the flexural strength at the
proportional limit, it also increased the elastic modulus 6. Bartolini JA, Murchison DF, Wofford DT, Sarkar
of the denture base resins. The decrease in the ultimate NK. Degree of conversion in denture base materials
flexural strength of denture resins results in weakness, for various polymerization techniques. J Oral
which is not acceptable in material science. However, no Rehabil 2000; 27: 488-93.
change in the flexural strength at the proportional limit 7. Lai CP, Tsai MH, Chen M, Chang HS, Tay HH.
of denture resins means keeping the resistance to plastic Morphology and properties of denture acrylic resins
deformation and an increase in the elastic modulus of cured by microwave energy and conventional water
denture resins causes stiffness, which are both clinically bath. Dent Mater J 2004; 20: 133-41.
acceptable. 8. Vergani CE, Seo RS, Pavarina AC, dos Santos Nunes
Reis JM. Flexural strength of autopolymerizing
Conclusion: denture reline resins with microwave post
Within the limitations of the study, it was concluded polymerization treatment. J Prosthet Dent 2005;
that, 93: 577-83.
9. Spartalis GK, Cappelletti LK, Schoeffel AC, Michel
1. The flexural properties of all the three denture base
MD, Pegoraro TA, Arrais CAG, Neppelenbroek
resins were affected by water immersion over a
KH, Urban VM. Effect of conventional water-bath
period of three months.
and experimental microwave polymerizationcycles
2. The ultimate flexural strength decreased after l water on the flexural properties of denture base acrylic
immersion over a period of three months. resins. Dent Mater J 2015;34(5): 623–628.
3. However the flexural strength at proportional limit 10. Powers JP, Sakaguchi RL. Craig’s restorative
remains the same after water immersion over a dental materials. 12th ed. St. Louis, MO; Mosby;
period of three months. 2006.p. 517-524
11. Mutluay MM, Ruyter IE. Evaluation of adhesion
4. The modulus of elasticity decreased after water
of chair side hard relining materials to denture base
immersion over a period of three months.
polymers. J Prosthet Dent 2005; 94:445-52.
5. When compared among the three brands the flexural 12. Mumcu E, Cilingir A, Gencel B, Sülün T.
properties were similar to each other and there was Flexural properties of a light-cure and a self-cure
no significant difference. denture base materials compared to conventional
Ethical Clearance: Taken from Institutional ethical alternatives. J Adv Prosthodont 2011; 3:136.9.
committee, Manipal.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 261
13. Takahashi Y, Chai J, Kawaguchi M. Effect of water term water immersion. Int J Prosthodont 1999;
sorption on the resistance to plastic deformation of 12:348–52.
a denture base material relined with four different 18. International Standard. ISO 1567 AMENDMENT 1
denture reline materials. Int J Prosthodont 1998; for Dentistry—Denture base polymers Amendment
11:49–54. 1. Genève, Switzerland: International Organization
14. Sasaki H, Hamanaka I, Takahashi Y, Kawaguchi for Standardization; 2003
T. Effect of long-term water immersion or thermal 19. Diaz-Arnold AM, Vargas MA, Shaull KL, Laffoon
shock on mechanical propertiesof high-impact JE, Qian F. Flexural and fatigue strengths of denture
acrylic denture base resins. Dent Mater J 2016; base resin. J Prosthet Dent 2008; 100:47-51.
35(2): 204–209
20. Smith DC. The acrylic denture. Mechanical
15. Vallittu PK, Ruyter IE, Ekstrand K. Effect of water evaluation, mid-line fracture. J Prosthet Dent.
storage on the flexural properties of E-glass and 1961;110:257–67
silica fiber acrylic resin composite. Int J Prosthodont
21. Takahashi Y, Hamanaka I, Shimizu H. Flexural
1998; 11:340–50.
properties of denture base resins subjected to
16. Vallittu PK. Effect of 10 years in vitro ageing long-term water immersion. Acta Odontologica
on flexural properties of fiber reinforced resin Scandinavica 2013; 71: 716–720.
composites. Int J Prosthodont 2007; 20:43-45.
22. Anusavice KJ, Shen C and Rawls HR. Phillip’s
17. Takahashi Y, Chai J, Kawaguchi M. Equilibrium Science of Dental Materials, 12th ed, WB Sanders:
strengths of denture polymers subjected to long- An imprint of Elsevier; 2013.
262 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Effect of Weight Bearing and Neurobic Exercises on

Bone Health and Physical Function in Elderly Individuals

Neha Dighe1, S. Anandh2, G. Varadharajulu3

1MPTh (Community Health Sciences), 2Professor, Unit Head (Community Health Sciences), 3Dean, Professor,
HOD, Krishna College of Physiotherapy, Krishna Institute of Medical Sciences Deemed to be University,
Karad, Maharashtra, India

Abstract
Aim: To study the effect of weight-bearing and neurobic exercises on bone health and physical function in
elderly individuals.

Objectives: The Objectives of the study are as follows: [1] To find out the effect of weight bearing on bone
health and physical function in elderly individuals. [2] To find out the effect of weight bearing and neurobic
exercises in combination on bone health and physical function in elderly individuals.

Method: Ethical clearance was obtained from Institutional Ethical Committee. 80 elderly individuals were
assessed and 62 were included in the study based on inclusion criteria, the individuals were allocated into
two groups: Group A (n= 31) received Weight-bearing exercises and Group B (n= 31) received Weight-
bearing and Neurobic exercises in combination. Pre and post-test were done for fasting serum calcium,
alkaline phosphatase and SF 36 Health related quality of life questionnaire physical function component and
the outcome measures were analysed after 6 weeks.

Result: Intergroup statistical analysis for serum calcium (p<0.0001), Alkaline phosphatase (p<0.0001) and
SF 36 physical function component (p<0.0001) revealed extremely significant difference post intervention.
Analysis of serum calcium, alkaline phosphatase and SF 36 score for group A (p<0.0001) and for group B
(p<0.0001) was extremely significant respectively.

Conclusion: The study results concluded that Weight bearing and Neurobic exercises was significantly
effective in improved bone health and physical function both individually and in combination.

Keywords: Weight bearing, Neurobic, Exercises, Bone health, Physical function, Elderly individuals.

Introduction and alkaline phosphatase.[3] Osteoporosis is a systemic,

skeletal disease characterised by low bone density
Geriatrics is the branch of medicine dealing with the
and micro-architectural deterioration of tissue with
physiologic characteristics of aging and the diagnosis
consequent increase in bone fragility. It is more common
and treatment of diseases affecting the aged.[1] Elderly
in postmenopausal women due to cessation of oestrogen
people show variations in age related physiological
secretion. There may be a risk in males also due to
decline and gives rise to disorders. Age related decline
calcium and vitamin deficiency of vitamin D, sedentary
in bone metabolism, reabsorption, nutrition, muscle
lifestyle, smoking, alcoholism and excess caffeine.
strength, memory, mobility and locomotion. [2] Elderly [4] The prevalence of osteoporosis in India (Delhi) as
individuals with nutritional deficiency of calcium,
24.6% in men and 42.5% in women above 50 years of
vitamin D and poor mobility experiences decline in
age.[5] There is a positive correlation for prevalence in
normal functioning which gives rise to osteoporosis and
low calcium levels and hampered reabsorption and bone
imbalance in bone biomarkers such as serum calcium
metabolism. Assessment of specific alkaline phosphatase
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 263
has an important role in prevention and treatment bone life in elderly individuals. The exercises will amplify the
related disorders Bone biochemical markers can provide efficacy of both bone health and physical function.
practical detection of the exercise response on bone cells.
Serum bone alkaline phosphatase (B-ALP) and serum Method
calcium used to indicate bone synthesis. The major • Study type: Experimental study
regulator of bone metabolism is Parathyroid hormone
(PTH) to maintain the calcium-ion concentration, • Study design: Pre-test Post-test
which is a primary determinant of intracellular calcium • Study duration: 1 year
homeostasis. The stimulation of bone formation and
reabsorption can be initiated by weight bearing exercises. • Sample size: 31+31 = 62
The use of biomarkers to determine the mechanism of • Place of study: Krishna Hospital, Karad
impact of exercises on bone health. [6,7] On the other
Criterion of the Study:
hand there is a gradual decline of cognitive function with
aging which causes difficulty in conducting activities of Inclusion Criteria:
daily living and worsens the quality of life, hence SF 36
• Elderly individuals of age group 60 to 80 years.
physical HRQOL questionnaire to assess the quality of
life and improve it by exercises for both the domains like • Both men and women are involved.
physical function and bone health.[8] • Elderly individuals diagnosed with low serum
Weight bearing exercises are mechanical loading calcium less than 8.5 mg/dL.
exercises on joints, which are essential for building and Exclusion Criteria:
maintaining healthy bones, and they include activities
• Elderly individuals with significant visual or hearing
recruiting muscle work and stimulate bone metabolism
impairment.
against gravity. During weight bearing, exercise bones
adopt to the impact of weight and pull of muscles help • Elderly individuals with neurological disorders.
building newer bone cells. In addition, it improves
• Elderly individuals with recent surgeries.
strength, joint mobility and reduces risk of fractures as
well as osteopenia and osteoporosis. [9] Procedure: An approval for the study was obtained
from the Protocol committee and institutional Ethical
A unique brain exercise program known as neurobic Committee of KIMSDU. Awareness program was carried
exercises are based on the latest findings of scientific out for elderly individuals in karad and surrounding rural
research, which include the combinations of physical areas near Krishna hospital.
senses such as hearing, vision and memory. Neurobic
exercises stimulate neural activity to strengthen and Geriatric subjects were screened and those fulfilling
grow brain cells continuously, which activates neural the criteria were involved. Participants were informed
systems to work and increases blood supply to the about the study, thorough information was given, and
brain. The cortex and hippocampus are involved during importance for testing serum calcium and alkaline
such activities, located at medial temporal lobe. In phosphatase was explained.
addition, Neurobic exercise stimulates pattern of neural
Informed Consent was taken from the subjects. Pre-
activity, which in turn improves cognitive function
test assessment was taken by using blood investigations of
and helps in better physical function. In this study the
serum calcium and alkaline phosphatase with permission
use of simultaneous performance of multiple tasks
and help of staff from biochemistry department and
is done which will concurrently challenge the motor
nursing staff and questionnaire SF 36 health related
and cognitive function.[10] These exercises are dual
quality of life, physical function component was taken
task technique to explore multi-tasking and effect of
and data collection sheets were collected.
this training on physical function. [11] Combination of
weight-bearing and neurobic exercises may demonstrate Subjects involved in the study were divided into
positive effects on physical function in aging. two groups. The sampling method was consecutive
sampling. Exercise protocol was started.
There are literatures which prove both physical and
cognitive training have potentials to improve quality of
264 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Group A: Subjects were given used weight-bearing investigation of serum calcium, alkaline phosphatase
exercises. and questionnaire SF 36 health related quality of life,
physical component to assess the patient.
Group B: Subjects were given weight bearing and
neurobic exercises in combination. The interpretation of the study was done on the basis
of comparing pre-test and post-test assessment using
After completing 6 weeks with 3 sessions per outcome measures and were statistically analysed.
week, post-test assessment was taken by using blood

Following exercises were given for Group A and B:

Sr. No. Weight-bearing exercises (Group A) Weight bearing and neurobic exercises (Group B)
Mini squat and table of 10 aloud as instructed by therapist
1. Mini squats 30 x 3 sets
30x3
Quadruped transition and leg raises and hand raises 30 x 3 Lunge walking with half kg dumbbells and count backward
2.
sets from 100 30x3 sets
Transitions in quadruped with reach outs and read the
3. Lunges with alternate legs 30x 3 sets
colour of the print shown 30x 3 sets
Squats and pick up the colour of ball from the basket as
4. Standing leg curls with support 30 x 3 sets
instructed by therapist 30x 3 sets
5. Wide leg squats with sit to stand 30 x 3 sets Wide leg squats with Swiss ball in the hand 30x3 sets
Standing leg curls with chart on the wall and point out the
6. Seated rowing with half kg dumbbells 30x 3 sets
instructed numbers 30 x 3 sets
Alternate step up with random number generation 30x 3
7. Step ups 30 x 3 sets
sets

Results
Table No. 1: Comparison of pre and post serum calcium, alkaline phosphatase and SF 36 score within the
group

Mean±SD P value T value df

Group A Pre Serum Calcium 7.643±0.4248
<0.0001 17.727 29
Group A Post Serum Calcium 8.686±0.3411
Group A pre alkaline Phosphatase 108±16.509
<0.0001 14.088 29
Group A post alkaline phosphatase 150.1±3.986
Group A pre SF 36 score 54.8±4.979
<0.0001 8.960 29
Group A post SF 36 score 69.033±7.384

Table No. 2: Comparison of pre and post serum calcium, alkaline phosphatase and SF 36 score within the
group

Mean±SD P value T value df

Group B Pre Serum Calcium 7.39±0.4788
<0.0001 13.524 29
Group B Post Serum Calcium 8.71±0.1788
Group B pre alkaline Phosphatase 107±17.486
<0.0001 11.032 29
Group B post alkaline phosphatase 140.73±11.298
Group B pre SF 36 score 58.9±5.851
<0.0001 18.058 29
Group B post SF 36 score 76.566
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 265
Table No. 3: Comparison of pre pre serum calcium, alkaline phosphatase and SF 36 score between the
groups

Mean±SD P value T value df

Pre 7.40±0.4266
Serum Calcium 0.8873 0.1424 58
Pre 7.39±0.4788
Pre 108±16.509
Alkaline Phosphatase 0.8798 0.1518 58
Pre 107±17.486
Pre 54.8±4.979
SF 36 Score 0.6340 0.4786 58
Pre 55.366±4.156

Table No. 4: Comparison of pre pre serum calcium, alkaline phosphatase and SF 36 score between the
groups

Mean±SD P value T value df

Post 8.686±0.3411
Serum Calcium 0.0012 0.3318 58
Post 8.71±0.1788
Post 140.733±11.298
Alkaline Phosphatase <0.0001 4.282 58
Post 150.1±3.986
Post 69.033±7.384
SF 36 Score <0.0001 4.433 58
Post 76.566±5.667

Discussion into two groups. Group A (Weight-bearing exercises)

group B (weight-bearing and neurobic exercises). Prior
In Geriatric age, the ability to carry out multiple
consent was taken. The treatment protocol was carried
tasks or common activities of daily living is diminished
out for 3 days per week for 6 weeks. The outcome
and they remain physically inactive, as many activities
measures for this study were serum calcium levels,
requires simultaneous performance of dual tasks.
alkaline phosphatase and SF 36 health related quality
There are literatures frequently adopting the dual task
of life questionnaire physical function component. The
techniques and find the effect on ability to perform
results of the study showed that there was significant
physical function, but there is limited pool of knowledge
difference in improving physical function component,
in neurobic exercises involving cognitive function that is
serum calcium levels and alkaline phosphatase after
expected in concomitant performance of different tasks,
6 weeks of intervention in both the groups. Group A
stability and balance deteriorates with lack of attention
(weight-bearing exercises) group B (weight-bearing and
and cognitive deficit. The second most important part
neurobic exercises) which was statistically analysed.
of the study is prevention of fall. As physical activity is
Paired ‘t’ test was used to analyse the results within
reduced gradual deconditioning occurs which increases
the groups (group A pre and post-test and group B pre
the risk of fall. Around 28-35% above age of 65 years fall
and post-test) and showed that there was extremely
at least once a year. The present study “effect of weight-
significant improvement in serum calcium (*p<0.0001)
bearing and neurobic exercises on bone health and
alkaline phosphatase (p<0.0001) SF 36 health related
physical function in elderly individuals” was conducted
quality of life questionnaire (*p<0.0001).
to improve health related quality of life and prevention
of declining bone health among elderly. A study done by Cavanagh et. al. in 2005 showed
that lack of load-bearing and physical inactivity leads
The objectives of the study were 1. To find the
to destructive blood loss, while bone formation increase
effect of weight-bearing exercises on bone health and
when immobilised subjects start physical activity. This
physical function in elderly. 2. To find out the effect of
concludes that physical activity enhances bone formation
weight-bearing exercises in combination with neurobic
and stimulates PTH which increases bone metabolism
exercises on bone health and physical function. The study
which in turn increases bone biomarkers such as alkaline
was conducted with 62 subjects. Subjects were divided
266 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
phosphatase and serum calcium, thus improves quality of HRQoL while Group A consisted weight-bearing
of life.[12] A study done by Nirupama Singh et, al. shows exercises.
that neurobic exercises aim to maintain mental fitness
and intact cognitive functions which is responsible for Conclusion
planning initiating and monitoring complex activities, Based on the statistical presentation, analysis and
there indispensable for independent ADL and better interpretation it can be concluded that the weight-
QoL.[13] bearing and neurobic exercises has shown significant
Comparison of serum calcium, alkaline phosphatase improvement in serum calcium, alkaline phosphatase
and SF 36 health related quality of life physical and Sf 36 score.
component score between two groups was done by using Thus, the present study provided the evidence to
unpaired t test to find out the effects in two groups. The support that weight bearing and neurobic exercises has
statistical analysis revealed that there was extremely shown improvement in the blood biochemical markers
significant difference found in serum calcium level in and physical function in elderly individuals.
both the groups post-test (*p<0.0001). The statistical
analysis revealed that there was extremely significant However, the subjects treated with weight bearing
difference found in alkaline phosphatase (*p<0.0001) in and neurobic exercises in combination showed
both the groups post-test. The statistical analysis revealed significant improvement rather than only weight-bearing
that there was extremely significant difference found in exercises alone.
SF 36 health related quality of life questionnaire score
in both the groups post-test. Thus this showed that there Conflict of Interest: The author declares that there
was improvement in bone health and SF 36 HRQoL are no conflicts of interest concerning the content of the
questionnaire physical function component in elderly present study.
individuals. Primary focus of the study was to improve Funding: The study was funded by Krishna Institute
physical component of health related quality of life and of Medical Sciences Deemed to be University, karad.
to see the effect of intervention on bone biochemical
markers in elderly individuals while performing dual Ethical Clearance: The study was approved by
task neurobic exercises improves cognitive function Institutional Ethics Committee, KIMSDU.
and executes marked improvement in physical function
component. References

For independent ADLs or better physical functions 1. Kumar V. Geriatric Medicine, In Manipal YP
like vigorous activity. moderate activity, lifting groceries, (Ed.). API Textbook of Medicine 9th edition, New
climbing several flights, climbing one flight of stair, Delhi: Jaypee Brothers Medical Publishers (P) Ltd;
bathing and dressing etc it is necessary to have better pp. 2038-42.
bone health. As for example, a person with osteoporosis 2. Ingle G.K, Nath A; Geriatric health in India:
may not be able to do his physical activities due to Concerns and Solution, Indian Journal of
lack of bone health causing pain or frequent fractures. Community Medicine 2008 volume 33; issue 4;
Moreover, elderly population have mild cognitive page 214-218
impairment due to aging. 3. Veldurthy. V, Wei R, Oz L, Dhawan. P, Review
article Vitamin D, Calcium homeostasis and aging;
Thus, this study is designed to provide a recreational
Bone research 2016;4;16041
treatment were involving subjects in interesting neurobic
activities to keep the subject’s compliance and treating 4. World health organization. Assessment of
them with weight bearing exercises. fracture risk and its application to screening for
postmenopausal osteoporosis. Report of a WHO
Therefore, the result of the present study showed study group. Geneva WHO 1994.
that intervention was effective in both groups. Group B 5. Nidhi S. Kadam, Shashi A, Chiplonkar, and
which consisted weight-bearing and neurobic exercises Vaman V. Khadilkar;prevalence of osteoporosis in
which showed marked effective results and were helpful apparently healthy adults above 40 years of age in
in improving bone health and physical component Pune city,India; Indian J Endocrinol Metab. 2018
jan-feb;22(1); 67-73
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 267
6. Price P.A, Parthemore J.G, Deftos L.S., new exercises with and without extrernal loading on
biochemical marker for bone metabolism. bone metabolism and balance in postmenopausal
Measurement by radioimmunoassay of bone GLA women with osteoporosis:Rheumatol Int:DOI 10.
protein in the plasma of normal subjects and patients 1007/s00296-012-2388-2 11 march 2012
with bone disease. The journal of endocrinology 11. Tom delvroek, wietsevermeylen, jokes spildooren;
66, 878-883. The effect of cognitive motor dual task training
7. Poole K.E., Reeve J., (2005) Parathyroid hormone a with bio rescue force platform on cognition
bone anabolic and catabolic agent. Current Opinion balance on dual task performance. The journal of
in pharmacology 5, 612-617 physiotherapyscience.J.phys.ther.sci:29;1137-1143
8. Deokju kim; correlation between physical 12. Anissa Bouassida, Imed Latiri, Semi Bouassida,
function, cognitive function, and health realted Dalenda Zalleg, Monia Zaouali Youssef Feki,
quality of life; the journal of physical therapy Najoua Gharbi, Abdelkarim Zbidi and Zouhair
science;28;1844-1848 2016 Tabka Journal of sports science and medicine
9. Saifonkantthamalee, kanidsripankaeu; Effect of (2006) 5, 367-374; Parathyroid hormone and
neurobic exercise on memory enhancement in physical exercise: a brief review
the elderly with dementia; Journal of nursing 13. Singh N., Narayan K,;occupational therapy
educational practice, 2014,vol 4. No.3 through metagym and neurobics improves quality
10. Roghani.T, Giti. T, S. Movasseghe, M. Hedayati, of life; The indian journal of occupational therapy:
B. Goosheh, N. bayat; Effect of short term aerobic vol.44:no.2 (may 2012-aughust 2012)
268 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Knowledge, Attitude and Practice of Biomedical Waste

Management in Nursing Staff of a Private and a Government
Tertiary Care Teaching Hospital: A Comparative Study

Nishitha K.1, Alice Matilda Mendez2, Nisha B.2, Timsi Jain3

13rd Year MBBS, 2Assistant Professor, 3Professor and Head, Department of Community Medicine,
Saveetha Medical College and Hospital, Thandalam, Tamil Nadu.

Abstract
Introduction: Biomedical waste is “Any waste which is generated in the diagnosis, treatment or immunization
of human beings or animals or during research” in a hospital. Improper disposal of hospital waste poses a
major threat to the environment. Lack of proper management, awareness, insufficient resources and poor
control of disposal of waste are the most pressing problems faced .
Objective: To compare the knowledge, attitude and practice of hospital waste management in nursing staffs
and nursing assistants of a private and government tertiary care hospital in Chennai, Tamil Nadu.
Methodology: This is a cross sectional study done in a private and a government tertiary care teaching
institute on 300 nursing staff (150 from each) using an orally administered structured questionnaire. The data
were entered into excel and analysis was done.
Result: Of the 150 participants from government hospital 71% had training in BMW management, 82%
knew where to report in case of a needle stick injury, 61% perceived that they have adequate knowledge
regarding BMW management, 98% were willing to attend programmes regarding BMW. 73% had good
knowledge regarding BMW management. 90% practice good management of BMW.
Of the 150 participants from private hospital 81%had training in BMW management, 79% knew where to
report in case of needle stick injury, 67% perceived that they have adequate knowledge regarding BMW
management, 95% were willing to attend programs regarding BMW management. 74% had good knowledge.
85% practice good management of BMW.
Conclusion: The knowledge, attitude and practice of BMW management among nurses and nursing
assistants of the private and the government hospital are found to be satisfactory. There is no significant
difference (at p<0.05) in the knowledge, attitude and practice of BMW management among the nurses and
nursing assistants of both the hospitals.
Keywords: Biomedical waste management, knowledge, attitude, practice, nursing staff.

Introduction diagnosis, treatment or immunisation of human beings,

mainly consists of needles, syringes, ampoules, dressing
Biomedical waste(BMW) is the waste that is
materials, disposable plastics and microbiological
generated in hospitals and health care centres during
wastes(1). With the aim of reducing health problems and
treating the sick, health care services inevitably produce
Corresponding Author: wastes that may be hazardous to health. According to
Dr. Alice Matilda Mendez the World Health Organisation (WHO), 10-25% of
Assistant Professor, Department of Community the biomedical waste are estimated to be hazardous(2).
Medicine, Saveetha Medical College and Hospital, Improper handling of biomedical waste increases the
Thandalam, Tamil Nadu airborne pathogenic microbes, adversely affecting the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 269
hospital environment and community at large. Apart waste management (BMWM) respectively. Questions
from polluting water, air & soil, it also has considerable related to demographic details like the participants
impact on human health due to aesthetic effects. name, age, sex,department they are currently working
in, total years of experience, years worked in the current
BMW management (BMWM) means the hospital,their training in biomedical waste management,
management of waste produced by hospitals using years of experience, vaccination against Hepatitis,
techniques that will check the spread of diseases. The needle stick injury were also included. It included eleven
objectives of biomedical waste management are toreduce questions to assess their knowledge, which included
waste generation, to ensure its efficient collection, questions regarding where they would dispose certain
handling, as well as safe disposal in such a way that it wastes like anatomical wastes, contaminated gauze,
controls infection as these wastes need a special attention disposable intravenous tubes and catheters, broken glass
for their proper disposal. Adequate knowledge, attitude vials, discarded disinfectants, contaminated mattresses
and practices regarding biomedical waste management and linens . The six attitude questions were regarding
is lacking in developing countries(3). The volume of whether they thought biomedical waste management
the health care wastes have also increased over the last as a financial burden on the setup, do they find it as a
30 years. The World Health Organisation has hence burden to report a needle stick injury, whether they are
prepared biomedical waste management guidelines to interested in attending programs to enhance and upgrade
ensure proper handling of these wastes. their knowledge on biomedical waste management and if
This study was done to assess and compare the they think it is important to dispose health care wastes in
knowledge, attitude and practice of biomedical waste a proper manner. Six questions regarding their practice
management among the nursing staff working in a of biomedical waste management was also included
private tertiary care hospital and a government tertiary (Table 2). One point was awarded to each correct answer
care hospital in Chennai. and the wrong answers weren’t given any point. Each of
the three aspects were assessed separately and a score
Materials and Method of more than 60% was considered that the participant
had good knowledge, attitude and practice of biomedical
This was an observational cross-sectional study waste management. The data was entered in MS- Excel
done from January 2019 to May 2019. This study was spreadsheet and analysis was done using SPSS software.
conducted in a private tertiary care hospital and in a Qualitative data was expressed as frequencies and
government tertiary care hospital situated in Chennai, proportions, quantitative data were summarised as mean
capital city of Tamil Nadu in South India. The study (standard deviation). Bivariate analysis was done using
included the nurses and nursing assistants working in the chi square.
above mentioned institutions.

The sample size of the study is n=300, 150

Results
from each of the above mentioned institutions. The A total of 300 nurses and nursing assistants took
sample size was measured using the formula {(Za-Z1- part in this study, of which 150 were from the private
b)^2*[P1(100-P1)+P2(100-P2)]}/(P1-P2)^2, where P1 institute and 150 were from the government institute.
= 35%, P2=20%(4), expected difference of 15%, alpha
error of 5% at 95% confidence interval. The mean age of the participants from the
government institute was 32.9 years whereas the that of
After obtaining permission from the human resource participants from the private institute was 25.17 years.
department, a list of all the nurses and nursing assistants Of the participants,81% from the government institute
working in the above mentioned institutions was obtained and 75% from the private institute were nurses. The
and the participants were selected randomly using mean years of experience was higher in the government,
random numbers table. Nurses and nursing assistants not which is 8.29 years compared to 3.06 mean years in the
willing to participate in the study were excluded. private institute (Table 1).

The study tool used was an orally administered Significantly more percent of the participants (90%)
structured questionnaire containing questions regarding from the government institute separate biomedical
the knowledge, attitude and practice of Biomedical waste during collection and they also collect liquid
270 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
waste in leakage proof bags (77%) when compared to had a needle stick injury in the past and 90% of them had
the participants from the private institute. Significantly reported the incident to appropriate authority, whereas
more participants from the private institute collect liquid 33% of the participants from the government institute
and other wastes together (43%) whereas more percent have had a needle stick injury and all of them had
(23%) of participants from the government institute reported the incident to the authority.
store infectious waste together with the other wastes.
83% of the participants from the government institute 61% of the participants from the government
use personal protection while handling biomedical institute showed a positive attitude towards biomedical
waste whereas only 77% of the participants from the waste management but only 48% of the private
private institute do so which is significantly less when institute participants showed positive attitude. 98%
compared.(Table 2) of the participants from the government institute and
95% of the participants from the private institute were
Only 71% of the participants from the government willing to attend programs regarding biomedical waste
institute and 81% of the participants from the private management.
institute have had training in biomedical waste
management.(figure 1). 70% of the participants from the private institute
and 62% of the participants from the government
Although the difference is not statistically institute think that there is an increased risk of injury if
significant, it was found out that increased percentage the health care waste is segregated at the source. 45%
of the participants from the government institute had a of the participants from the private institute and 33%
good knowledge, attitude regarding biomedical waste of the participants from the government institute think
management and a good practice of biomedical waste BMWM setup as a financial burden on the institute. 31%
management when compared with the participants from of the total study population consider it as a burden to
the private institute (Table 3). report needle stick injury .

All the participants from the private institute had Table 1: General profile of the participants
been vaccinated against Hepatitis B compared to the
73% from the government institute and 82% of the General Profile Government Private
government institute participants knew to whom they Mean age 32.89 years 25.17 years
were supposed to report an incident of needle stick Mean years of experience 8.29 years 3.06 years
injury compared to the 79% from the private institute. Nurses 122 (81%) 112(75%)
25% of the participants from the private institute have Nursing assistants 28 (19%) 38 (25%)

Figure 1: Participants with training in BMWM.

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 271
Table 2: Comparison between the various practice stick injury was high in both the study groups (100%
habits of the participants from the two institutes in the government and 90% in the private institutions)
when compared to a study done by Stein et al(7) which
Practice Habits Government Private P- Value showed only 37% reporting .

Sort BMW during 0.015293 83% of the participants from the government institute
135 (90%) 120 (80%)
collection * use personal protection while handling biomedical waste
Separate sharps whereas only 77% of the participants from the private
140 (93%) 137 (91%) 0.515049
from blunt waste institute do so. In a study by Madhu Kumar et al(8) all the
Use personal participants wore personal protective equipments while
protection tools handling biomedical waste.
125(83%) 116 (77%) 0.191118
while handling
BMW
98% of the study population knew about the
Collect liquid different biomedical waste categories compared to 56%
waste in leakage 115 (77%) 91(61%) 0.002815*
proof bags of the participants in a study done by Basu et al(9), 45%
Collect liquid
of nurses of a study by Anand P et al(10)and 90% of the
and other wastes 44 (29%) 64 (43%) 0.016145* study population consisting of doctors and nursesin a
together study conducted by Mathur et al(11).
Store infectious
wastes together 35 (23%) 14 (9%) 0.001039* Sixty one percent (61%) of the participants from the
with other wastes government institute and only forty eight percent (48%)
* Significant at P < 0.05
of the private institute participants showed a positive
attitude towards biomedical waste management. In a
Table 3 Comparison between the percentage of study done by Adekunle Olalfa et al(12), 54% of the staff
participants having good knowledge, practicing who participated showed a positive attitude towards
good management of BMW and having a good biomedical waste management.
attitude regarding the same
70% of the participants from the private institute and
Government Private P- Value 62% of the participants from the government institute
Good knowledge 73.33% 74% 0.872707 think that there is an increased risk of injury if the health
Good attitude 61.33% 48.33% 0.076136 care waste is segregated at the source, whereas in a study
Good practice 90% 85.33% 0.285049 by Adekunle Olalfa(12)et al 24% of the participants had
the same idea. 31% of the participants consider it as a
Discussion burden to report needle stick injury, while 44% of the
This is a cross sectional study conducted in a private nurses who participated in a study by Anand P et al(10)
and a government tertiary care hospitals regarding the thought the same. But in a study by Malini et al(13), the
knowledge, attitude and practice of BMW among their participants did not consider it as a burden to report an
nurses and nursing assistants. incident of needle stick injury. 45% of the participants
from the private institute and 33% of the participants
In this study it was found that 71% of the from the government institute think biomedical waste
participants from the government institute and 81% of management setup as a financial burden on the institute.
the participants from the private institute had training in In a study done by Khan MJ et al(14),53% of the
biomedical waste management, compared to 68% of the physicians who took part thought BMWM setup as a
nurses who participated in a study done by Lohani N et financial burden on the institute.
al(5).
Conclusion
All the participants from the private institute had
been vaccinated against Hepatitis B compared to the In this study it has been found that the difference in
seventy three percent (73%) from the government the knowledge, attitude and practice of biomedical waste
institute. Only 20% of the nurses who participated in the management was not significant. But certain aspects
study done by Soyam GC et al(6) had been vaccinated in the practice of biomedical waste management like
against Hepatitis. Reporting of an incident of needle segregation of waste during collection and collection
272 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
of liquid and other wastes separately were better among Workers in a Tertiary Care Government Hospital in
the participants from the government institute, whereas Western India [Internet]. Vol. 9, National Journal
more percent of participants from the private institute of Community Medicine│Volume. Available
stored infective and other wastes separately. The attitude from: www.njcmindia.org
regarding biomedical waste management was better in 5. Lohani N, Dixit S. Biomedical waste management
the participants from the government institute than that practices in a tertiary care hospital: a descriptive
of the participants from the private institute and more study in Srinagar, Garhwal, India. Int J Community
participants from the government institute were willing Med Public Heal. 2017 Jan 25;4(2):465.
to attend programs to improve their knowledge and
practice of biomedical waste management . 6. Soyam GC, Hiwarkar PA, Kawalkar UG, Soyam
VC, Gupta VK. KAP study of bio-medical waste
Even though the knowledge, attitude and practice management among health care workers in Delhi.
of biomedical waste management are not poor among Int J Community Med Public Heal. 2017 Aug
the participants of this study, it can be further improved 23;4(9):3332.
by conducting programs stressing not only on the
7. Stein AD, Makarawo TP, Ahmad MF. A survey
knowledge and practice but also should stress about
of doctors’ and nurses’ knowledge, attitudes and
the attitude of the workers towards biomedical waste
compliance with infection control guidelines in
management by educating them about the importance
Birmingham teaching hospitals. J Hosp Infect.
of it and by enlightening them about the hazardous
2003;54:68-73.
effects of improper management of biomedical waste
management on the environment, public health and also 8. Madhukumar S, Ramesh G. Study about awareness
on health of the health care workers themselves. and practices about health care wastes management
among hospital staff in a medical college hospital,
Conflict of Interest: Nil Bangalore. Intern J Basic Med Sci. 2012;3(1):7-11.
Source of Funding: Nil 9. Basu M, Das P PRA of future physicians on
biomedical waste management in a tertiary
Ethical Clearance: Approval was obtained from care hospital of WBJNSBM 2012 J-42. doi: 10.
Institutional Research Board of Saveetha Medical 4103/097.-9668. 95945. P 22690049; PP Available
College and Hospital, Thandalam, Chennai. from: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3361776/
References
10. Anand P, Jain R, Dhyani A. Knowledge, attitude and
1. Ola-Adisa EO, Mangden YPE, Sati YC, Adisa practice of biomedical waste management among
JO. Knowledge, Attitudes/Beliefs and Practices health care personnel in a teaching institution in
in Medical Waste Management-An Appraisal of Haryana, India. Int J Res Med Sci. 2016;4246–50.
Jos North LGA, Plateau State, Nigeria. Int J Res
11. Mathur V, Dwivedi S, Hassan MA, Misra
Humanit Soc Stud. 2015;2:43.
RP. Knowledge, attitude, and practices about
2. Y. Chartier, J. Emmanuel, U. Pieper, A. Prüss, P. biomedical waste management among healthcare
Rushbrook, and R. Stringer, Safe Management of personnel: A cross-sectional study. Indian J Comm
Wastes from Healthcare Activities, World Health Med. 2011;36:143-5.
Organization(WHO),Geneva,Switzerland,2ndediti
12. Olaifa A, Govender RD, Ross AJ. Knowledge,
on,2014.
attitudes and practices of healthcare workers about
3. Ehrampoush MH, Baghiani Moghadam MH. healthcare waste management at a district hospital
Survey of Knowledge, Attitude and Practice of in KwaZulu-Natal. South African Fam Pract. 2018
Yazd Universityof Medical Sciences Students Sep 3;60(5):137–45.
about Solid Wastes Disposal and Recycling. Iranian
13. Malini A, Eshwar B. International Journal of
J Environ Health Sci Eng. 2005;2(2):26.
Biomedical Research Knowledge, Attitude and
4. Mehta TK, Shah PD, Tiwari KD. A Knowledge, Practice of Biomedical waste management among
Attitude and Practice Study of Biomedical Waste health care personnel in a tertiary care hospital
Management and Bio-safety among Healthcare in Puducherry. Int J Biomed Res [Internet].
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 273
2015;6(03):6. Available from: www.ssjournals. health care staff regarding hospital waste handling
com in tertiary care hospitals of Muzaffarabad, AJK,
14. Khan MJ, Hamza MA, Zafar B, Mehmod R, Pakistan. Int J Sci Reports. 2017 Jun 30;3(7):220.
Mushtaq S. Knowledge, attitude and practices of
274 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

WTO and its Impact on Indian Pharmaceutical Production:

A Legal Perspective

Nitesh Kumar Srivastava

Prof. (Dr.) R.L. Koul

Abstract
Pharmaceutical Company and Pharmaceutical production plays a significant role in the economic
development of a country. It is even more important for developing country like India which needs to
generate employment, achieve higher rate of growth, poverty elevation programs, improve the standard of
living of its people and stabilize the price level of healthcare. Role of World Trade Organisation (WTO) is
very important for regulation. The WTO was established in 1995 and when compared with the GATT is
much wider in scope, with a stronger institutional basis and with treaty status. The main aim of this paper
is to analyze the Indian pharmaceutical production performance, pre and post implementation of WTO
policies. It is clear that the implementation of WTO policies, Compound Annual Growth Rate (CAGR) of
India’s pharmaceutical production has minute effect on it. The topic is of essence as in based on doctrinal
study where by different set of data has been gathered from the primary and secondary sources. The research
Article is an outcome of research which the research scholar is under taking in pursuance and for conferment
of Ph.d Degree.

Keywords: GATT,WTO, Pharmaceutical production, Compound Annual Growth Rate, Economic

Development.

Introduction destined to more than 200 countries around the globe

including highly regulated markets of US, Europe,
Pharmaceutical industry has long being regarded
Japan and Australia. Indian Pharmaceutical Industry
as one of the most important areas blocking the way to
has made phenomenal progress over the years and made
the strengthening of a liberal trade system. The Indian
its impact in the global market. Indian Pharmaceutical
pharmaceutical industry, now a USD 20 billion (over Rs
industry has been recognized as reliable source for drugs
90,000 crore) Industry, has shown tremendous progress
and drug intermediates, pharmaceutical formulations.
in terms of infrastructure development, technology base
Tremendous opportunities are available for Indian
creation and a wide range of products. It has established
Pharma industry in post 2005 era to manufacture
its presence and determination to flourish in the changing
and export many products getting off-patented. Its
environment. The industry now produces bulk drugs
immense strength in manufacturing quality medicines
belonging to all major therapeutic groups requiring
at affordable prices made the Indian Pharma industry to
complicated manufacturing technologies. Formulations
compete both in regulated and non-regulated markets.
in various dosage forms are being produced in Good
Apart from its strengths in manufacturing and exporting
Manufacturing Practice (GMP) compliant facilities.
allopathic medicines, India is known for its own systems
Strong scientific and technical manpower and pioneering
of medicines with about 7000 units manufacturing
work done in process development have made these
various Indian system of medicines viz., Ayurveda,
possible.8 The country now ranks 4th worldwide
Unani, Siddha, Homeopathy etc. Though strong in
accounting for 8% of world’s production by volume and
cultivation/manufacture of Indian system of medicines,
1.5% by value. It ranks 17th in terms of export value
India’s share in the global herbal market, estimated at
of bulk actives and dosage forms. Indian exports are
US$ 63 billion, is less than 0.2%, which shows that there
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 275
is a tremendous scope for export market. Fast growing flow of investment in accordance with certain national
Biotech industry estimated at about US$ 2 billion priorities. Conditions that can affect investment flows are
market, is a another part of Indian Pharma industry known as Trade Related Investment Measures10. There
in India, which has great potential in the international are 24 such TRIMs those countries all over the world
market and which needs focused attention to improve use. WTO prohibits use of the following five measures
its performance in the international market. While its under TRIMS:
generics market is growing strong, it is also evolving into
a cradle for new drug. As one of the strongest emerging • Local Content Requirements (ICRs) imposing use
market in the global pharma industry, India presents of certain amount of local inputs in production.
great opportunities for all international pharmaceuticals • Trade Balancing Requirements: Limiting use
companies to explore and benefit from. of import content in proportion to the export of
investing company.
WTO and TRIPS Agreement: The World Trade
Organization’s Agreement on Trade-Related Aspects • Trade Balancing Requirements: restricting imports
of Intellectual Property Rights (TRIPS) set global to an amount or value of the producer exported.
minimum standards for the protection of intellectual • Exchange Restrictions: restrictions on access to
property. The TRIPs Agreement deals not only with foreign exchange to an amount of foreign exchange
patents but also with other forms of intellectual property earnings attributable to the enterprise.
rights such as copyright, trademark, industrial designs,
geographical indications, and confidential information.9 • Domestic sales requirements: requiring a company
The TRIPS Agreement forced not only product patents to sell certain proportion of its production locality.
for pharmaceuticals to be introduced but also twenty- Once restrictions are removed, MNCs whichare
year periods of patent protection at the leastto be ensured. permitted to set up wholly owned subsidiaries as 100%
WTO members must comply with the obligations of the export oriented units, could also start catering to the
TRIPS Agreement. TRIPS compliance was postponed domestic market and this seriously affect the share of
until 2005 for developing countries. Until the deadline for indigenous units.11
TRIPS compliance, India undertook three amendments
in March 1999, June 2002, and March 2005. InMarch Indian Position:
2005, India completed the amendment of the Patent Act
The Pharma Industry Prior to Patents Regime:
of 1970 to comply with the TRIPS Agreement.
At the time of independence in year 1947 the total drug
The new patent act came into force on 4 April, production in the country was around Rs. 10 crores.
2005. It introduced product patents for drugs,foods, and At that time the MNCs taking the help of the colonial
chemical products and the patent term was increased to Patent and Designs Act, 1911 exploited the drug market
twenty years. The Indian patent regime has become fully of our country. They were engaged mainly in the
TRIPS compliant. The amendment of the Act changed import of drugs from their country of origin. Between
the institutional factors that had supported the growth of 1947-57 99% of the 1704 drugs and pharmaceutical
the Indian pharmaceutical industry. patents in India were held by foreign MNCs. During
that time the MNCs who were controlling 80% of the
Under the TRIPS agreement, all WTO members have market did not come forward with financial investment
to make patents available for pharmaceutical inventions and technological help to establish drug production
in their countries. A company that has invented a new centers in India. Drug prices in India were amongst the
pharmaceutical product or process is able to apply for a highest in the world in 195412. The first public sector
20 year patent protection in any WTO member country. drug company Hindustan Antibiotic Ltd.(HAL) was
established with the help of WHO and UNICEF. The
Agreement on Trade Related Investment
Indian Drugs and Pharmaceutical Limited (IDPL) were
Measures (TRIMs): The Indian Industry can become
established in 1961 with the help from the Soviet Union.
more competitive due to inflow of Foreign Direct
The establishment of these two public sector units and
Investment(FDI) in the fields of Research & Development
the coming into force of the Drug Policy of 1978 had
(R & D) and technology. Governments often impose
been mainly responsible for the availability of drugs
conditions on foreign investment in order to direct
and medicines at relatively lower prices in India. The
276 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
country became almost self-sufficient in the production Case Analysis: Towards the aforesaid deliberation,
of drugs. it is imperative to study some few selected cases
concerning pharmaceutical sector involving India as
It is also a fact that after Independence, the Indian complainant and also as respondent in others before
government appointed two committees namely Tek WTO Dispute settlement board. For this purpose, five
Chand Patents Enquiry Committee (1948-50) and cases have been indentified where it is found that in
Ayyangar Committee (1959) in order to improve three cases India has been the complainant while in two
accessibility and afford ability of essential drugs in others as respondent. Accordingly the analysis dealt on
India. These committees recommended amending the sere tom basis year wise in manner as under.15
Designs and Patents Act of 1911, which recognised
product patents for pharmaceuticals. The Designs and (a) Certain Pharmaceutical Products16 Dispute
Patents Act of 1911 was replaced by the Patent Act of Settlement (D.S No. 168): In this case India against
1970. The Patent Act of 1970 recognised only process South Africa. Subject matter of the case is “Anti-
patents, and reduced the patent period from sixteen years Dumping Duties on certain Pharmaceutical Products
to seven years. Automatic licenses of right could be from India.” And the measures at issue include the
issued three years after granting of the patent. The Act initiation of the investigation, the conduct of the
allowed Indian pharmaceutical companies to produce investigation, and the final determination.
alternative processes for drugs that were not patented in
On 1 April 1999, India requested consultations
India. During the period from the 1970s to the 1980s,
with South Africa in respect of a recommendation
Indian companies began to take up R & D work on their
for the imposition of definitive anti-dumping duties
own. The weak intellectual property protection regime
by the South African Board on Tariffs and Trade
as envisaged in the Patent Act of 1970 was a turning
(BTT), The BTT allegedly made a preliminary
point in the development of indigenous pharmaceutical
determination on 26 March 1997 that ampicillin
R & D. The Act encouraged reverse engineering and
and amoxycillin of 250mg and 500mg capsules,
the development of alternative processes for products
exported by M/S Ranbaxy Laboratories Ltd of India,
patented in other countries.13
were being dumped into the South African Customs
The Drug Policy of 1978 was the first comprehensive Union (SACU). This was allegedly followed by a
drug policy enacted in India. The basic framework of recommendation to impose final duties on these
the Policy remained largely valid even up until the products by the BTT, which was reported on 10
1990s. The basic objective of thePolicy was to achieve September 1997. India contended that:
self-sufficiency in the production of drugs. The Policy • the definition and calculation by the BTT of normal
emphasised the role of R & D and technology, and value is inconsistent with South Africa’s WTO
enhanced the technological capabilities of the Indian obligations, because erroneous methodology was
pharmaceutical industry by providing R & D promotion used for determining the normal value and the
measures. Several measures to guide and control foreign resulting margin of dumping;
companies with a 75 percent share of the domestic
market were implemented so as to be consistent with the • the determination of injury was not based on
basic objective of the Drug Policy of 1978 and promote positive evidence and did not include an evaluation
the production of bulk drugs and intermediates.14 of all relevant economic factors and indices having a
bearing on the state of the industry, which led to an
The Patent Act of 1970 and the Drug Policy of erroneous determination of material injury suffered
1978 paved the way for the progress of indigenous R by the petitioner.
& D. The ability to develop generic drugs was acquired
• the South African authorities’ establishment of the
and improved during the mid-1970s to 1990s. Besides,
facts was not proper and that their evaluation was
other industrial policy measures such as the Foreign
not unbiased or objectives; and
Exchange Regulation Act of 1974 (FERA) and the
Drug Price Control Order of 1970 (DPCO 1970), which • the South African authorities have not taken into
were disincentives to foreign companies, also played account India’s special situation as a developing
important roles in the development of the industry. country.
India alleged violations of Articles 2, 3, 6(a) to (c)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 277
individually and in conjunction with 12, 12 and 15 of country destinations. India alleges that the measures
the Anti-Dumping Agreement; and Articles I and VI of at issue are, in several respects, inconsistent as such
GATT 1994. and as applied, with the obligations of the European
Union and the Netherlands under Articles V and X
(b) Import of Pharmaceutical Products: (D.S of GATT 1994 and under various provisions of the
No.233): In this case India against Argentina. The TRIPs Agreement, namely, Article 28 read together
Subject matter of the case is “Measures affecting with Article 2, Articles 41 and 42, and Article 31
the importation of Pharmaceutical products.” And read together with the provisions of the August 2003
the measures at issue include the initiation of the Decision on TRIPs and Public Health.
investigation, the conduct of the investigation, and
the final determination. India as a Respondent: Dispute Settlement (DS)
50was filed by the US on 9th July 1996, whereas,
According to India, the above measures require that Dispute DS 79was filed by theEC on 6th May 1997. Both
before entering the Argentinean market, all drugs of these disputes pertained to absence of ‘either patent
and other pharmaceuticals must be registered with protection orformal systems that permit the filing of
the National Administration of Drugs, Foodstuffs patent applications for pharmaceutical and agricultural
and Medical Technology, Ministry of Health of chemical products and that provide exclusive marketing
Argentina. The above Decree contains two annexes rights in for pharmaceutical and agricultural chemical
listing countries. products’. On the 5th Sept. 1997 the panel submitted its
• In respect of Annex I countries, pharmaceutical report and on 19thDec. 1997 the Appellate Body report
products are required to be manufactured in facilities directed India to comply with the TRIPS provisions of
approved by the relevant governmental bodies of the WTO agreement. In response to this Government
these countries or by the Argentinean Ministry of of India had introduced a Bill in the Indian Parliament
Health and meet the National Health Authority’s to effect certain Amendments to the Patents Act, 1970.
manufacturing and quality control requirements. These Amendments to the Patents Act, 1970, as passed
by both Houses of Parliament, have been approved by
• In respect of Annex II countries, manufacturing
the President of India and notified in the Gazette of India
facilities are required to be inspected and approved
on 26th March 1999 as the Patents (Amendment)Act,
by the Ministry of Health of Argentina before export
1999.
of these pharmaceutical products into Argentina.
India says, it does not figure in either of those Conclusion & Suggestions
two annexes. This alleged discrimination would have From the aforesaid deliberation this gathered.
led to total lack of market access for Indian drugs and The Patent Act of 1970 and the DPCO have not only
pharmaceutical products in Argentina. India considered boosted the development of the Indian pharmaceutical
that infringement of the following provisions have taken industry but have also contributed to improving health
place: Articles 2 (especially 2.2), 5 (especially 5.1 and and welfare in India. However, since the mid-1990s,
5.2) and 12 of the TBT Agreement; Articles I and III of the Indian pharmaceutical industry has faced new
the GATT 1994; and Article XVI: 4 of the Agreement challenges onaccount of the WTO-TRIPS Agreement. It
establishing the WTO. was considered that introducing pharmaceutical product
(c) Seizure of Generic Drugs: (D.S No.408): In this patents would have a negative influence on the Indian
case India against European Union and Netherland. pharmaceutical industry because it would hamper its
The Subject matter of the case is “Seizure of Generic growth. The industry can no longer manufacture by
Drugs in Transit.” And the measures at issue include reverse engineering or export drugs whose product
the initiation of the investigation, the conduct of the patents are in effect. However, against expectations, the
investigation, and the final determination. Indian pharmaceutical industry has been growing the
post-TRIPS period and its productivity is improving even
On 11 May 2010, India requested consultations with in post-TRIPS period. It can be said that the introduction
the European Union and the Netherlands regarding of pharmaceutical product patents has given rise to
the repeated seizures on patent infringement grounds business opportunities for the Indian pharmaceutical
of generic drugs originating in India but transiting industry and is promoting the growth of the industry.
through ports and airports in the Netherlands to third
278 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Indian Pharmaceuticals faces both opportunities and 3. Myneni S.R.World Trade Organisation. 3rd ed.
challenges with liberalization of domestic and global Asia Law House; 2014.104-107p.
market. There is need to develop strategy for an Indian 4. Koul A.K..Guide to the WTO and GATT
pharmaceutical sector. Appropriate measures are require Economic, Law and Politics. 2nd ed. Satyam Law
to move away from the traditionally approach and build International; 2010. 499-502p.
a productive and internationally competitive products.
5. Mittal J.K, K.D Raju. World Trade Organisation
Rapid pharma growth is important not only to achieve
and India: A Critical Study of Its First Decade.2nd
higher economic growth but also to lift healthcare
ed. New Era Law Publications Delhi; 2005 45-50p.
system in India. The most important suggestion is to
increase public investment in a pharmaceutical with a 6. Hamied Y.K. Indian Pharmaceutical Industry:
view to robust growth of pharmaceutical sector. Public Decades of Struggle and Achievements. Hyderabad;
Pvt. Partnership is a key of development in this sector. 2005.11-13p.
7. Kamiiko Atsuko and Sato Takahi editors. The
Ethical Clearance: Ethical Clearance taken from TRIPs Agreement and the Pharmaceutical Industry:
Departmental Research Committee of Amity Law The Indian Experience. Sapporo; 2012.81-85p.
School, Amity University, NOIDA, Uttar Pradesh.
8. World Trade Organisation. Trade Topic [Internet].
Source of Funding: Self Geneva: wto.org; [Updated 2019; cited 2019
Mar.15]. Available from: https://www.wto.org
Conflict of Interest: Nil 9. Dispute Settlement [Internet]. Geneva:wto.org;
1999 April 1. Chronological list of disputes cases;
References [Date cited 2019 March 15]; [About 5 Screens].
1. Annual Report of DGCIS.New Delhi: Ministry of Available from: https://www.wto.org/english/
Commerce and Industry: 2015-2016. tratop_e/dispu_e/cases_e/ds168_e.htm
2. Bermann George A. and Mavroidis Petros C. WTO
Law and Developing Countries.2nd ed. Cambridge
University Press; 2007.213-216 p.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 279

Prevalence and Molecular Characterization of Glucose-6-

Phosphate Dehydrogenase Deficiency among Brahmins and
Muslims of Manipur, India

Nongthombam Achoubi1, Mohammad Asghar2, Anand Kumar Gyanendra Singh Wahengbam3,

Soibam Jibonkumar Singh4, Kallur Nava Saraswathy5, Benrithung Murry5

1Research Associate, Department of Anthropology, Manipur University, Manipur, 2Assistant Professor, Department
of Anthropology, Rajiv Gandhi University, Arunachal Pradesh, 3Research Scholar, Department of Anthropology,
University of Delhi, Delhi, 4Professor, Department of Anthropology, Manipur University, Manipur, 5Assistant
Professor, Department of Anthropology, University of Delhi, Delhi, India

Abstract
G6PD deficiency offers protection against malaria infection and is strongly associated with the distribution
of malaria endemicity. Genetic studies, including those of inherited blood disorders at the molecular levels,
are very limited in northeastern India including Manipur. The present study aims to determine the prevalence
and its molecular characterization of G6PD deficiency among the Brahmins and the Muslims of Manipur. A
total of 263 unrelated blood samples (127 Brahmins and 136 Muslims) was screened for G6PD deficiency
using Fluorescent Spot Test. DNA was extracted using salting out method and for molecular analysis, PCR
was done using 3 most common Indian mutations (G6PD Mediterranean, G6PD Odisha, and G6PD Kerala
& Kalyan) and 4 most common Southeast Asian mutations (G6PD Canton, G6PD Kaiping, G6PD Mahidol
and G6PD Union). A higher prevalence frequency of 21.32% of G6PD deficient individuals was found
among the Muslims as against the Brahmins with 9.45%. Out of the 7 mutations screened for G6PD that
are common to Indian populations, only 4 Brahmins are found to have one each of these mutations. The
4 mutations found among the Brahmins were one G6PD Mediterranean, one G6PD Kerala & Kalyan, and
two G6PD Mahidol. The Muslim population with a relatively higher frequency of G6PD deficiency as
compared to Brahmin population needs special attention by health planners specifically while administering
anti-malarial drugs.

Keywords: G6PD, Meitei Brahmin, Meitei Muslim, Manipur.

Introduction commonly affecting people of Africa, Asia, Mediterranean

or Middle-Eastern descent1. It is mainly found in Africa,
Glucose-6-phosphate dehydrogenase (G6PD)
Asia, and Mediterranean Europe, areas where malaria is
deficiency is a common hereditary enzymatic defect
endemic, or has been endemic2. Other evidence supports
worldwide. It is an X-linked inherited disorder most
the idea of a selective advantage of enzyme-deficient
cells with regard to Plasmodium falciparum. Almost
all cases of G6PD deficiency are caused by one amino-
Corresponding Author: acid change due to a point mutation of the genomic
Benrithung Murry DNA, and about 140 molecular abnormalities of the
Assistant Professor, Department of Anthropology, G6PD genotype have been identified3. The worldwide
University of Delhi, Delhi, India prevalence of G6PD deficiency has been estimated
e-mail: [email protected] to be around 5%4 but frequency as high as 70% has
Mobile: +91 9868616678 been reported among the Kurdish Jews5. In India, the
280 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
prevalence varies from 0 to 27.9% across ethnic groups6. G6PD deficiency, a total of 263 (only males) unrelated
The average prevalence of Malaria in Manipur is 1,995 blood samples (127 Brahmins and 136 Muslims) were
per 1,00,000 populations. Rural inhabitants are almost collected by finger prick after obtaining prior informed
twice as likely to suffer from malaria and the state has written consent. All the blood samples were tested G6PD
seen a substantial increase in malarial cases from 708 deficiency using Fluorescent Spot Test10. Intravenous
to 1,069 (51%) in the year 2009 and an increase in blood (5ml each) was collected from G6PD deficient
Plasmodium falciparum cases has been documented from individuals for further molecular analysis after obtaining
356 to 620 during the same period7. Only few studies prior informed written consent and DNA isolation was
report the prevalence of specific variants and fewer still done following the standard Salting out method11.
have reported the prevalence of different G6PD variants Molecular analysis was done by using the protocols
at the DNA level in the north-eastern India. Genetic given in table-1 below.
studies, including those of inherited blood disorders
at the molecular levels are very limited in this region, Results
including Manipur and such studies may help explain Out of 127 Brahmin males screened for G6PD
the origin and spread of these disorders and may also deficiency only 12 were found to be deficient with the
shed some light on the history of these ethnic groups. frequency of 9.45% and of the 136 Muslim males, a higher
The present study aims to determine the prevalence frequency of 21.32% of G6PD deficient individuals (29)
and its molecular characterization of G6PD deficiency were found among them as shown in Table 2 below.
among the Brahmins and the Muslims of Manipur. The allele frequencies of G6PD deficiency of Meitei
Brahmins (0.0945) and Meitei Muslims (0.2132) are the
Material and Method same as their percentile phenotype frequencies. A Chi
Brahmins belong to the larger Manipuri Meitei square comparison of both the populations with respect
community of Manipur. Ethno-historically, the Brahmin to the allele frequencies showed that there is a significant
settlers represent the eastern-most part of the so called difference between the studied populations (χ2 = 7.0373;
Caucasoid types but consequent upon their inter- p= 0.007983).Of the many mutations reported for G6PD
marriages with Meitei women over a long period of time deficiency only 3 most common Indian mutations and
they show both Caucasoid and Mongoloid features8. 4 most common Southeast Asian variants are selected
They inhabit the four valley districts of Manipur namely, for the present study. This is because both Brahmins
Imphal-East, Imphal-West, Thoubal and Bishnupur. But and Muslims are expected to be admixture populations
the bulk of the Brahmins is scattered in BamonLeikai of India and South-East Asian ethnic elements.All the
of Imphal-East. Muslims are a Caucasoid group, in 41 G6PD deficient individuals were screened for the
contrast to the neighboring Mongoloid groups9. They selected 7 mutations. Only 4 individuals out of the 12
spread throughout Manipur and practice consanguineous Brahmin G6PD deficient could be characterized at the
marriages. However, most of them inhabit the Imphal- molecular level i.e. G6PD Mediterranean (8.33%) in one
East and Thoubal districts of Manipur. The Brahmin individual, G6PD Odisha (8.33%) in one individual and
samples were collected from Imphal-East district and G6PD Mahidol (16.67%) in two individuals, whereas
for Muslims, sampling was done from both Imphal- none of the 29 G6PD deficient Muslims could be
East and Thoubal districts of Manipur. For screening of characterized.

Table 1: Protocols used for molecular characterization of G6PD deficient individuals.

G6PD deficiency variant Markers References

G6PD Mediterranean (563 C→T)
Kaeda et al., 1995
Common Indian variants G6PD Odisha (131 C→G)
G6PD Kerala and Kalyan (131 C→G) Ahluwalia et al., 1992
G6PD Canton (1376 G→T)
G6PD Kaiping (1388 →A)
Common South-East Asian variants Nuchprayoonet al., 2007
G6PD Mahidol (487 G→A)
G6PD Union (1360 C→T)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 281
Table 2: Distribution of G6PD deficiency among Brahmins and Muslims of Manipur.

G6PD
Total No.
Population Normal Deficient P-value
Tested
No. Percentile No. Percentile
Meitei Brahmin 127 115 0.9055 12 0.0945
0.007
Meitei Muslim 136 107 0.7868 29 0.2132

*significant at p < 0.05

Discussion studies have revealed that the G6PD Mediterranean

mutation is the most common variant followed by G6PD
The G6PD deficiency prevalence frequency in
Kerala-Kalyan and G6PD Odisha27.The prevalence of
India varies from 1% to 27% in different communities
G6PD deficiency individuals were significantly high
and regions of India12. In eastern India, the frequency is
among Muslims as compared to that of Brahmins.
the highest in Angami Nagas (27.1%), followed by Adi
However, though 4 common mutations were detected
(19.4%), Apatani (16.7%), Nishi (16%), Rabha (15.8%),
in the Brahmin population, all the 7 common mutations
Mikir (15.6%), Santhal (14.1%), etc.13. The distribution
screened for in the populations were found to be absent
of G6PD deficiency among the Brahmins (9.45%) and
among Muslim G6PD deficient individuals, suggesting
Muslims (21.32%) of the present study is within the
a different origin and migrational history in these two
reported ranges of India. The reported frequencies of
groups which is in conformity to their historical records.
G6PD deficiency in India vary from complete absence
Further, the Muslim population with a relatively higher
among the Ganchha of Rajasthan14, Lepchas of
frequency of G6PD deficiency are expected to have
Assam15, Dharwa, Halba and Maria of Madhya Pradesh,
mutations that are not common to Indian populations.
and Marathi of Maharashtra16, Brahmin of Manipur and
Hence, the Muslim population needs special attention
Jamatia of Tripura17 to 0.279 among Vataliya Prajapati of
and further in depth molecular research in respect to
Surat, Gujarat18. Very limited studies have been carried
G6PD deficiency.
out in Manipur, the prevalence of G6PD deficiency
among the Brahmins was reported to be 2.8%19 and Kabui Conflict of Interest: No
(7.8%)20. In the north-eastern region of India, the highest
frequency (27.1%) has been reported among the Angami Ethical Clearance and Consent: The present study
Nagas of Nagaland21. However, zero frequency has been is approved by the Ethical Committee of the Department
reported among the Lepchas15. Among the populations of Anthropology, University of Delhi. Blood samples
of the eastern region of India, highest frequency (17%) were collected after obtaining duly signed prior informed
of G6PD deficiency was reported among the Warli of written consent from the participants.
Orissa22 followed by Munda and Paraja having the same
Acknowledgements: The authors are thankful to
frequency of 15.9%23. The lowest frequency (3.6%)
the University Grants Commission, Delhi for funding
was reported among the Hindus of West Bengal24. The
this study.
frequency of G6PD deficiency in Northern India ranges
from 1.5% among the Rajputs of Himachal Pradesh25 to References
12% among the Tharu of North India17. The frequencies
of G6PD deficiency were also reported among the 1. WHO. Glucose-6-phosphate dehydrogenase
Dhurwa, Halba and Maria of Madhya Pradesh16. The deficiency. Bull. World Health Orga. 1989; 67,
frequency of G6PD deficiency range of western India 601-611.
is 2.1% among the Rajputs of Dadra Nagar Haveli26 to 2. Tishkoff S.A., Varkonyi R., Cahinhinan N.,
27.9% among the Vataliya Prajapati of Surat18. Abbes S., Argyropoulos G., Destro-Bisol G., et al.
Haplotype diversity and linkage disequilibrium at
Conclusion human G6PD: Recent origin of alleles that confer
The spectrum of mutations causing G6PD deficiency malarial resistance. Science. 2001; 293: 455-462.
in India has not been well elucidated and several 3. Cappellini M, Fiorelli G. Glucose-6-phosphate
282 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
dehydrogenase deficiency. The Lancet. 2008; 15. Saha, N., Bhattacharyya, S.P., Mukhopadhyay,
371(9606):64-74. B., Bhattacharyya, S.K., Gupta, R. & Basu, A.A.
4. Nkhoma E.T., Poole, C., Vannappagari, V., et al. Genetic study among the Lepchas of the Darjeeling
The global prevalence of glucose-6-phosphate area of eastern India. – Hum. Hered. 1987; 37, 113-
dehydrogenase deficiency: a systematic review and 121.
meta-analysis. – Blood. Cells. Mol. Dis. 2009; 42: 16. Das K, Roy M, Das M, Sahu P, Bhattacharya S,
267-278. Malhotra K et al. Study of enzyme polymorphism
5. Beutler, E. G6PD deficiency. – Blood. 1994; and haemoglobin patterns amongst sixteen tribal
84(11), 3613-3636. populations of central India (Orissa, Madhya
Pradesh, and Maharashtra). The Japanese Journal
6. Tripathy, V. & Reddy, B.M. Present status of
of Human Genetics. 1993;38(3):297-313.
understanding on the G6PD deficiency and natural
selection. – J. Postgrad. Med. 2007; 53(3), 193- 17. Sarkar, S., Biswas, N.K., Dey, B., Mukhopadhyay,
202. D. & Majumder, P.P. A large, systematic molecular-
genetic study of G6PD in Indian populations
7. Office of the Registrar General & Census
identifies a new non-synonymous variant and
Commissioner, India [Internet]. Censusindia.gov.
supports recent infection. - Genetics and Evolution.
in. 2019 [cited 10 April 2019]. Available from:
2010; 10.1228-1238.
http://www.censusindia.gov.in/
18. Joshi, Sukumar, Patel, Colah, Patel. High
8. Chakraborty R, Walter H, Sauber P, Mukherjee
prevalence of G6PD deficiency in Vataliya Prajapati
B, Malhotra K, Banerjee S et al. Immunoglobulin
community in western India. Haematologia.
(Gm and Km) allotypes in nine endogamous groups
2001;31(1):57-60.
of West Bengal, India. Annals of Human Biology.
1987;14(2):155-167. 19. Singh, K.S., Mukherjee, B.M., Walter, H.,
Lindenberg, P., Gilbert, K., Dannewitz, A.,
9. Shah, L. Bio-anthropology of the Muslim of
Malhotra, K.C., Banerjee, S., Roy, M. & Dey, B.
Manipur. - Unpublished thesis, Manipur University,
Genetic markers among Meiteis and Brahmins of
Imphal, Manipur.1990.
Manipur India. – Hum. Hered. 1986; 36, 177-187.
10. Beutler, E. & Mitchell, M. Special modification
20. Achoubi N, Asghar M, Meitei S, Sachdeva M,
of the fluorescent screening method for glucose-
Saraswathy K, Murry B. Haemoglobinopathies and
6-phosphate dehydrogenase deficiency. – Blood.
glucose-6-phosphate dehydrogenase deficiency in
1968; 32, 816–818.
a malaria endemic region of Manipur, northeast
11. Miller, S.A., Dykes, D.D. & Polysky, H.F. A India. Anthropological Science. 2010;118(3):201-
simple salting out procedure for extracting DNA 204.
from human nucleated cells. – Nucl. Acids. Res.
21. Seth, P.K. & Seth, S. Biogenetical studies of Nagas:
1988; 16, 12-15.
Glucose-6-phosphate dehydrogenase deficiency in
12. Bhasin M. Genetics of Castes and Tribes of India: Angami Nagas. – Hum. Biol. 1971; 3, 557-561.
Glucose-6-Phosphate Dehydrogenase Deficiency
22. Balgir R. The spectrum of haemoglobin variants
and Abnormal Haemoglobins (HbS and HbE).
in two scheduled tribes of Sundargarh district in
International Journal of Human Genetics. 2006;
north-western Orissa, India. Annals of Human
6(1):49-72.
Biology. 2005; 32(5):560-573.
13. Balgir R. Do tribal communities show an inverse
23. Balgir R, Dash B, Murmu B. Blood Groups,
relationship between sickle cell disorders and
Hemoglobinopathy and G-6-PD Deficiency
glucose-6-phosphate dehydrogenase deficiency in
Investigations Among Fifteen Major Scheduled
malaria endemic areas of Central-Eastern India?.
Tribes of Orissa, India. The Anthropologist. 2004;
HOMO. 2006; 57(2):163-176.
6(1):69-75.
14. Choubisa, S.L. Erythrocyte glucose-6-phosphate
24. Kotea R, Kaeda J, Yan S, SemFa N, Beesoon
dehydrogenase deficiency and thalassaemic genes
S, Jankee S et al. Three major G6PD-deficient
in the scheduled castes of Rajasthan. - Indian
polymorphic variants identified among the
Journal Medical Research. 1985; 82, 554–558.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 283
Mauritian population. British Journal of Glucose-6- Phosphate Dehydrogenase Deficiency
Haematology. 1999;104(4):849-854. among the Rajputs of Dadra and Nagar Haveli. The
25. Kabita S, Khurana P, Saraswathy K, Sachdeva M. Anthropologist. 2009;11(1):45-47.
Glucose-6-Phosphate Dehydrogenase Deficiency 27. Mukherjee, M. B., Colah, R. B., Martin, S., &
among the Rajputs and Brahmins of Solan Ghosh, K. Glucose-6-phosphate dehydrogenase
District, Himachal Pradesh. The Anthropologist. (G6PD) deficiency among tribal populations of
2011;13(1):39-41. India - Country scenario. The Indian journal of
26. Devi N, Sachdeva M. Sickle Cell Haemoglobin and medical research. 2015; 141(5), 516-20.
284 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Efficacy of Technology Basded Method to Improve Knowledge

on Health Promoting Behaviour towards Maternal
Hypothyroidism among Primi Mothers with Hypothyroidism

P.M. Arulmozhi Baskaran1, Prasanna Baby2

1Professor, (Scholar Student) Head of the Department of Community Health Nursing, Narayana Hrudayalaya
College of Nursing, Bangalore, 2Principal, Sri Ramachandra University, Chennai

Abstract
Background: Maternal hypothyroidism, in simple terms, refers to low thyroid hormone levels during
pregnancy. The diagnosis is made by a TSH that is greater than normal, and this situation deserves
therapy. Many studies have shown that maternal thyroid hormones are very important in pregnancy1. Most
importantly, emerging data seems to suggest that thyroid hormones are especially important for fetal brain
development, especially during early pregnancy2. Pregnancy has a profound impact on the thyroid gland
and thyroid function. The gland increases 10% in size during pregnancy in iodine-replete countries and by
20%–40% in areas of iodine deficiency. Production of thyroxine (T4) and triiodothyronine (T3) increases by
50%, along with a 50% increase in the daily iodine requirement. These physiological changes may result in
hypothyroidism in the later stages of pregnancy in iodine-deficient women who were euthyroid in the first
trimester3. The range of thyrotropin (TSH), under the impact of placental human chorionic gonadotropin
(hCG), is decreased throughout pregnancy with the lower normal TSH level in the first trimester being
poorly defined and an upper limit of 2.5 mIU/L4,2.

Aim of the study: To determine teaching primigravida mothers with hypothyroidism on health promoting
behaviors towards maternal hypothyroidism has efficacy in improving their knowledge.

Method: Evaluative with Quasi experimental study one group pre and post-test design and Simple
random sampling technique were adapted for this study. The knowledge questionnaire regarding health
promoting behaviour towards maternal hypothyroidism was distributed among 60 primigravida mothers
with hypothyroidism followed by the session of technology based education on health promoting behaviour
regarding maternal hypothyroidism was given to the primigravida mothers. The data were analysed by using
descriptive, inferential statistical method.

Result: In pre-test the mean score of knowledge level is 9.45 and the SD is 3.13. In the post test the mean
score of knowledge level is 20.06 and the SD is 11.40, which shows that the technology based education
on health promoting behaviour of maternal hypothyroidism is highly significant in improving knowledge.

Keywords: Primigravida mothers, hypothyroidism, health promoting behaviour, technology based method,
knowledge.

Introduction
Corresponding Author: Hypothyroidism is a relatively common illness in
P.M. Arulmozhi Baskaran pregnancy. Between 2.2% and 2.5% of women have been
Professor, Head of the Department of Community found to have serum thyroid stimulating hormone (TSH)
Health Nursing, Narayana Hrudayalaya College of levels of 6 mU/L or greater at 15 to 18 weeks’ gestation.
Nursing, Bangalore Raised maternal serum TSH in the second trimester
e-mail: [email protected] is also associated with an increased rate of fetal death
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 285
after 16 weeks’ gestation5. Emerging research indicates Sample Size: 60 primigravida mothers with
that thyroid hormones play a key role in fetal brain hypothyroidism
development, and asymptomatic hypothyroidism during
pregnancy may have an adverse effect on fetal growth and Sampling Technique: Simple Random Sampling
neurologic development. Findings published in the past technique
year call our attention to the importance of identifying Independent Variable: Technology based
and adequately treating thyroid-deficient gravidas: education.
Maternal free thyroxine (FT4) concentration below the
10th percentile at 12 weeks is associated with significant Dependent Variable: Knowledge regarding health
impairment of psychomotor development at ages 1 promoting behaviour towards maternal hypothyroidism
and 2 years6. The average serum thyroid-stimulating
hormone (TSH) and FT4 levels of neonates born to Sampling criteria
hypothyroid mothers were significantly higher than Inclusion criteria:
those of controls; birth weight and head circumference
Antenatal mothers who have:
were significantly lower7. Treatment and awareness of
maternal hypothyroidism is essential, because adverse • Primigravida mothers
outcomes for both mother and baby are greatly reduced,
• age above 20 years
if not eliminated, when patients are treated. Even when
treatment is initiated later in pregnancy or is insufficient • Willing to participate in the study.
to restore a euthyroid state, the babies of treated mothers • Gestational age 1- 12 weeks.
will show more normal neurodevelopment than the
babies of non-treated mothersi8,9. • Registered and attending the antenatal OPD for
visits.
Objectives: To assess and associate the pre and
• The antenatal mother whose laboratory values falls
post intervention of knowledge on health promoting
below criteria:
behaviour towards maternal hypothyroidism among
primigravida with hypothyroidism with the selected • TSH level more than 2.5 mlU/L (Ist trimester)
demographic variables. • Free T4 ((thyroxin) decreased with compare to
Hypothesis: Hypothesis were tested at 0.05 level of normal (Normal reference range- 0.8 -2.8 nanograms
significance. per deciliter (ng/dL))
Exclusion Criteria:
H1: There will be significant difference and
association in the pre and post-test knowledge and score • Health professional mothers
and their selected demographic variables. • Mothers coming in antenatal OPD in Gestational
age of above 13 weeks
Method and Materials
Ethical Consideration: The study was conducted
Research Methodology:
after approval from the concerned institution. Assurance
Research Design: Evaluative with Quasi was given to the participants regarding the confidentiality.
experimental study one group pre and post-test design.
Description and Development of the Tool:
Setting: Narayana Hrudayalaya Hospital, Narayana
The tool comprised of 3 sections:
health city, Bangalore.
Section A: The demographic variables of the clients.
Population: The target population for the study
includes the primi gravida mothers with hypothyroid Section B: Structured Questionnaire on Knowledge
with TSH level more than 2.5 mlU/L (IST trimester) and regarding Health Promoting Behaviour of Mothers with
Free T4 ((thyroxin) decreased with compare to normal. Hypothyroidism.
Primigravida mothers attending antenatal OPD in
Narayana Hrudayalaya Hospital, Narayana health city,
Bangalore.
286 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Section C: Technology Based method on Maternal Hypothyroidism (Intervention Module)

Sl.No. Topics Method of Technology

1 Meaning, causes, risk factors and symptoms of maternal hypothyroidism
Power Point Presentation
2 Adverse Outcomes of Maternal Hypothyroidism (Maternal & Foetal Disorders)
3. Screening & Monitoring
Video assisted teaching
4. Modification of Diet & Activity
5. Guidelines for maternal and Newborn care CD instruction

Scoring Technique: • The knowledge of maternal hypothyroid mothers

regarding health promotion behaviour before and
Section A: Scoring key for demographic data after intervention of technology based approach
variables. analyzed in terms of frequency and percentage,
It consists of antenatal mothers profile such as age in mean, Standard deviation.
years, type of family, type of food, occupation, monthly • The significance of the difference between pretest
income, educational status and source of awareness of and posttest knowledge score determined by paired
maternal hypothyroidism. ‘t’ test.
Section B: Scoring key for structured interview • The association between the pre- test levels of
schedule format. knowledge score with demographic variables would
be determined by using “Chi-Square”.
Knowledge questionnaire consists of 30 questions
to assess knowledge. Each correct answer was given a The analysis of the data was mainly classified as:
score of one mark and wrong answer or unanswered was Section-A: Frequency and percentage distribution
given a score of ‘0’. The maximum score was 30. of socio demographic variables of primigravida mothers
Classification of knowledge score based on arbitrary with hypothyroidism.
division Table 1: Frequency and percentage distribution of
Below 50% Inadequate Knowledge
sample characteristics: n = 60
50-75% Moderate adequate knowledge Sl.No. Sample Characteristics Frequency Percentage
76% and above Adequate knowledge 1. Age (in Years):
a. 20-25 10 16.67
Procedure for data collection: The data was
collected after the written informed consent obtained b. 26-30 10 16.67
from primigravida mothers with hypothyroidism. The c. 31-35 18 30.00
pre-test was conducted for primigravida mothers during d. 36 and above 22 36.66
their first antenatal visit (3rd months) about 15 minutes 2. Type of Family:
followed by technology based training to the antenatal a. Nuclear family 37 61.67
mothers with hypothyroidism for 30 minutes. The post b. Joint family 23 38.33
test was conducted to the same primigravida mothers 3. Occupation:
during their 3rd antenatal visit at the month of 7th months. a. House wife 31 51.67
b. Private employee 15 25.00
Data Analysis Plan:
c. Government employee 14 23.33
The plan of data analysis was as follows: 4. Educational Status:
a. Primary school 36 60.00
• Organize data in a master sheet or computer.
b. High school & above 18 30.00
• Demographic data would be analyzed in terms of c. Graduation & above 6 10.00
frequency and percentage.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 287

Sl.No. Sample Characteristics Frequency Percentage Table: 2 Pre- test level of knowledge regarding
5. Food habits: health promoting behaviour of primigravida
a. Vegetarian 37 61.67 mothers with Hypothyroidism.
b. Non vegetarian 23 38.33
Knowledge level
6. Family Income per Month (in Rs): regarding health
a. Below 3000 21 35.00 promoting
Knowledge levels
behaviour
b. 3001 – 6000 14 23.33
on maternal
c. 6001-9000 15 25.00 hypothyroidism
d. 9001-12000 4 6.67 Inadequate Moderate Adequate
e. Above 12000 6 10.00 Pre-test Below 50% 51 – 75% Above 75%
Overall level of No % No % No %
7. Information sources about the illness:
knowledge
Mass media (TV, Radio, 50 83.3 10 16.7 00 00
a. 21 35.00
News Paper, Magazine)
Professionals (Doctor, Table No - 2 shows that overall pre-test level of
b. Nurses, Health 18 30.00 knowledge scores regarding health promoting behaviour
Personnel) of antenatal mothers with Hypothyroidism.
c. Friends 13 21.67
d. Relatives 8 13.33 Majority 50 (83.3%) of them had inadequate level
of knowledge, 10 (16.7%) of them had moderate level
Section B: Structured Questionnaire on Knowledge of knowledge and none of them were had adequate
regarding Health Promoting Behaviour of Mothers with knowledge.
Hypothyroidism.

Fig No. 1: Pre- test level of knowledge regarding health promoting behaviour of primigravida mothers with
Hypothyroidism

Table No. 3: Post- test level of knowledge regarding health promoting behaviour of primigravida mothers
with Hypothyroidism

Knowledge regarding health promoting

Knowledge levels
behaviour on maternal hypothyroidism
Inadequate Below 50% Moderate 51 – 75% Adequate Above 75%
Post-test
No % No % No %
Overall level of knowledge
00 00 15 25 45 75
288 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 3 shows that overall post-test level of Majority 45(75%) of them had adequate level of
knowledge scores regarding health promoting behaviour knowledge, 15 (25%) of them had moderate level of
of antenatal mothers with Hypothyroidism knowledge and none of them were had inadequate
knowledge.

Fig. No. 2: Post- test level of knowledge regarding health promoting behaviour of primigravida mothers with
Hypothyroidism

Table No. 4: Mean, standard deviation and Table No. 4 Represents that the mean post-test
paired ‘t’ value of pretest and posttest knowledge knowledge score (20.06) is apparently higher than mean
scores regarding health promoting behaviour of pre-test knowledge score (9.45). Standard deviation of
primigravida mothers with Hypothyroidism post test score is (11.40) and standard deviation of pre-
test score is (3.13) and the computed paired ‘t’ test value
Standard Paired ‘t’ (t59 = 19.68, P< 0.05) is greater than the table value (ttab
Test Mean
deviation value
= 2.2) which represents significant gain in knowledge
Pre- test 9.45 3.13 19.68
through the technology based approach.
Post- test 20.06 11.40 D f = 59
Ttab = 2.2, P< 0.05 level

Fig. No. 3: Mean, standard deviation and paired ‘t’ value of pre-test and post-test knowledge scores
regarding health promoting behaviour of primigravida mothers with Hypothyroidism
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 289
The hypothesis stated as follows: 2. Montoro MN. 1997. Management of
hypothyroidism during pregnancy. Clin Obstet-
H1: The mean post-test knowledge score will be Gynecol 40(1):65‑80.
significantly higher than the mean pre-test knowledge
3. Morreale de Escobar G, Obregon M, Escobar
score of the primigravida mother with hypothyroidism.
del Rey F. 2004 Role of thyroid hormone during
The findings indicated that the computed Paired ‘t’ test
early brain development. Eur J Endocrinol
value 19.68 is greater than t table value (2.2). So that
2004;151:U25-37.
the researcher reject the null hypothesis and accepted the
research hypothesis 4. LaFranchi SH, Haddow JE, Hollowell JG. 2005. Is
thyroid inadequacy during gestation a risk factor for
The association between the pre- test levels of adverse pregnancy and developmental outcomes?
knowledge score with demographic variables would Thyroid;15(1):60–71.
be determined by using “Chi-Square” revealed that 5. Idris I, Srinivasan R, Simm A, Page RC. 2005.
there was no significant association between level of Maternal hypothyroidism in early and late gestation:
knowledge score and selected variables such as age, level effects on neonatal and obstetric outcome. Clin
of education, occupation, type of family and sources of Endocrinol (Oxf) 63(5):560–7. Leung A, Millar
information. L, Koonings P, Montoro M, Mestman J.1993
Perinatal outcome in hypothyroid pregnancies.
Conclusion
Obstet Gynecol 81:349-53.
The findings reveal that the majority of primigravida 6. Pop VJ, Brouwers EP, Vader HL, Vulsma T,
mothers with hypothyroidism had inadequate knowledge van Baar AL, de Vijlder JJ.2003. Maternal
regarding hypothyroidism during pregnancy. It indicates Hypothyroxinaemia during early pregnancy and
that there is a need for creating awareness and regular subsequent child development: a 3-year follow-up
follow up. The researcher concludes that creating study. Clin Endocrinol (Oxf).;59:282–288.
awareness through the technology based had more
7. Blazer S, Moreh-Waterman Y, Miller-Lotan
impact and the subjects were shown more interest and
R, Tamir A, Hochberg Z. 2003. Maternal
received the teaching content with highly motivated.
hypothyroidism may affect fetal growth and
Hypothyroidism in pregnancy is associated with adverse
neonatal thyroid function. Obstet Gynecol.
fetal and maternal outcomes. Women with thyroid
102:232–241.
disorders should be followed closely and motivate them
throughout pregnancy by maintaining daily check, 8. Klein RZ, Haddow JE, Faix JD, Brown RS, Hermos
telephonic reminder, text messages to the antenatal RJ, Pulkkinen A, et al. Prevalence of thyroid
mothers hypothyroidism for the prevention of maternal deficiency in pregnant women. Clin Endocrinol
complications, and good perinatal outcome. (Oxf) 1991;35(1):41–6.
9. Allan WC, Haddow JE, Palomaki GE, Williams
Interest of Conflict: None JR, Mitchell ML, Hermos RJ, et al. Maternal
thyroid deficiency and pregnancy complications:
Source of Funding: Funded by the primary
implications for population screening. J Med
researcher
Screen 2000;7(3):127–30.
References
1. Cleary-Goldman J, Malone FD, Lambert-
Messerlian G, Sullivan L, Canick J, Porter TF
et al. 2008. Maternal thyroid hypofunction and
pregnancy outcome. Obstet Gynecol; 112: 85–92.
290 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Effect of Water Aerobic and Aerobic Exercise on

VO2 Max Parameter among College Men Students

P.R. Nagaraj1, R. Senthil Kumar2

1M.Phil Scholar, 2Assistant Professor, Dept. of Physical Education and Sports Sciences, SRMIST, Kattankulathur

Abstract
The motivation behind the present review was to research the impact of water cardio respiratory endurance
and oxygen consuming activities on vo2 max parameter among school men understudies. To accomplish
the reason for the review thirty school men understudies were chosen from Erode in the year 2018-19. The
subject’s age ranged from 18 to 25 years. They chose players were isolated into three equivalent gatherings
comprises of 10 men understudies each specifically test aggregate I, exploratory gathering II and control
gathering. The test bunch I experienced water vigorous exercise and trial assemble II experienced oxygen
consuming activities for a month and a half. The control gathering was not partaking in any activity over
the span of the review. The reliant variable vo2 max was taken as standard factors and they were tried by
utilizing cooper vo2 max test for this review .Pre-test was taken before the activity timeframe and post-test
was measured instantly after the a month and a half of preparing period. Factual procedure “f” proportion
was utilized to break down the method for the pre-test and post test information of test gatherings and
control gathering. The outcomes uncovered that there was a huge distinction found on the paradigm factors.

Keywords: Water aerobic exercises, Aerobic exercises, Vo2 max, Pre Test and Post Test.

Introduction for example, in a swimming pool.4 Done for the most

part vertically and without swimming ordinarily in
Cardio-Respiratory Endurance: Oxygen
abdomen profound or more profound water, it is a sort of
consuming activity is any physical movement that
resistance preparing. Water vigorous exercise is a type
requires the heart rate to reach no less than 60% of the
of high-impact practice that requires water-submerged
maximal heart rate for an augmented timeframe. It is
members. Most water vigorous exercise is in a gathering
a movement that can be supported for an augmented
wellness class setting with a prepared proficient
timeframe without building up an oxygen deficiency.
instructing for 60 minutes. The classes concentrate on
High-impact practice program is to expand the most
high-impact perseverance, resistance preparing, and
extreme measure of oxygen that the body can handle
making a pleasant environment with music. Distinctive
inside a given time which is termed as “High-impact
types of water vigorous exercise include: water high
limit”. It is a required capacity to ¹ quickly inhale a lot
impact exercise, and water run. While like land high
of air.2 It conveys substantial volumes of blood with
impact exercise, in that it concentrates on cardiovascular
compulsion.3 It conveys oxygen to all parts of the body
preparing, water vigorous exercise varies in that it
in an adequate amount. To put it plainly, it relies on
includes the part of water resistance and lightness.5In
effective lungs, a capable heart, and a decent vascular
spite of the fact that heart rate does not increment as
framework which shows the states of these crucial
much as in land-based high impact exercise, the heart is
organs, the high impact exercise limit is considered to
working similarly as hard and submerged exercise really
be the best for improving general physical wellness.
draws more blood to the heart. Practicing in the water is
Water Aerobics: Water vigorous exercise, sea- vigorous, as well as quality preparing focused because
going wellness, water wellness, water fit which are the of the water resistance. Moving your body through
water high impact exercises involve in the execution of the water makes a resistance that will initiate muscle
oxygen consuming activity in genuinely shallow water, gatherings. Hydro heart stimulating exercise is a type
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 291
of a vigorous exercise that requires water-submerged Water aerobic exercises group performed 10 drills
members.6 namely toning arms, jumping jacks, side stretch, total
body stretch, standing kick backs, leg adduction and
Statement of the problem: The research aims to abduction, crunch and floating on water. Aerobic
assess the impact of water cardio respiratory endurance exercises group performed 10 drills namely v step, turn
and oxygen consuming activities on vo2 max parameter step, over the top, L step, basic straddle step, side to side,
among school men understudies. double step side, knee kick, kick forward, kick sideward.
This aqua aerobics exercises group and aerobic exercises
Methodology group starts with 3 set of 12-10 repetitions in the first
The motivation behind the present review was to two weeks and progressed to 4 set of 10-8 repetitions
explore the impact of water Cardio respiratory endurance in the second two weeks and 5 sets of 8-6 repetitions in
and vigorous exercise on the vo2 max parameter of the last two weeks. 30sec rest was given in between the
school men competitors. The accomplish this review was sets. As the intensity start with 60% for first four weeks,
haphazardly chosen forty five school men understudies 10% of intensity was increased for every two weeks.
from Erode locale swimming pool relationship amid the The subjects of all the three groups were tested on vo2
year 2016-17 and their age gone from 18 to 25 years. max prior to and after the training period. To ascertain
The chosen subjects (N=45) were isolated into three vo2 max was used and accordingly cooper vo2 max test
gatherings similarly and arbitrarily. Forty five subjects was administered mean value count by ml/min/kg.
from school men understudies were haphazardly chosen
and they were allocated into three equivalent gatherings. Statistical Analysis: The significance of the
Each gathering comprised of fifteen subjects. Of which difference among the means of experimental group was
Experimental Group I experienced Water oxygen found out by pre-test. The data were analyzed analysis
consuming activities (WAEG), Group II experienced of covariance (ANCOVA) technique at .05 levels as
Cardio respiratory endurance activities (Aerobic confidence. Analysis was performed using SPSS 20.0
Exercises) (AEG) and Group III gone about as Control (SPSS Inc Software).
Group (CG). The two test gatherings were treated with
their individual preparing for one hour for each day for
three days seven days for a time of a month and a half.

Results and Interpretations

Table I: Means Values for water aerobic exercises Group, Cardio Respiratory Endurance and Control
Group on Vo2 Max (Cooper vo2 max test Mean value count by ml/min/kg)

Water aerobic Cardio respiratory Control Source of Sum of Mean F Table

Test Df
exercises endurance Team varaiance Square Square Ratio value
PTM 38.46 30.74 37.03 Between 3.711 2 1.856
0.842 3.45
SD 2.02 1.50 1.29 Within 112.795 42 2.686
PT 38.92 39.24 33.01 Between 112.035 2 56.017
32.03* 3.35
SD 1.36 1.22 1.37 Within 73.486 42 1.75
Between 105.923 2 52.962
APTM 36.42 36.20 36.34 40.12* 3.43
Within 55.32 1.349

*Significant .05 level of confidence

The table I demonstrated that the pre‐test mean for pre‐test mean was not as much as the table esteem
esteems on vo2 max for water oxygen consuming 3.45 for df 2 and 42 required for importance at 0.05 level
activities gathering, cardio respiratory endurance of certainty on vo2 max. The post‐test mean esteems
gathering and control gathering are 38.46,30.74 and on vo2 max for water oxygen consuming activities
37.03 individually. The result of “F” proportion 0.842 gathering, Cardio respiratory endurance gathering and
292 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
control gathering are 38.92, 36.08 and 33.01 individually. proportion 40.12* for adjusted post‐test mean was more
The result of “F” proportion 32.03* for post‐test mean noteworthy than the table esteem 3.43 for df 2 and 41
was more noteworthy than the table esteem 3.35 for required for centrality at 0.05 level of certainty on vo2
df 2 and 42 required for criticalness at 0.05 level of max. Since the got “F” proportion esteem was critical
certainty on vo2 max . The adjusted post‐test method further to discover the matched mean distinction, the
for water oxygen consuming activities gathering, Cardio Scheffe’s post hoc test was utilized and exhibited in
respiratory endurance gathering and control gathering table II.
are 36.42, 39.24 and 36.34 individually. The got “F”

Table II: Cooper vo2 max test Mean value count by ml/min/kg

Means
Mean Difference Required CI
Aqua aerobic exercises Aerobic exercises Control Group
36.42 36.195 - .330 1.07
36.42 - 33.053 3.266* 1.07
- 36.195 33.053 3.432* 1.07

*Significant 0.05 level of confidence

The table II demonstrates that the adjusted post- Conclusions

test mean contrast in vo2 max between water aerobic
Significant improvement occurred in vo2 max on
gathering and oxygen consuming activities gathering
college men students.
is .330 it is critical at 0.05 level of certainty and
demonstrated there was an inconsequential change. 1. Experimental groups with water aerobic exercises
Water oxygen consuming activities gathering and performed better than the aerobic exercises and
control gathering is 3.266* it is huge at 0.05 level of control group.
certainty and demonstrated there was a huge change.
2. Experimental groups with aerobic exercises
Oxygen consuming activities gathering and control
performed better than the control group.
gathering is 3.432* it is critical at 0.05 level of certainty
and demonstrated there was a huge change. Henceforth, Ethical Clearance: Nil
there was critical distinction amongst control and test
bunches in vo2 max among school men understudies. Source of Funding: Self
The after effects of the review demonstrated that there Conflict of Interest: Nil
were a critical contrast between water aerobic gathering
and control gathering, oxygen consuming activities References
gathering and control assemble on vo2 max.
1. Meredith-Jones, K., Waters, D., Legge, M., &
Discussion on Findings Jones, L. . Upright water-based exercise to improve
cardiovascular and metabolic health: a qualitative
The investigator was convinced with the results review. Comp therap med. 2011: 19(2), 93-103.
that the group training in vo2 max with the aqua aerobic
2. Delevatti, R., Marson, E., & Fernando Kruel, L.
exercises and aerobic exercises improve vo2 max. The
Effect of aquatic exercise training on lipids profile
training given to the experimental group with aqua
and glycaemia: a systematic review. Sports Med..
aerobic exercises and aerobic exercises had an influence
2015:8(4), 163-170.
on the experimental group and had shown improvement
in vo2 max than the control group in the final test. The 3. de Souza, A. S., Pinto, S. S., Kanitz, A. C.,
training given to the experimental group was planned Rodrigues, B. M., Alberton, C. L., Da Silva, E.
by the investigator in consultation with his guide and M., & Kruel, L. F. M. Physiological comparisons
with great care. The investigator felt that anyone could between aquatic resistance training protocols with
become good athletes if he has good vo2 max. and without equipment. J Strength Cond Res, 2012:
26(1), 276-283.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 293
4. Sawka MN. Physiological consequences of 5. Layne MR. Water Exercise. Hum Kinet; 2018
hypohydration: exercise performance and Nov 15.
thermoregulation. Med Sci Sports Exerc. 1992 Jun; 6. Gleeson M. Immune function in sport and exercise.
24(6):657-70. J Appl Physiol. 2007 Aug 1.
294 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Assessment of Different Types of Malocclusion Using IOTN

Index and Geographic Information System:
A Cross-sectional Observational Study

Bhagyalakshmi Avinash1, Balasubramanian S.2, Ravikumar S.3, Suma Shekar4, Avinash B.S.4
1Reader
Dept of Orthodontics JSS Dental College & Hospital, 2Research Director JSS Academy of Higher
Education & Research, 3Assistant Professor Dept of Geoinformatics JSSAHER, 4Reader Dept of Orthodontics JSS
Dental College & Hospital, Mysore

Abstract
Objective: Beauty is often considered as one of the most pleasant aspects of life, and its influence is often
almost unavoidable. A person’s dental appearance has a significant bearing on his psychological well-being.
The various research studies conducted in India have shown prevalence of malocclusion ranging from 20
to 55%.

Method: A cross-sectional Descriptive survey was planned in the school children of Mysuru district. The
sample size was 840 subjects. To assess the prevalence of malocclusion and different types of malocclusion
present, DHC of the IOTN was used. GIS mapping of prevalence and frequency of different malocclusions
was done using Arc GIS software.

Results: The IOTN classification reveals that among 409 Boys, 121 (29.6%) had definite need for
orthodontic treatment. Among 436 girls, 124 (28.4%) had definite need for orthodontic treatment. There was
no statistically significant difference with regard to orthodontic treatment need between boy and girl study
participants in the present study (p = 0.53).

Conclusion: The prevalence of malocclusion is 58.2 & and displacement is the commonest type of
malocclusion present.

Keywords: Malocclusion, Orthodontic Treatment Needs, IOTN Index, Geographic Information System
(GIS).

Introduction the two dental arches when they approach each other as
the jaws close2. Malocclusion varies from country to
Health is the extent of functional or metabolic
country and also among different races. The reported
regulation of a living body1. Oral health connects with
incidence according to previous studies has a broad range
other health systems of the body. Malocclusion is a
varying from 39% to 93% which reveals that majority
misalignment or incorrect relation between the teeth of
of the children have malocclusion. The reason for this
broad divergence may be because of the differences in
ethnic groups, variations in the age group of the sample
in different studies and most importantly because of the
Corresponding Author: differences in the method of registration3.
Dr. Bhagyalakshmi Avinash
Reader Dept. of Orthodontics JSS Dental College & India is a vast and a developing country. Our
Hospital Mysore-570015 country is striving to put an end to the many health
e-mail: [email protected] related disorders. The results of the epidemiological
Mobile: 9902764927 studies on malocclusion not only helps in planning
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 295
orthodontic treatment but also offers a rational approach Inclusion Criteria:
for determining the etiological factors of malocclusions4.
1. Children of 12 year old in the sampled schools.
Scenario of malocclusion in different states of India 2. Children who provided both informed consent from
(Table 1). Following are some of the states wherein the parents and informed assent to participate in the
epidemiological data about malocclusion is available5,6. study.
A Geographic Information System (or GIS) is a Exclusion Criteria:
system which is designed to capture, store, manipulate,
1. History of previous orthodontic treatment.
analyse, manage and present spatial or geographical
data. GIS technology is a powerful aid for public health 2. Children undergoing orthodontic therapy.
profession as it provides data which can be used to 3. Rampant caries
communicate important facts about community. Also,
GIS ties health to where people live. 4. Any other craniofacial anomalies and syndromes.
Ethical considerations- Prior permission to conduct
The objectives of this study are:
the survey was taken from the Deputy Director Public
1. To assess the severity of malocclusion in 12-year- Instructions (DDPI) and also from the concerned school
old school going children of Mysuru district, authorities. The survey protocol was reviewed and
2. To assess the different types of malocclusion present approved by the Institutional Review Board. Informed
in 12-year-old school going children of Mysuru consent and Informed Assent were given a week prior
district, to the parents of the child and the child. Only those
children who provided both informed assent and consent
3. To locate the different types of malocclusion present were included in the survey.
in 12-year-old school going children of Mysuru
district using the Geographic Information System Data Collection: To assess the normative
(GIS) Data. orthodontic treatment need, DHC of the IOTN was used.

Materials and Method The examination was carried out under bright
day light in the school premises. Sufficient sterilized
Study Design: A cross-sectional descriptive survey
instruments were carried out to the school on the day of
was planned in the school children of Mysuru district.
examination.
Study Setting: The epidemiological survey was
Data Entry: At the end of each day of the survey,
planned to be conducted in four taluks of Mysuru district.
the data were entered to the personal computer by the
Three grades of school i.e., Government school, Private
investigator. Data were coded and entered into excel
aided and Private Unaided school in the four taluks of
sheet. 10% of the observations were randomly selected
Mysuru district were considered.
and cross-checked to detect any error and to validate
Sample and Sampling Technique: Sample size the data entry. At the end of the survey, the data were
was determined using sample size formula for prevalence scrutinized again and was handed over to the Statistician.
study. The prevalence rate was fixed at 40% and relative
Statistical Analysis-Data were transformed into
precision was 0.12. The sample size obtained was 840
SPSS Windows version 16, where cleaning, coding,
subjects.
recoding, cross-checking, and processing and analysis
Two stage sampling was planned for the present were done by the statistician.
study. In the first stage of sampling, four taluks were
The following statistical tests were applied.
selected using simple random sampling by lottery
method. Out of 840 subjects, 210 subjects were equally 1. Frequency
distributed to four taluks of Mysuru district. In the
2. Descriptive
second stage of sampling, from each Taluk, schools were
selected randomly to include 210 subjects by lottery 3. Cross-tabulations (Contingency table analysis)
method. In each school children in the age group of 12 4. Chi-square test.
years were chosen using the class Attendance register.
296 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
GIS Mapping: Prevalence of different types of malocclusion in
relation to gender
The Base Map Creation: The Base Map for the
study is a district and taluk outer boundary layer that Among 409 Boys:
was created for Mysuru district. The individual taluk
• 04 (1%) had Missing teeth,
maps and the district map was merged together to create
the overall study area map. The information different • 153 (37.4%) had an increased Overjet,
types of malocclusion for each taluk and for Mysuru • 35 (8.6%) had Cross bite,
district was incorporated into the baseline map and
the maps depicting the frequency of different types of • 191 (46.7%) had Displacement and
malocclusion for each taluk and the Mysore district was • 26 (6.4%) had Overbite.
created using Arc GIS software.
Among 436 girls:
Findings: Abundant epidemiological data relating
• 03 (0.7%) had Missing teeth,
to malocclusion have been published by many others
in the developed countries. The number of studies is • 184 (42.2%) had an increased Overjet,
limited in India due to the orthodoxy of Indian culture. • 32 (7.3%) had Cross bite,
We have selected 13 schools in 4 taluks of Mysuru • 198 (50.9%) had displacement and
district (Government, Private aided and Private un-aided
• 19 (4.4%) had overbite.
schools) and 845 participants were used for the study.
Out of the 845 participants, 409 (48.4%) were boys and Displacement of teeth was the most common
436 (51.6%) were girls. malocclusion trait followed by an increase in Overjet
among both Boys and girls in the present study with
The malocclusion/IOTN classification reveals Missing teeth being the least prevalent. However, the
that among 409 Boys, 163 (39.9%) had little need for difference in the distribution of these malocclusion traits
orthodontic treatment while 125 (30.6%) had moderate between Boys and girls was not statistically significant
need and 121 (29.6%) had definite need for orthodontic (p = 0.48). This was evident even when a separate
treatment. Among 436 girls, 190 (43.6%) had little need comparison was made among participants from Mysuru
for orthodontic treatment while 122 (28%) had moderate (p = 0.94), Nanjangud (p = 0.38), Hunsur (p = 0.07) T-
need and 124 (28.4%) had definite need for orthodontic Narsipurtaluk (p = 0.07) (Table 2)
treatment. There was no statistically significant
difference with regard to orthodontic treatment need Mapping of different traits of malocclusion- This
between boy and girl study participants in the present was done using Arc GIS software.
study (p = 0.53),

Table 1: Epidemiology of Malocclusion- Indian Scenario

Sl No. State Author Malocclusion Status

Chauhan et al 31% severe malocclusion
1. Himachal Pradesh
Pruthi et al 53% malocclusion
Trehan et al 66.7%
2. Rajasthan
Dhar et al 36.42%
14.3% class I
9.95% class II
R Muppa et al
3. Andhra Pradesh 5.33% Class III
Suma S et al
20.8% Urban
14.9% Rural
4. Kerala Jacob PP et al 49.2%
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 297

Sl No. State Author Malocclusion Status

Kannappan et al 19.6%
Radha Krishna et al 62.5%
5. Tamil Nadu
25.1% Definite malocclusion
Joseph John et al
6.2% Handicapping malocclusion
91.6% class I
6. Delhi Kharbanda et al 4.6% Class II
3.4% Class III
7. Madhya Pradesh Jalili VP et al 14.4%
14.4% class I
Gauba K et al 13.5% class II
8. Haryana
1.3% class III
Singh et al 55.3%
9. Punjab Robert S et al Crossbite
2.9% Definite malocclusion
10. Chattisgarh Ashok Kumar D et al 25% Severe malocclusion
1.4% Handicapping malocclusion
11. Uttar Pradesh Singh M et al 34.09%
77.9% class I
12. Maharastra JT Nainani et al 5.04% class II
2.5% class III
13. Gujarath Joshi et al spacing
23% class I
Rao DB et al 4.5% class II
1.3% class III
3.7% Severe malocclusion
Shivakumar KM et al 15.7% Moderate malocclusion
14. Karnataka 80.1% Little/No malocclusion
Prasad AR et al 51.5%- 85.7%
17.8% class I
Sandesh Phaphe et al 30.1% Class II
1.6% class III
Roopa et al 32.8%

Table 2: Prevalence of various malocclusion traits in relation to gender among participants in four taluks of
Mysuru district

Missing teeth Overjet Crossbite Displacement Overbite Total

Sl. Statistical
Taluk Name Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls
No. inference
N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%)
X2: 0.76
1(33.3) 2(66.7) 16(45.7) 19(54.3) 11(45.8) 13(54.2) 18(51.4) 17(48.6) 1(33.3) 2(66.7) 47(47.0) 53(53.0)
1. Mysuru df: 4
(2.1) (3.8) (34.0) (35.8) (23.4) (24.5) (38.3) (32.1) (2.1) (3.8) (100) (100)
p: 0.94
X2: 4.20
1(50.0) 1(50.0) 74(54.4) 62(45.6) 10(71.4) 4(28.6) 72(47.7) 79(52.3) 3(37.5) 5(62.5) 160(51.4) 151(48.6)
2. Nanjangud df: 4
(0.6) (0.7) (46.2) (41.1) (6.2) (2.6) (45.0) (52.3) (1.9) (3.3) (100) (100)
p: 0.38
X2: 8.54
2(100) 0(0) 38(45.2) 46(54.8) 10(47.6) 11(52.4) 40(60.6) 26(39.4) 10(76.9) 3(23.1) 100(53.8) 86(46.2)
3. Hunsur df: 4
(2.0) (0) (38.0) (53.5) (10.0) (12.8) (40.0) (30.2) (10.0) (3.5) (100) (100)
p: 0.07
X2: 6.97
0(0) 0(0) 25(30.5) 57(69.5) 4(50.0) 4(50.0) 61(44.5) 76(55.5) 12(57.1) 9(42.9) 102(41.1)
4. T-Narsipura 146(58.9) df: 4
(0) (0) (24.5) (39.0) (3.9) (2.7) (59.8) (52.1) (11.8) (6.2) (100)
p: 0.07
X2: 3.49
4(57.1) 3(42.9) 153(45.4) 184(54.6) 35(52.2) 32(47.8) 191(49.1) 198(50.9) 26(57.8) 19(42.2) 409(48.4) 436(51.6)
Total df: 4
(1.0) (0.7) (37.4) (42.2) (8.6) (7.3) (46.7) (45.4) (6.4) (4.4) (100) (100)
p: 0.48
298 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Discussion • Overjet- overjet is observed in 39.9% of the subjects.

The prevalence of malocclusion had been found • Crossbite- crossbite is observed in 7.9% of the
to vary with the different population, race and origin7. subjects.
A similar study in Travancore population8 in Kerala • Displacement- displacement is observed in 46% of
reported 53.3% in need of orthodontic treatment. the subjects.
However, studies done by Singh S et al9, Narayan RK
et al10 showed 68.4% and 83.8% in need of orthodontic • Overbite- overbite is observed in 5.3% of the
therapy. This difference could because the latter studies subjects
were done on the adolscent subjects. Source of Funding: Self
Distribution of malocclusion in population showed Conflict of Interest: Nil
that a maximum number of children i.e. 46% presented
with Displacement, 39.9% presented with increased References
overjet, 7.9% presented with crossbite, 5.3% presented
1. Machteld Huber, J André Knottnerus, Lawrence
with increased overbite and 0.8% presented with
Green et al. How should we define health? BMJ.
missing teeth. The increased frequency of displacement
2011; 343: 1-3.
and overjet in the study population can be explained
by the fact that there is reduction in the jaw size with 2. Gruenbaum, Tamar. Famous Figures in Dentistry
evolution and due to the transition of diet from coarse Mouth–JASDA. 2010;30(1):18
to soft. These results are in accordance with the results 3. Hassan M, Al-Ibrahim Hani D, Telfah, Ayman
of other studies by other researchers11.Our finding that N, Hys T. Frequency of Malocclusion in an
displacement is the most common feature (46%) contrast Orthodonticallyreffered Jordian population. Journal
with that of Tania Arshad et al12. Increased overjet is of the Royal Medical Services 2010; December
an obvious sign of malocclusion in one’s mouth and Vol. 17:No.4, 19-23.
patients presenting to clinics will be to some extent 4. Hassan R, Rahimah AK Occlusion, malocclusion
aware of their malocclusion status whereas patients and method of measurements-An overview.
presenting displacement may or may not be aware of Archives of Oro-facial Sciences. 2007; 2: 3-9.
their clinical malocclusion. The results of our study are
5. Agarwal SS, Jayan B, Chopra SS. An Overview
also supported by a study done by Borzabadi- Farahani
of Malocclusion in India. J Dent Health Oral
et al13.
DisordTher. 2015; 3(3), 1-4.
While applying statistical technique we found 6. Sandhu SS, Bansal N, Sandhu N. Incidence of
that there was no statistically significant difference Malocclusions in India - A Review. J Oral Health
between the type of malocclusion and gender. This is in Comm Dent. 2012; 6(1): 21-24.
accordance with the study done by Grand G et al, Kashif 7. Prasad AR, Savadi SC. Epidemiology of
Aslam et al, Reddy et al, Onyeaso CO et al, Kaur H et al malocclusion- a report of a survey conducted in
and Lauc T et al14-19. Bangalore. J Indian Orthod Society 1971; 3: 43-55.
8. Roopesh R, Manoj KM, Sidharthan B, Manjusha
Conclusion
KK. Evaluation of Prevalence and Severity of
The observations recorded from our study are as Malocclusion in South Travancore Population. JInt
follows: Oral Health. 2015 Jul; 7(7): 94–97.
The prevalence of malocclusion was 58.2% as 9. Singh S, Sharma A, Sandhu N, Mehta K. The
recorded by IOTN. prevalence of malocclusion and orthodontic
treatment needs in school going children of
The malocclusion parameters as recorded by the Nalagarh, Himachal Pradesh, India. Indian J Dent
modified version of IOTN index is as follows, Res. 2016 May-Jun; 27(3):317-22.
10. Narayanan RK, Jeseem MT, Kumar TA.
• Missing teeth- missing teeth is observed in 0.8% of
Prevalence of Malocclusion among 10-12-year-
the subjects.
old Schoolchildren in Kozhikode District, Kerala:
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 299
An Epidemiological Study. Int J Clin Pediatr Dent. years old school children in three sectors of Pakistan
2016 Jan-Mar; 9(1):50-5. Oral & Dental Journal. 2014; 34(3).
11. Kharbanda OP. What is the prevalence of 16. Reddy ER, Manjula M, Sreelakshmi N, Rani ST,
malocclusion in India? Do we know Orthodontic Aduri R, Patil BD. Prevalence of Malocclusion
treatment needs of our country. Journal of Indian among 6 to 10 Year old Nalgonda School Children.
Orthodontic Society. 1999; 32: 33-41 Journal of international oral health: JIOH. 2013;
12. Tania Arshad Siddiqui, Attiya Shaikh, Mubassar 5:49.
Fida. Agreement between orthodontist and patient 17. Onyeaso CO. Prevalence of malocclusion among
perception using Index of Orthodontic Treatment adolescents in Ibadan, Nigeria. American Journal
Need, The Saudi Dental Journal. 2014; 26: 156-165 of Orthodontics and Dentofacial Orthopedics.
13. Borzabadi-Farahani, A., Borzabadi-Farahani. A., 2004;126:604-7.
Eslamipour. F. Orthodontic treatment needs in an 18. Kaur H, Pavithra U, Abraham R. Prevalence of
urban Iranian population in epidemiological study malocclusion among adolescents in South Indian
of 11-14 years old children. Eur. J. Paediatric Dent. population. Journal of International Society of
2009; 10: 69-74 Preventive & Community Dentistry. 2013; 3: 97-
14. Grando G, Young AA, VedovelloFilho M, 102.
Vedovello SA, Ramirez-Yañez GO. Prevalence of 19. Lauc T. Orofacial analysis on the Adriatic islands:
malocclusions in a young Brazilian population. Int an epidemiological study of malocclusions on Hvar
J Orthod Milwaukee. 2008; 19(2):13-6. Island. The European Journal of Orthodontics.
15. Karachi Rizwan Nadim, Kashif Aslam,, Saher 2003; 25: 273-8.
Rizwan, Frequency of malocclusion among 12‑15
300 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Hair Mercury Exposure and Hypertension among Community

Artisanal and Small Scale Gold Mining in Banten, Indonesia

Budi Hartono

Department of Environmental Health, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia

Abstract
Background: Mercury was a heavy metal that persistent in the environment and harmful to human health
and still used by Artisanal Small Scale Gold Mining (ASGM), especially in Indonesia. Cimanggu was one
of ASGM in Banten province who still active using mercury and had found high levels of mercury that
exceed the threshold in wastewater and human hair. Mercury exposure can affect human health, such as
hypertension. This research aimed to determine the levels of hair mercury, hypertension, and individual
characteristics such as age, sex, and smoking habits. And also determine the association between hair
mercury with hypertension among communities in ASGM.

Material and Method: Design studies in this research using cross-sectional design. The data from
BBTKLPP Jakarta datasheet “Analysis of Potential Impact of Risk Factors Environment Based for Disease
Outbreaks on Interest Mining Society”. Retrieved data was hair mercury that analyzed in the laboratory
BBTKLPP Jakarta using Mercury Analyzer (MA) 3000 with cold pavor method and blood pressure were
measured directly two times using sphygmomanometer merk ABN and individual characteristics taken
through a questionnaire. Totaling 100 samples analyzed were taken by quota sampling. Findings: Univariate
test showed that most of the respondents had abnormally hair mercury levels (55%), hypertension 29%,
woman 78%, smoking 23%, and > 40 years 46%. Chi-square test showed no significant association between
hair mercury levels and hypertension (P value=1, OR= 1.01, 95% CI = 0.42-2.40).

Conclusion: Respondents who had normal or abnormally hair mercury levels had the same odds to have
hypertension risk. Further research is needed by using a larger sample with high-intensity process mercury
use to clarify the association of hair mercury levels with hypertension.

Keywords: Mercury; hypertension; Artisanal and Small Scale Gold Mining (ASGM).

Introduction from the seeds by forming an amalgam. The widespread

of mercury use in ASGM because simple to use, can be
Mercury emissions in the environment can from
done individually, and relatively quick to separate the
human activities such as fossil fuels burning, solid
gold. Globally around 15 million people, including 3
waste burning, and Artisanal Small Scale Gold Mining
million women and children participate in ASGM in 70
(ASGM)(1). In the ASGM, mercury used to extract gold
countries(2). Based on the survey results consisting of 800
ASGM in Indonesia with estimated 250,000 miners and
1 million, whereas women and children(3).ASGM had
an increase in Indonesia. It’s in line with many studies
Correspondence Author: have shown that mercury pollution has occurred the sea,
Budi Hartono sediments, water wells, fishes, plants, and communities
Department of Environmental Health, Faculty of Public have an impact on public health(4–6). Such as Hartono
Health, University Indonesia, 16424 Depok, Indonesia research which found mercury exposure in fish in Buyat
e-mail: [email protected], [email protected] Bay and Teluk Ratotok which has improved health for
Phone: (+62)8129568913, (+62)217863579 people who consume air from the Ratotok River Estuary,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 301
Buyat River Hulu, and clean water/drinking water Pandeglang, Banten Province. Cimanggu was an area
storage PT. Newmont Minahasa Raya(7). The results of the ASGM who around a residential area that still
of a study conducted in ASGM Gorontalo showed used mercury to gold processing and has operated for
that the concentration of hair mercury respondents had approximately eight years. Balai Besar Teknik Kesehatan
exceeded the established standard of 2 with an average Lingkungandan Pengendalian Penyakit (BBTKLPP)
concentration of hair mercury in 5.0480 ppm(8). Jakarta in 2017 had found mercury in wastewater
in the processing of gold and mercury hair on people
ASGM donate 37% of mercury emissions in air and living around ASGM above the predetermined quality
water. Mercury vapor present in the air around ASGM standards(13). If it continuously happened could have a
always high and the mercury pollution in water almost negative impact on human health one of hypertension
exceeds the quality standards by WHO. Continuously disorders due to exposure to mercury.
exposure can affect the central nervous system, the
reproductive system and the cardiovascular system(2). Material and Method
The last few years, the impact of mercury on the This study was conducted using a quantitative
cardiovascular system, especially hypertension has method with cross-sectional study design and use
become a concern. Hypertension has been proved as a secondary data derived from datasheet “Analysist of
major risk factor for cardiovascular disease triggers. The Potential Impact of Risk Factors Environment Based
incidence of hypertension has increased for the last three for Disease Outbreaks on Interest Mining Society”
decades. Besides food consumption which high salt intake conducted by BBTKLPP Jakarta. This research will
and obesity, exposure to mercury in the environment describe mercury levels in the hair and it’s association
also one important factor driving the incidence of with hypertension in community living around ASGM,
hypertension. Epidemiological and experimental studies Cimanggu, Pandeglang, Banten.
showed association between mercury exposure and
increased blood pressure. Chronic mercury exposure The population in this study was communities who
levels in humans can be determined by examining live around ASGM in Cimanggu with total of 5442
the hair biomarker are considered most suitable for people, the samples in this study were communities
chronic exposure, easy to collected, and non-invasive(9). who selected based on inclusion criteria among men or
Several studies in the world showed an association women have equal opportunity to participate, length of
between mercury exposure to increased blood pressure stay ≥1 year around ASGM, in good health and willing
among the gold miners who use mercury were found to become respondents signed an informed consent.
significant increased sistolee blood pressure (P <0.01) Calculation of sample size using the formula Lemeshow
correlated with lipid peroxidation and oxidative stress sought, in order to obtain a maximum sample is 100
(P <0.01)(10). A case-control study showed the incidence sample. Sampling was conducted using quota sampling.
of gold miners who have hypertension 46% greater This study will use Univariateanalysist to describe
than the control group. Other studies showed that a Hair mercury level, blood pressure, and individual
significant correlation between hair mercury levels with characterictics respondents, and bivariate analysist
hypertension(11).A study of 251 people in the Brazilian used a chi square test to show association between hair
Amazon showed that blood pressure was associated mercury with hypertension. Hair mercury analyzed
with higher levels of total mercury in the hair where in the laboratory BBTKLPP Jakarta using Mercury
an increased in blood pressure sistolee along with the Analyzer (MA) 3000 with cold pavor method and
increased amount of mercury in the hair of <10 lg/g(12). blood pressure were measured directly two times
In Indonesia research about association between hair using sphygmomanometer merk ABN and individual
mercury exposure with hypertension is still not received characteristics taken through a questionnaire.
attention by researchers.
Findings: Based on Table 1 showed that of the
This research aims to determine the levels of hair 100 respondents who checked his blood pressure, only
mercury, blood pressure as well as individual factor 29% who have hypertension, that was systolic≥140 or
characteristics (age, sex, and smoking habits) and diastolic pressure ≥90(14). Respondents who had hair
determine the association between hair mercury with mercury levels above the quality standards that have
hypertension in communities around ASGM Cimanggu, been established by UNEP (2 ppm) is 55%. Individual
302 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
characteristics show that respondents >40 years old only population living around the Amazon River containing
46%, which was man 22%, and smokers only 23%. hair mercury levels ≥ 10 mg/g(12).

Table 1. Distribution of Hair Mercury, Hypertension was defined as increasing systolic

Hypertension, and Individual Characteristics blood pressure or diastolic after at least 2 times
Around ASGM in Cimanggu 2018 measurement. Hypertension in this study defined as
blood pressure that had systole pressure of 140 mmHg
Variables Total Presentation (%) or diastolic pressure of 90 mmHg(14).This study showed
Hypertension just a few respondents with hypertension. This result
No (<140/90) 71 71 was lower than research conducted by Valera et al.
Yes (≥140/90) 29 29
that showed 53.9% of people living around the mining
Hair Mercury Levels
have hypertension(18). And about 46% of miners in
Normal (≤ 2ppm) 45 45
Europe have hypertension(10). Many factors can lead to
Abnormally (> 2ppm) 55 55
hypertension such as age, sex, smoking, obesity, lack
Age
of exercise, excessive salt consumption, and stress(19).
≤ 40 years 54 54
And from this research, we can show that most of the
> 40 years 46 46
respondent had a low risk of hypertension, because most
Gender
of the respondents were woman, ≤ 40 years and do not
Woman 78 78
Man
smoke.
22 22
Smoking Status In this study showed no significant association
Do Not Smoke 77 77 between hair mercury levels and hypertension with
Smoking 23 23
OR = 2.072. It’s not in line with Bautista et al. where
The association showed There is no association people with high levels of hair mercury was four times
between hair mercury levels and hypertension (P value more at risk for hypertension (p value= 0.02)(17). The
= 1, OR= 1.01, CI 95% = 0.42-2.40). OR = 1.01 that same results also proved by Fillion et al. and Valera
means respondents with abnormally hair mercury level who reported a positive association between mercury
have equal odds to have hypertension with normally levels and hypertension(12,20). In recent years there had
hair mercury with 95% confidence interval hair mercury increased attention to mercury effects on cardiovascular
respondents between 0.42-2.40 ppm. Mercury exposure system like atherosclerosis, cardiac arithema, and renal
in society was measured using hair as a biomarker dysfunction(21,22). The mechanism of mercury affecting
because can explain mercury levels long term in the blood pressure cannot be explained with certainty, but
body, hair mercury also quite persistent even not lost the accumulation of mercury can affect endothelial
when washing with shampoo and coloring, and hair function by inhibiting NO synthesis(23)and increasing
mercury levels 250 times in blood(15). Hair will be oxidative stress, lipid peroxidation, and TNFα and
examined using Mercury Analyzer (MA) 3000 and cold interculin(17,24,25). Increased oxidative stress from lipid
vapor method with the results of measuring parts per peroxidation and decrease in antioxidants can trigger
million (ppm) with quality standards set by UNEP (2 endothelial and renal dysfunction, which can increase
ppm)(16). the risk of hypertension and atherosclerosis, and result
increase in blood pressure and pulse(22,23,25).
The analysis showed most of the respondents have
hair mercury level abnormally. Abnormally hair mercury The same result with this study showed by Rajaee
level in ASGM communities related to their exposure to who cannot found association between mercury levels
mercury from combustion processes and the separation with blood pressure around communities ASGM(26). The
of gold which exposes humans through intermediary of lack of association between hair mercury levels with
water, air, and land for a long time, in additionally the hypertension because there had many factors causing
hair shaft grows to combine mercury from the blood(17). hypertension behind mercury contaminants such as age,
This result same with previous studies conducted around smoking, obesity, alcohol consumption, high natrium
ASGM in Krueng Sabee, Aceh, 90.28% of respondents consumption, and low physical activities(27). Besides
contains mercury levels above the quality standard value that small sample size and low hair mercury levels can
10 μg/g set by the WHO. Fillion found 67.9% of the effect significance result study. Therefore need further
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 303
verification by using a larger sample with high intensity 5. Grishela VV, Tamba E, Kristen U, Wacana K,
process mercury use. Although statistically there’s no Korespondensi A, Arjuna J, et al. Artikel Penelitian
association between hair mercury and blood pressure, Gambaran Pencemaran Merkuri terhadap Masalah
mercury exposure continuously for a long time can had Kesehatan Penambang dan Masyarakat di Sekitar
a negative impact on health, one of them is hypertension, Aliran Sungai Behe Bulan Juli - Agustus 2016
so monitoring of mercury use in ASGM areas should be Mercury Pollution Profiles among Miner and Local
monitored and conducted routine health monitoring in Residence at Behe River from July – August 2016.
the community around ASGM. 2017;23(61):48–59.
6. Pratiwi CA, Ariesyady HD. Analisis Risiko
Conclusion Pencemaran Merkuri Terhadap Kesehatan Manusia
The study concluded that most of (55%) respondent yang Mengonsumsi Beras di Sekitar Kegiatan
had abnormally hair mercury level, but only 29% had Tambang Emas Tradisional (Studi Kasus: Desa
hypertension with the characteristics age >40 years old Lebaksitu, Kecamatan Lebakgedong, Kabupaten
46%, man 22%, and smoking 23%. There’s no significant Lebak, Banten). 2012;18:106–14.
association between hair mercury and hypertension 7. Hartono B. Distribusi Risiko Kesehatan Logam
(p value = 1) with OR = 1.01 means respondents with Merkuri Di Lokasi Pertambangan Emas Kabupaten
abnormally hair mercury level have equal odds to have Minahasa Selatan Provinsi Sulawesi Utara Tahun
hypertension with normally hair mercury. 2004. Universitas Indonesia; 2006.

Conflict of Interest: The authors declare they have 8. Singga S, Kementerian P, Kupang K. Analisis
no conflict of interest. Risiko Kesehatan Pajanan Merkuri Pada Bone
Bolango Provinsi Gorontalo Health Risk
Source of Funding: This research supported by the Assessment of Mercury Exposurein the Bulawa
grant from PITTA Program in Universitas Indonesia. District Community, Bone Bolango Regency,
Gorontalo Province. 2013;21–8.
Ethical Clearance: The research protocol was
9. WHO. Concise International Chemical Assessment
approved by the research and community engagement,
Document 50 Elemental Mercury and Inorganic
the ethical committee of public health faculty of
Mercury Compounds : Human Health Aspects.
the Universitas Indonesia with number of ethics 95/
Geneva; 2003.
UN.2.F10/PPM.00.02/2019.
10. Kobal AB, Horvat M, Prezelj M, Briški AS, Krsnik
Reference M, Dizdarevič T, et al. The Impact of Long-
Term Past Exposure to Elemental Mercury on
1. ATSDR. Toxizine Mercury. Atlanta; 2015.
Antioxidative CCapacity and Lipid Peroxidation
2. WHO. Mercury Exposure and Health Impacts in Mercury Miners. J Trace Elem Med Biol.
among Individuals in the Artisanal and Small-Scale 2004;17(4):261–74.
Gold Mining (ASGM) Community [Internet].
11. Salonen JT, Seppänen K, Lakka TA, Salonen
Geneva; 2013. Available from: http://www.who.
R, Kaplan GA. Mercury Accumulation and
int/ipcs/assessment/public_ health/mercury_asgm.
Accelerated Progression of Carotid Atherosclerosis:
pdf?ua=1
A Population-Based Prospective 4-Year
3. Ismawati, Y., I. Said, I. Nur, W. Selvia and M. Follow-Up Study in Men in Eastern Finland.
Isnaeni. Social and Environmental Production of Atherosclerosis [Internet]. 2000 Feb 1 [cited
Suffering: Socio-Economic Impact of Artisanal and 2019 Jan 29];148(2):265–73. Available from:
Small-Scale Gold Mining in Indonesia, Case Study https://www.sciencedirect.com/science/article/pii/
Palu, Central Sulawesi. 2012; S0021915099002725
4. Sofia, Husodo AH. Kontaminasi Merkuri pada 12. Fillion M, Mergler D, Passos CJS, Larribe F,
Sampel Lingkungan dan Faktor Risiko pada Lemire M, Guimarães JRD. A Preliminary Study
Masyarakat dari Kegiatan Penambangan Emas of Mercury Exposure and Blood Pressure in
Skala Kecil Krueng Sabee, Provinsi Aceh. the Brazilian Amazon. Environ Heal [Internet].
2016;23(3):310–8. 2006 Oct;5(1):29. Available from: https://doi.
org/10.1186/1476-069X-5-29
304 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
13. BBTKLPP Jakarta. Analisis Dampak Faktor 21. Mass R, Patch S, Sergent K. A Statistical Analysis
Risiko Penyakit KLB Berbasis Lingkungan pada of Factors Associated With Elevated Hair Mercury
Masyarakat Sekitar Pertambangan Kecamatan Levels in the U.S. Population. An Interim Progress
Cimanggu, Kabupaten Pandeglang, Provinsi Report. Unc-ashv Environ Qual Insitute Tech Rep.
Banten, Tahun 2017. Jakarta; 2017. 2004;
14. JNC VII. The Seventh: Report of Joint National 22. Salonen JT, K E, Nyyssonen K. Intake of mercury
Committee on Prenention, Detection, Evaluation, from fish, lipid peroxidation, and the risk of
and Treatment of High Blood Pressure. 2003. myocardial infarction and coronary, cardiovascular,
15. Chamid dkk. Kajian Tingkat Konsentrasi Merkuri and any death in eastern Finnish men. 1995;91:645–
(Hg) Pada Rambut Masyarakat Kota Bandung. 655.
Eksata; Bandung (Prosiding SNaPP 2010 Ed 23. Kishimoto T, Oguri T, Abe M et al. Inhibitory
Eksata- ISSN). 2010;2089–3582. Effect of Methylmercury on Migration and
16. UNEP, WHO. Guidance for Identifying Population Tube Formation by Cultured Human Vascular
at Risk From Mercury Exposure. Geneva; 2008. Endothelial Cells. Arch Toxicol. 1995;69:357–361.
17. Bautista LE, Stein JH, Morgan BJ, Stanton N, 24. Kim SH, Johnson VJ SR. Mercury Inhibits Nitric
Young T, Nieto FJ. Association of Blood and Oxide Production But Activates Proinflammatory
Hair Mercury with Blood Pressure and Vascular Cytokine Expression In Murine Macrophage:
Reactivity. WMJ J. 2015;108(5):250–2. Differential Modulation Of Nfkappab And
P38 MAPK Signaling Pathways. Nitric Oxide.
18. Valera B, Dewailly É, Poirier P, Counil E, Suhas E.
2002;7:67–74.
Influence of mercury exposure on blood pressure,
resting heart rate and heart rate variability in 25. Pellizzari ED, Fernando R, Cramer GM, Meaburn
French Polynesians: A cross-sectional study. GM BK. Analysis of Mercury in Hair of EPA
Environ Heal A Glob Access Sci Source [Internet]. Region V Population. J Expo Anal Env Epidemiol.
2011;10(1):99. Available from: http://www. 1999;9:393–401.
ehjournal.net/content/10/1/99 26. Rajaee M, Sánchez BN, Renne EP, Basu N. An
19. Casey A, Benson H. Menurunkan Tekanan Darah. Investigation of Organic and Inorganic Mercury
New York: PT Bhuana Ilmu Populer; 2006. Exposure and Blood Pressure in a Small-Scale
Gold Mining Community in Ghana. Int J Environ
20. Valera B, Dewailly É, Poirier P. Environmental
Res Public Health. 2015;10020–38.
Mercury Exposure and Blood Pressure
Among Nunavik Inuit Adults. Hypertension. 27. WHO. The Atlas of Heart Disease and Stroke. 2010
2009;54(5):981–6. [cited 2019 Jan 29]; Available from: https://www.
who.int/cardiovascular_diseases/resources/atlas/en
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 305

Effect of Lavender Oil Massage on Pain among

Patients with Knee Osteoarthritis

Enas Mahmoud El Sayed1, Hanan Ahmed Al Sebaee2, Heba Ahmed Mohammed3, Zeinab Osman Nawito4
1Clinical instructor, Medical Surgical Nursing, 2Professor, Medical Surgical Nursing, 3Assistant Professor, Medical
Surgical Nursing, 4Professor of Rheumatology and Rehabilitation, Faculty of Medicine,
Cairo University, Egypt

Abstract
Osteoarthritis (OA) is a progressive chronic joint disease with global relevance with up to 250 million people
being affected from knee OA worldwide. The aim of this study was to evaluate the effect of Lavender oil
massage on pain among patients with knee osteoarthritis. A convenient sample of 60 adult male and female
patients who admitted to Rheumatology and Rehabilitation unit affiliated to Cairo University hospital in
Egypt with confirmed diagnosis of knee OA divided into experimental (study) and control group. A quasi-
experimental Time Series pre-post test non equivilant interrupted control design was utilized in the current
study. Data was collected using Personal and Medical Background Information Form, Pain Numerical
Rating Scaleand Lequesne Algo Functional Index of Severity. The study findings revealed that there were
significant statistical differences of pain intensity score and OA severity between study and control group
after application of lavender oil massage.

Conclusion: Lavender oil massage was proved in this study to be effective on pain and OA severity among
patients with knee osteoarthritis.

Keywords: Lavender oil massage, pain, Patients with osteoarthritis.

Introduction Knee OA is divided into two types either idiopathic

(primary) or secondary (post-traumatic). The primary
Osteoarthritis is one of the most common
OA is a gene-dependent disease, while secondary OA
musculoskeletal diseases, with an estimated prevalence
occurs after a traumatic event. Clinical characteristic of
of 12% to 22% worldwide1. In Egypt OA is the third
knee OA include pain, swelling,stiffness, crepitationand
leading cause of disability just after heart disease and
loss of movement that results in functional limitation,
back disorder; 1.6 million people were affected by
physical disability and reduced health-related quality of
OA in Egypt2. According to the American College of
life3.
Rheumatology, OA is defined as a group of conditions
which are associated with the defective integrity of Aromatherapy is one of complementary and
articular cartilage result in changes in the underlying alternative therapy (CAT) uses essential oils and herbal
bone and articular margins3. essences for improving mental health or relieving
physical symptoms. Previous studies have examined
the effect of aromatherapy on anxiety, pain and wound
healing4. As result of its simplicity and affordability,
Corresponding Author: aromatherapy has been used as an optional choice in
Enas Mahmoud El Sayed some medical settings, either alone or together with
Clinical Instructor, Medical Surgical Nursing, Faculty standard pain control protocol5.
of Nursing, Cairo University, Egypt
e-mail: [email protected] Nursing practices for patient with osteoarthritis
Mobile Phone: 01066228895 should be focused on performing regular follow up,
306 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
training, and determining the most effective symptom 2. The pain Numerical Rating Scale (NRS): It is an
management method. Aromatherapy and massage are 11-point scale (0-10). Pain intensity can be classified
among the non‐pharmacological method which nurses into mild, moderate, and severe levels based on the
may directly and independently use to control pain NRS score.
so they should increase their knowledge and skills
3. Lequesne Algo Functional Index of Severity: it is
regarding aromatherapy massage like recognizing the
a disease questionnaire related to severity of OA.
pharmacological actions of the essential oils and how to
It consists of three scales with eleven items. Its
apply aromatherapy massage properly6.
scoring system 0= none, 1-4 mild, 5-7 moderate,
8-10 severe, 11-13 very severe and >= 14 extremely
Method
severe
Aim of the Study: The aim of the current study
Validity & Reliability: Tools were validated by
was to evaluate the effect of Lavender oil massage on
a panel of five experts in the field of Medical-Surgical
pain among patients with knee osteoarthritis. To fulfill
Nursing and modifications were carried out. Reliability
the aim of this study the following research hypotheses
was tested using Cronbach’s alpha with value of 0.98.
were tested:
Procedure: Patients were randomly divided into
H1. Total mean score of pain of OA patients who
study and control group. Participants in the study
receive lavender oil massage will be different from total
group were instructed to massage their affected knee
mean score of pain of OA patients who receive routine
joint for 20 min 3 times per week for 3 weeks using
protocol of care.
5 ml lavender essential oil diluted in sweet almond
H2: The severity of osteoarthritis in OA patients oil at a concentration of 3% and continued to receive
who receivelavender oil massage will be different from conventional drugs. While the participants in the control
the severity of osteoarthritis in OA patients who receive group receive similar conventional drugs described by
routine protocol of care. the rheumatologist.

Research Design: Quasi-experimental time series Results

pre-post test nonequivilant interrupted control design
Section I: Demographic characteristics and
was utilized in the current study.
medical data of the study and control groups.
Sample: A convenient sample of adult male and
The age of 60% of the study group and 56.6% of
female patients with confirmed diagnosis of OA of the
the control group ranged from41-60 years old and the
knee, their age ranged between 18 and 50 years. All
mean age was 41.83 ± 6.828. Female gender constituted
patients admitted to rheumatology unit and met the
83.3% of both study and control group.86.7% and 93.4%
inclusion criteria throughout 6 months from July 2018
of study and control group respectively were married.
to January 2019 were allocated to either study or control
Less than half of study group (40%) and around one
group starting with control group.
third of control group can read and write,66.6% in both
Setting: The current study was conducted in a groups were housewives and 73.3% were rural areas’
selected Rheumatology and Rehabilitation unit, at Cairo inhabitants.
university hospital, Egypt.
According to medical data, around two thirds and
Data Collection Tools: 63% of study and control group respectively had gradual
onset of osteoarthritis. 73% and 77% of study and
1. Personal and Medical Background Information
control group respectively had no chronic diseases. 60%
Form (PMBIF): It is consisted of two parts: (a)
and 43% of study and control group respectively had no
Personal data sheet (b)Medical data sheet related to
family history of osteoarthritis.
disease onset, duration, medical treatment, etc.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 307
Section 2: Delineates hypothesis testing for being supported or not among study and control groups.

Table (1): Comparison between pain intensity score at four time points of both study and control group (N=60).

Study Group Control Group

Pain Intensity X2 P value
No. % No. %
Mild 1 (3.3) 0 (0)
Base Line Moderate 5 (16.7) 7 (23.3) 1.355 0.508
Severe 24 (80) 23 (76.7)
Mild 5 (16.7) 2 (6.7)
First Week Moderate 13 (43.3) 7 (23.3) 5.540 0.063
Severe 12 (40) 21 (70)
Mild 11 (36.7) 3 (10)
Second Week Moderate 8 (26.6) 7 (23.3) 7.251 *0.027
Severe 11 (36.7) 20 (66.7)
Mild 13 (43.3) 3 (10)
Third Week Moderate 7 (23.4) 7 (23.4) 9.583 *0.008
Severe 10 (33.3) 20 (66.6)

*significant at P≤ 0.05.

Table (1) denotes that there was significant statistical difference between study and control group along study
period.

Table (2): Comparison between levels of algofunctional index score at four time points of both study and
control group (N=60).

Study Group Control Group

Disease Severity X2 P value
No. % No %
Severe 5 (16.7) 3 (10)
Base line Very severe 7 (23.3) 7 (23.3) .605 0.739
Extremely severe 18 (60) 20 (66.7)
Mild 1 (3.3) 0 (0)
Moderate 4 (13.3) 0 (0)
First week Severe 11 (36.7) 7 (23.3) 8.865 0.065
Very severe 7 (23.4) 8 (26.7)
Extremely severe 7 (23.3) 15 (50)
mild 4 (13.3) 0 (0)
Moderate 4 (13.3) 0 (0)
Second week Severe 10 (33.4) 9 (30) 11.910 *0.018
very severe 6 (20) 6 (20)
extremely severe 6 (20) 15 (50)
mild 5 (16.7) 0 (0)
Moderate 4 (13.3) 0 (0)
Third week Severe 10 (33.3) 9 (30) 13.001 *0.011
very severe 5 (16.7) 6 (20)
extremely severe 6 (20) 15 (50)

*significant at P ≤ 0.05.

Table (2) clarifies that there was significant statistical difference between study and control group along study
period.
308 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Figure 1: shows that there was statistical significant significant difference in pain score between study group
difference in pain score among study and control group when compared to control group in the 1st, 2nd, and 3rd
(ANOVA test: 46.229, p-value: *0.000) respectively weeks of intervention.
along the study period. Alsothere was a statistical

Figure 1: Differences of pain score between study & control group at four time points.

Figure 2: Differences of algofunctional index score between study & control group at four time points.

Figure 2: clarifies that there was statistical significant finding is almost consistent with Arslan, Kutlutürkan
difference algofunctional index score among study and and Korkmaz, (2019)7,the majority of their study
control group (ANOVA test: 52.260, p-value: *0.000) participants were 35-64 years old. The findings can be
along the study period.Alsothere was a statistical explained with the fact that OA development starts much
significant differencein algofunctional index score earlier than originally thought, and ranked among the
between study group when compared to control group in top 20 diseases in the 40–45 years age group.
the 1st, 2nd, and 3rd weeks of intervention.
Regarding gender, more than half of the participants
Discussion were females. This finding is congruent with the
findings of the studies by Nasiri and Mahmodi, (2018);
The current study revealed that, the majority of the Arslan, Kutlutürkan and Korkmaz (2019) & Pehlivan
study participants aged between 41-60 years old with and Karadakovan, (2019)8,7,6 all affirmed that the
mean and standard deviation of age 41.83 ± 6.828. This
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 309
majority of their study participants were females. In when compared with the massage and control group.
addition, Mahajan and Patni, (2018)9 confirmed that Other study done by Arslan et al.’s (2019)7revealed
OA strikes women more often than men and it increases that aromatherapy massage performed in patients
in prevalence, incidence and severity after menopause. with osteoarthritis had positive effect to reduce knee
The majority of study participants were housewives. pain scores, morning stiffness, and improve physical
These findings were relatively congruent with Nasiriand functioning status and considered that complementary
Mahmodi, (2018); 8. The finding that the majority of the treatment modalities are useful for nurses who
participants were housewives could be explained that can perform aromatherapy massage for symptom
the majority are females and reside from rural areas. management in OA.

More than two thirds of study participants had In the current study, there was a statistical significant
gradual onset of disease. This could be explained with difference in mean score of pain between study group
that OA develops slowly and that’s why it takes time when compared to control group in the 1st, 2nd, and 3rd
to induce symptoms that appears gradually starting weeks of intervention. This findings is consistent with
with pain which worsens overtime. The majority of Nasiri and Mahmodi, (2018); Nasiri et al., (2016);8,
study participants had no comorbidities as diabetes and 12who reported that pain severity differed significantly

hypertension. In contrast Swain et al., (2019)10 reported immediately, 1 week, and 4 weeks after the intervention
that 67% of patients with OA had at least one other with p value (<0.001) compared with placebo and
chronic condition, being 20% higher than those without control groups.
OA. In addition, Hawker et al., (2017)11 mentioned that
77% of their study sample had hypertension, added On the same stream, another study finding belongs
that OA-related difficulty walking was a significant to Zhang et al., (2018)13 revealed that patients with
and potentially modifiable risk factor for diabetes bilateral knee OA has been demonstrated that lavender
complications.The mean age of the current study oil aromatherapy massage, significantly reduced the
participants was 41.83 ± 6.828 years old that could be patients’ knee pain, tenderness, and morning stiffness.
the reason why the majority of study participants had Furthermore, other study conducted by Won andChae,
no co morbidities as the prevalence of co morbidities (2011)14, reported that aromatherapy massage could be
increases with advancing age. recommended as an effective intervention to decrease
pain and to increase stride length in the elderly with
The findings of the present study revealed that knee osteoarthritis. Atkins and Eichler (2013)15added
a significant reduction in the mean score of pain 5.27 aromatic massage therapy was more beneficial than
±2.083 and OA severity 9.633±5.0085 after application massage alone among knee OA patients.
of lavender oil massage on knee joint compared to
the control group 7.17±1.802 and 13.333±3.4996 Conclusion:Lavender oil massage was proved in
respectively. This finding supports the effectiveness of this study to be effective on pain among patients with
lavender oil massage on pain and OA severity among knee osteoarthritis.Implications:The complementary
patients with osteoarthritis. The findings of the present therapy is useful to healthcare providers who can learn,
study are consistent with other study conducted by Nasiri apply, or recommend aromatherapy massage techniques
& Mahmodi, (2018); Nasiri et al., (2016)8, 12. The findings as a component of care for symptoms management of
showed that pain severity reduced significantly in the OA patients.
group undergoing massage with lavender oil compared Recommendations:
to control group. This finding could be explained in
the light of fact that the direct pharmacological effects • Replication of the study using a larger probability
of lavender oil is possibly because of lynalyl acetate sample selected from different geographical areas in
and linalool, which can effectively decrease pain and Egypt.
inflammation, prevent muscle spasms and reduce
• Longitudinal study should be designed to determine
tensions, leading to improve pain and physical function.
the long term effect of lavender oil massage for this
In this respect, other study conducted by Seda group of patients over a long period of time.
Pehlivan (2018)6, reported that there were significant Ethical Clearance: A research approval was
differences in pain score in the aromatherapy group obtained from the Research and Ethical committee
310 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
at Faculty of Nursing - Cairo University and official 7. Efe Arslan D, Kutlutürkan S, Korkmaz M. The
permission was obtained from the administrators at Effect of Aromatherapy Massage on Knee Pain and
study setting. Written informed consent was obtained Functional Status in Participants with Osteoarthritis.
from each patient. Pain Management Nursing. 2019;20(1):62-69.
8. Nasiri A, Mahmodi M. Aromatherapy massage
Conflict of Interest: The authors declare that there
with lavender essential oil and the prevention of
is no conflict of interest.
disability in ADL in patients with osteoarthritis of
Source of Funding: Self-funding. the knee: A randomized controlled clinical trial.
Complementary Therapies in Clinical Practice.
References 2018;30:116-121.
1. Smith T, Hawker G, Hunter D, March L, Boers 9. Mahajan, A., & Patni, R. 2018. Menopause and
M, Shea B et al. The OMERACT-OARSI Core Osteoarthritis: Any Association?. Journal of Mid-
Domain Set for Measurement in Clinical Trials life Health. 2018; 9(4), 171.‫‏‬
of Hip and/or Knee Osteoarthritis. The Journal of 10. Swain S, Sarmanova A, Coupland C, Doherty
Rheumatology. 2019;46(8):981-989. M, & Zhang W. Comorbidities in Osteoarthritis:
2. ‫‏‬Abdel-Magied R, AbdelGawad E, El-Shereef A systematic review and meta‐analysis of
R, Lotfi A, Saedii A. Relationship between observational studies. Arthritis care & research.‫‏‬
serum 25-hydroxy vitamin D levels, knee pain, 2019.
radiological osteoarthritis, and the Western Ontario 11. Hawker G, Croxford R, Bierman A, Harvey P, Ravi
and McMaster Universities Osteoarthritis Index B, Kendzerska T & Lipscombe L. Osteoarthritis-
in patients with primary osteoarthritis. Egyptian related difficulty walking and risk for diabetes
Rheumatology and Rehabilitation. 2014;41(2):66. complications. Osteoarthritis and cartilage. 2017;
3. Khuman R, Chavda D, Surbala L, Bhatt U. 25(1), 67-75.‫‏‬
Reliability and validity of modified western 12. Nasiri A, Mahmodi M & Nobakht Z. Effect of
ontario and mcmaster universities osteoarthritis aromatherapy massage with lavender essential
index gujarati version in participants with knee oil on pain in patients with osteoarthritis of the
osteoarthritis. Physiotherapy - The Journal of Indian knee: A randomized controlled clinical trial.
Association of Physiotherapists. 2018;12(1):8. Complementary therapies in clinical practice.
4. Fazlollahpour-Rokni F, Shorofi S, Mousavinasab 2016;25, 75-80.‫‏‬
N, Ghafari R, Esmaeili R. The effect of inhalation 13. Zikri E. Evaluation of the effect of aromatherapy
aromatherapy with rose essential oil on the anxiety in management of knee osteoarthritis patients.
of patients undergoing coronary artery bypass graft International Journal of Complementary &
surgery. Complementary Therapies in Clinical Alternative Medicine. 2018;11(2).
Practice. 2019;34:201-207.‫‏‬ 14. Won S, & Chae Y. The effects of aromatherapy
5. Chen S, Wang C, Chan P, Chiang H, Hu T, Tam massage on pain, sleep, and stride length in the
K et al. Labour pain control by aromatherapy: A elderly with knee osteoarthritis. Journal of Korean
meta-analysis of randomised controlled trials. Biological Nursing Science.2011;13(2):142-148.‫‏‬
Women and Birth. 2019;32(4):327-335. 15. Atkins D, & Eichler D. The effects of self-massage
6. Pehlivan S, Karadakovan A. Effects of aromatherapy on osteoarthritis of the knee: a randomized,
massage on pain, functional state, and quality of controlled trial. International journal of therapeutic
life in an elderly individual with knee osteoarthritis. massage & bodywork. 2013; 6(1), 4
Japan Journal of Nursing Science. 2019.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 311

How Soon Can You Expect to Get Pregnant after Discontinuing

Reversible Contraceptive Method? A Survival Analysis of the
2017 Indonesia Demographic and Health Survey Data

Maria Gayatri1, Budi Utomo2, Meiwita Budiharsana2

1Ph.D. in Public Health, Training and Development Staff, National Population and Family Planning Board, East
Jakarta, 2Professors, Department of Biostatistics and Population, Faculty of Public Health,
University of Indonesia, Depok, West Java, Indonesia

Abstract
Objectives: The information about the return of fertility was important for women use contraceptives for
delaying and spacing. The objective of this study was to analyze time to pregnancy following contraceptive
discontinuation among reproductive women in Indonesia.

Material and Method: Data on the return of fertility after discontinuation of various reversible contraceptive
method were collected through a calendar contraceptive history among currently married women taking part
in the Indonesia Demographic and Health Survey (IDHS) 2017. There were 3,887 women who discontinued
using injectables, 1,641 women who discontinued using oral contraceptives, 228 women who removed their
IUDs and 233 women who removed their implants for planning a pregnancy, who were followed up in this
study to assess the return of fertility after discontinuation of their respective reversible contraceptives.

Findings: This study found that there is a delay in conception or pregnancy following discontinuation
of a reversible contraceptive, but there is no permanent infertility among women after discontinuation
of reversible contraceptives. The cumulative pregnancy rate for a-year is 75% for discontinuers of oral
contraceptive users, 72% for discontinuers of IUD users, 75% discontinuers of implant users and 64% for
discontinuers of injectable users.

Conclusions: The study found that contraceptive method significantly influenced the length time to become
pregnant after discontinuation of reversible contraceptive method. However, the duration of contraceptive
use has no relationship to time to pregnancy. To conclude, there is no impaired fertility after contraceptive
discontinuation. Implication of this study is important for counseling process.

Keywords: Reversible contraceptives, pregnancy rates, discontinuation.

Introduction safety and effectiveness of the chosen contraceptive

method for the duration of their use, but also for
The success of the family planning program in
the reversibility of the method in order to become
Indonesia is shown by the rapid decline in the country’s
pregnant after their discontinuation. Method other than
fertility. Indonesia’s Total Fertility Rate (TFR) dropped
sterilization (vasectomy and tubectomy), do not bring
by more than half in approximately 50 years from
about an irreversible change in fertility2 Therefore, the
5.61 children per woman in 1971 to 2.4 children per
ideal contraceptive method for spacing is that which can
woman in 20171. In Indonesia, injectables and oral
reverse fertility as soon as possible after the method has
contraceptives are the most commonly used form of
been discontinued3.
modern contraceptive method followed by IUDs and
implants. Women who used contraceptive for delaying More than a quarter of all women of reproductive
and spacing pregnancy must consider not only the age had discontinued the use of contraceptives1. Over
312 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
two-thirds of these women had discontinued for reasons defined as the life table. The Kaplan Meier life table
other than wanting to have a child, and it can be assumed method is used to examine the return of fertility and the
that none of them had information about precisely when median time to first ovulation after contraception was
they would become fecund again and have a child. stopped. Furthermore, this analysis also utilizes the Cox
Thus, a considerable proportion of childbearing women regression method to estimate the survival experience
would be exposed to the risk of having unplanned or based on the proportional of hazard model. All analyses
unwanted pregnancies and they would potentially put are adjusted using the complex survey design. The entire
themselves at the risk of their consequences. Yet, not analyses of this study will use a two-tailed p-value. Only
much is known in Indonesia about when these women the probability values at level of p ≤ 0.05 are considered
would be likely to return to fertile status. It is essential significant to the model.
to provide these women with information not only
about method of contraceptive and their side effects, but Findings: Based on the IDHS 2017 data set, there
also about information regarding the return of fertility are about 5,989 episodes of women having planned a
after discontinuation. The objective of this study was pregnancy following their contraceptive discontinuation.
to analyze time to pregnancy following contraceptive These episodes are divided to 3,887 episodes of women
discontinuation among reproductive women in who discontinued using injectables, 1,641 episodes of
Indonesia. women who discontinued using oral contraceptives,
228 episodes of women who removed their IUDs and
Material and Method 233 episodes of women who removed their implants for
planning a pregnancy.
This study is a secondary data analysis of the 2017
Indonesia Demographic and Health Survey (IDHS). Of the 5,989 women who had discontinued the
The contraceptive calendar data of the Women’s reversible contraception in order to become pregnant,
Questionnaire form the source of data for the present almost 60% were aged 25-34 years and 29% of
study. The calendar data record the information on respondents were aged 35-49 years. There were 49%
history of contraceptive use, history of pregnancy, and women used contraception for 2 years, 38% women
other information related to the survey respondents from used contraception for 2-4 years and only about 13%
January 2012 to the date of the interview in 2017. This used contraception for 4 years or above. More than
survey only provides monthly data of reproductive and three-quarters of women in this study were not smoking
contraceptive patterns. The data on the date of the last (neither active smoking nor passive smoking). About
menstrual period are not collected. Therefore, the time a-half of respondents were not working. Most of the
of return of fertility (in number of months) is calculated women who discontinued reversible contraceptives lived
from the month that women stopped using reversible in Java Bali islands and had sexual intercourse for less
contraceptive method in order to plan a pregnancy, up than twice a week. The data indicates that women who
until the month that women became pregnant and had discontinued IUDs and implants for a planned pregnancy
either a live-born or still-born child. are totally parous with at least one child, but women who
discontinued injectables and oral contraceptives are both
Survival analysis will form almost all of the parous and nulliparous.
multivariate data analyses. With respect to each method,
the dependent variable is the time of needed for return Considering women of all characteristics the data
of fertility, or the delay in conception. The dependent show that the pregnancy rates after six months of the
variable is considered in two ways: In the first case, the discontinuation of contraceptives were 59.3% for the
dependent variable is censored (survival code = 0) if the use of oral contraceptive, 59.1% for the use of implants,
terminal event has not occurred (i.e., there is no pregnancy 42.9 for the use of injectables, and 59.6% for the use
from the time of contraceptive discontinuation until the of IUDs. The cumulative pregnancy rates after a-year of
survey date). In the second case, the dependent variable contraceptive discontinuation were 75.4%, 71.5%, 64.2%
is uncensored (survival code = 1) if the terminal event and 74.9% for women who stopping oral contraceptives,
has occurred (i.e., there is a pregnancy from the time of implants, injectables and IUDs respectively (Figure 1).
contraceptive discontinuation until the survey date).
A cox regression analysis adjusted with complex
The suitable methodology for the analysis of sample design was performed to estimate some
return of fertility which contains censored samples is determinants on pregnancy after contraceptive
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 313
discontinuation among women in Indonesia. The data contraceptive method were nearly similar. In this study,
shows that the probability to conceive significantly the duration of contraceptive use has no influence on the
influenced by the types of contraceptive method. In this probability to become pregnant following contraceptive
study, it can be known that IUDs and oral contraceptives discontinuation. Hence, women do not need to be fear to
have faster time of return to pregnancy, compared use contraceptive in a long duration because it doesn’t
to implants and injectables. However, the pregnancy impact on the future fertility.
rated after 2-years of discontinuation among four

Figure 1. Cumulative Pregnancy Rates

Discussion as consistent to the Government of Indonesia’s Medium-

Term Development Plan 2015-2019.
This study examined the type and duration of
reversible contraceptives used by women in reproductive The fear of side effect especially related to fertility
age. Some factors such as demographic factors and socio- resumption following contraceptive discontinuation
economic factors were used as controlled variables in such as infertility have made many women do not use
influencing the time of return to fertility after reversible any modern contraception4–7. Therefore, comprehensive
contraceptive discontinuation. The results showed that counselling for every woman is crucial.
oral contraceptive and injectables were the most popular
contraceptive method in Indonesia compared to IUDs Cumulative pregnancy rates for implants did not
and implants. About 92% of episodes of contraceptive differ from oral contraceptives and injectables. Another
discontinuation in this study were for injectable and oral study explains that implants are known to release
contraceptive users. The low uptake of Long-Acting low doses of progestogen that can clear rapidly from
Reversible Contraceptives (LARC) was consistent women’s circulation followed by the resumption of
to the result of Indonesia Demographic and Health regular menses and ovulatory8.
Survey1. Therefore, improving family planning services
The longest delay to become pregnant is experienced
to increase the use of long-acting method is still needed
by women who discontinued injectables. Women’s
to reduce the risk of drop out and unintended pregnancy
314 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
fertility will be returned soon after discontinuation of formulating a policy to strengthen effective counseling
contraceptive method with the exception of progestogen to determine appropriate contraception selection and
only injectables – Depot medroxyprogesterone (DMPA) discontinuation. The results of this study should be
or Norethisterone enantate (NTE-EN)9. Furthermore, important as information for the preparation of material
the length delay to conception following injectables for counselling for family planning users. The information
discontinuation is not influenced by the duration of about the return of fertility should be conveyed to
injectable use10. the couples to clear their misperceptions about the
inability to become pregnant after discontinuation of
However, women’s age has an impact on the return use reversible contraceptive method. Married women
of fertility itself. This is because fertility has a strong who want to choose their contraceptive method should
association with women’s age which means that the older have counselling by the health care providers. This
women have a reduced ability to conceive naturally11– counselling process is important to help women to use
13
followed by subsequent stages of overt cycle the best contraceptive method that suits their family size
irregularity. The gradual decline in the size of the antral goals.
follicle cohort is best represented by decreasing levels
of anti-Mullerian hormone. The variability of ovarian Conclusion
ageing among women is evident from the large variation
in age at menopause. The identification of women who In conclusion, there is no impaired fertility after
have severely decreased ovarian reserve for their age is contraceptive discontinuation. The study found that
clinically relevant. Ovarian reserve tests have appeared contraceptive method significantly influenced the
to be fairly accurate in predicting response to ovarian length time to become pregnant after discontinuation of
stimulation in the assisted reproductive technology reversible contraceptive method. The impact of duration
(ART. It also could be happened in older women who of contraceptive use has no significant relationship
were not succeed to become pregnant after contraceptive to the time to pregnancy following contraceptive
discontinuation because they entered the perimenopause discontinuation. Implication of this study is important
or menopause period8. for counseling process.

The study has concluded that there is no impaired Conflict of Interests: The author has no conflicts
fertility among Indonesian women following of interest associated with the material presented in this
discontinuation of reversible contraceptive use paper
(injectables, oral contraceptives, IUDs and implants). Funding: We grateful to University of Indonesia
Based on this result, there needs to be a policy to and National Population and Family Planning Board for
inform men and women of reproductive age (and the funding
also adolescents) that there is no fear of impairment
of fertility from using reversible contraceptives and Acknowledgements: The authors would like to
that fertility returns after discontinuation of these thank their colleagues from Faculty of Public Health,
contraceptives, albeit after a delay depending on the type University of Indonesia for the critical inputs given
of reversible contraceptive used. This would allay any during the writing of the manuscript. This study was
worry that women (and their partners) may have about supported by Indonesia National Population and Family
the loss of fertility by using reversible contraceptives. Planning Board under the project of doctoral education.
This policy needs to supplemented by a policy of We also thank DHS Program for giving us permission to
increased promotion of reversible contraceptives use the IDHS 2017 data for this analysis.
among reproductive age couples to meet their needs of
contraception for spacing pregnancies and also to reduce Ethical approval and consent to participate: Data
the probability of unwanted pregnancies. Information of the 2017 Indonesia Demographic and Health Survey
about return of fertility is also crucial for ensuring did not attach any personal identity. However, the
informed choice about contraceptives and for the authors had received ethical approval from the Ethical
assessment of the quality of care of reversible modern Committee the Faculty of Public Health University of
contraceptive method. Indonesia, number 652/UN2.F10/PPM.00.02/2018.
Permission to use IDHS data was obtained from The
The findings of this study also lead to the need for Demographic and Health Survey (DHS) Program.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 315

Reference for Contraceptive Nonuse among Women Having

Unmet Need for Contraception in Developing
1. National Population and Family Planning Board
Countries For decades, the of unmet need for the
(BKKBN), Statistics Indonesia (BPS), Ministry of
contr. Stud Fam Plann. 2014;45(2):151–69.
Health (Kemenkes), ICF. Indonesia Demographic
and Health Survey 2017. Jakarta; 2018. 8. Glasier A. Implantable contraceptives for
women: effectiveness, discontinuation rates,
2. Mansour D, Gemzell-Danielsson K, Inki P, Jensen
return of fertility, and outcome of pregnancies.
JT. Fertility after discontinuation of contraception:
Contraception. 2002;65(1):29–37.
A comprehensive review of the literature.
Contraception. 2011;84(5):465–77. 9. World Health Organization. Selected Practice
Recommendation for Contraceptive Use. Third
3. Fotherby K, Yong-En S, Howard G, Elder MG,
edit. Geneva: Department of Reproductive Health
Muggeridge J. Return of ovulation and fertility
and Research; 2016.
in women using norethisterone oenanthate.
Contraception. 1984 May;29(5):447–55. 10. World Health Organization, John Hopkins
Bloomberg School of Public Health/Center for
4. Gueye A, Speizer IS, Corroon M, Okigbo CC.
Communication Programs. Family Planning: A
Belief in Family Planning Myths at the Individual
Global Handbook for Providers (2018 update).
And Community Levels and Modern Contraceptive
Updated 3r. Baltimore and Geneva: CCP and WHO
Use in Urban Africa. Int Perspect Sex Reprod
Press; 2018.
Health. 2015;41(4):191–9.
11. Broekmans FJ, Soules MR, Fauser BC. Ovarian
5. Hyttel M, Rasanathan JJK, Tellier M, Taremwa
Aging: Mechanisms and Clinical Consequences.
W. Use of injectable hormonal contraceptives:
Endocr Rev. 2009;30(5):465–93.
Diverging perspectives of women and men, service
providers and policymakers in Uganda. Reprod 12. Homan GF, Davies M, Norman R. The impact of
Health Matters. 2012;20(40):148–57. lifestyle factors on reproductive performance in the
general population and those undergoing infertility
6. Russo JA, Miller E, Gold MA. Myths and
treatment: A review. Hum Reprod Update.
misconceptions about long-acting reversible
2007;13(3):209–23.
contraception (LARC). J Adolesc Heal. 2013;52(4
SUPPL.):S14–21. 13. Williams CJ, Erickson GF. Morphology and
Physiology of the Ovary. Endotext. MD Text.com,
7. Sedgh G, Hussain R. Reasons for Contraceptive
Inc.; 2000.
Nonuse among Women Having Unmet Need for
Contraception in Developing Countries Reasons
316 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Reviving the Lost Extremity: A Case Report

Nitika Gupta1, Jeewan Bachan Dhinsa2, Urvashi Sukhija3, Sanjeev Mittal3

1Assistant
Professor, 2PG Student, 3Professor, Department of Prosthodontics,
MM College of Dental Sciences and Research, Mullana, Haryana, India

Abstract
The hand in the human body plays a major role in daily life, communication, social contact and basic
functions such as grasping. Finger and partial finger amputations are the most frequently found forms of
hand loss and trauma which lead to an impact on the psychological health, functional abilities and aesthetics
of an individual. A prosthesis with good fitting, comfort and aesthetics can make the patient feel capable and
whole again. This article describes a technique for fabrication of a custom made glove type finger prosthesis
using silicone elastomers along with a ring for providing more retention to the prosthesis. Shade matching
has been achieved by using intrinsic acrylic paints. This case report paper describes a technique to prosthetic
rehabilitation of an amputated finger by fabrication of custom finger prosthesis by using silicone elastomer,
which is aesthetically acceptable, comfortable to use and is cost effective with a simple approach.

Keywords: Silicone elastomer, finger prosthesis, color matching, retention.

Introduction and Research, Mullana, Ambala, for the fabrication

of Complete Denture. On general examination, it was
It is rightly said “Grief is in two parts, the first is loss,
noticed that the patient had lost part of his left index
and the second is the remaking of life.” The loss of a limb
finger (distal phalange) about 5 years back, due a
or a digit has an immense impact on one’s mind, it can
traumatic injury. On physical examination a solitary
manifest as anxiety, depression or post-traumatic stress
healed scar was seen on palmar surface of the amputated
disorder on an individual.[1]Replacement of the missing
finger. The surrounding surface and area of the finger
finger by fabrication of an artificial finger is a very
appeared to be normal with no signs of pain, infection
challenging process and technique sensitive procedure
or any inflammation. Informed consent was made with a
in the terms of artistic abilities and skill expertise.
detailed explanation of the procedure. [Figure 1].
Prosthesis made for patients should be comfortable to
wear, durable, light weight, aesthetically pleasing and
easy to put on and remove.

Case Report: A 60 year old male patient reported

to the Department of Prosthodontics Crown and Bridge,
Maharishi Markendeshwar College of Dental Sciences

Corresponding Author:
Dr. Jeewan Bachan Dhinsa
P.G. Student, Department of Prosthodontics, M.M. Figure 1: Amputated left index finger
College of Dental Sciences and Research, Mullana,
Technique:
Haryana-133207, India
e-mail: [email protected] 1. Patient was requested to keep his hand in normal
Phone: +91 7018495659 resting position and not stretched. Lubrication with a
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 317
uniform thin layer of petroleum jelly is done, which finger should be of the same side of the patient’s
prevents the adhering of the hydrocolloid to the skin amputated finger and same sex. The donor was
on the site of the impression surface. A cardboard selected by matching the appearance and size of the
box was selected larger in size than the patient’s fingers using the model obtained. The impression
hand. One side of the cardboard box was cut open made was poured with heated liquid modelling wax
to place and remove the hand.[2] A thin uniform mix (MAARC).[4] The wax pattern is carefully sculpted
of hydrocolloid (Zhermack) was poured inside the hollow from the inside followed by finishing and
box creating the base of the impression on which carving to give it a natural appearance. [Figure 4]
the patient was instructed to place the palmar
4. The custom made glove type wax pattern prosthesis
aspect of the hand over of the impression material,
is tried on the patient’s amputated index finger.
simultaneously the dorsal surface of the whole hand
Proper fit and length is established with verification
was covered.[3] In the end, a layer of dental plaster
of the correct orientation. [Figure 4].
(Kalabhai Kaldent) was poured over the impression
material for imparting strength to the impression
made as well as to prevent its tearing on removal of
the patients hand. [Figure 2]

Figure 4: Trial of wax pattern on amputated finger

5. The wax pattern was invested. After complete set,

de-waxing is carried out. A mould is obtained.[5]
Figure 2: Alginate Impression and Impression
6. Silicone (RTV Silicone, MP Sai Enterprises,
surface
Mumbai) was used along with acrylic paints
2. The impression made was poured with dental stone (KURTZY Acrylic color paintv12 shades) as
(Kalabhai Kalstone) with vigorous tapping ensuring intrinsic shades. The colors Red, Blue, Yellow,
the complete flow of the dental stone. A positive Black, were used to create the natural skin tone of
replica of the site was obtained and finished.[2] the patients hand, mixing was carried out on a glass
[Figure 3]. slab. Color matching was done in natural light.[6]
After desired shade was achieved and the silicone
material was packed into the mould, bench pressed
and was left overnight for processing. [Figure 5].

Figure 3: Dental stone model

3. In this case, the wax pattern was fabricated by Donor

Finger which involved making a hydrocolloid
impression of the donor index finger. The donor Figure 5: Shade Matching
318 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
7. A prefabricated artificial nail was used (Electromania angle of amputation along with the number of fingers
Acrylonitrile Butadone Styrene Style Plane Nail involved and the choice and acceptance of the person
Tips Pack of 24). for the restoration of the finger. There are numerous
replacement techniques accessible to restore the finger.
8. The final prosthesis was retrieved, excess was [8] A well fitted and color matched prosthesis gets rid of
trimmed and finished. The artificial nail was
the constant reminder of disability to a person.[9][10]
trimmed and glued according to esthetics, followed
by insertion of the final prosthesis on the patient’s
Conclusion
amputated left index finger.A ring was placed over
the silicone finger prosthesis, which provided more Rehabilitating the finger or its partial finger segment
retention to it. The prosthesis was delivered to the with an artificial prosthesis can be rewarding and
patient, was completely satisfied and contented with satisfying with a pleasant outcome for a maxillofacial
the outcome.[4] prosthodontist. The artificial prosthesis given can
greatly enhance the psychological health, self-esteem of
9. To maintain its hygiene, the prosthesis should be
the patient. The process requires great skill, technique
washed with antibacterial soap from inside and
sensitivity and artistic skills along with the understanding
outside air dried and then worn.[7] Exposure to high
of the patients need.
temperatures should be avoided. Smoking may
discolour and stain the prosthesis. The prosthesis is Ethical Clearance: Not Applicable
not to be worn overnight as it will lead to irritation
of the underlying skin. [ Figure 6] Source of Funding: Self

Conflict of Interest: Nil

References
1. Kamble VB, et al. Silicone finger prostheses
for single finger partial amputations: Two case
reports,Indian Journal of Dentistry (2012)
2. Dogra, et al. Fabrication of a silicone finger
prosthesis,The Journal of Indian Prosthodontic
Society, September 2008,Vol 8,Issue 3, page
number-166-68
3. Mehta S, Leela B, Karanjkar A, HalaniAJ.
Figure 6: Silicone Finger Prosthesis Prosthetic rehabilitation of a partially amputated
finger using a customized ring-wire substructure. J
Discussion Indian Prosthodont Soc 2018;18:82-85.
It has been reported that the most common found 4. Deepesh Saxena et al. Rehabilitation of Digital
amputations are partial hand amputations, presenting with Defect With Silicone Finger Prosthesis: A Case
loss of one more fingers. They are commonly resulted Report Journal of Clinical and Diagnostic Research.
from occupational hazard, automobile accidents.[3] 2014 Aug, Vol-8(8): ZD25-ZD27
Other causes of amputations can be congenital, diabetes, 5. Shanmuganathan N et al. Aesthetic Finger
gangrene and infections resulting from lack of basic Prosthesis, J Indian Prosthodont Soc (Oct-Dec
public health. Partial finger amputations lead to 2011);11(4):232–237
functional deficiencies, aesthetic problems resulting 6. Mallikarjuna Ragheret al. Finger Prosthesis Made
in poor self-esteem, and psychological instability and Easy: A Case ReportSch. Acad. J. Biosci., 2014;
economic damage to the individual.Many materials such 2(11):841-844
as Acrylic, Polyurethane, polyvinylchloride have been
7. Anand, Shafi FM, Pradeep N (2015) A Cost
used to produce finger prosthesis.[7] The restoration of
Effective Method to Fabricate an Interim Finger
the lost limb, finger depends upon the amount of the
Prosthesis. Dentistry 5: 323.
tissue involved and bone involvement, the level and the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 319
8. Satyanarayana N et al, Beauty At Fingers Tips:An 9. Wilson RL, Carter-Wilson MS. Rehabilitation after
Anaplastic Finger Prosthesis case report Indian amputations in the hand. Orthop Clin N Am.1983;
Journal of Dental Sciences, December 2013, 14: 851–72.
Issue:5, Vol.:5 10. Kanter CJ, The use of RTV silicones in maxillofacial
prosthetics. J. Prosthet Dent. 1970; 24 (6):646-53.
320 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Lower Extremity Perfusion among Patient with Type 2

Diabetes Mellitusin a Tertiary Care Hospital, Kochi

Reshma K. Sasi1, Rafia Islam1, Anjana Sunil2, Anju Markose2

1Lecturer, Amrita College of Nursing, Amrita Vishwa Vidyapeetham, Health Science Campus, Kochi,
2IVth Year B.Sc. Nursing Students, Amrita College of Nursing, Kochi

Abstract
Introduction: Diabetes as one of Non-communicable diseases has consumed a large share of money, material,
time and human resources of health systems. Now, due to advancement in lifestyle and industrial process,
prevalence of diabetes and its associated complications have been raised. Among these complications,
diabetic foot considered as a common complication of diabetes.

Method: The present study was a quantitative quasi experimental two group pretest posttest design. The
study was done at Amrita Hospital, Kochi. The main objective of the study was to evaluate the effectiveness
of Burger Allen exercise on level of lower extremity perfusion among patients with type 2 Diabetes Mellitus.
Totally 100 samples were taken in which 50 are in experimental and 50 in control group using convenience
sampling technique.

Results: In the present study, majority were males with the average age among experimental group were
55.30 +- 4.58, 36(72%) and 55.30+- 4.58, 34 (68%) in the control group. The study result showed that mean
and standard deviation of ABPI score among both groups on Day 1(0.07±0.01), day 2 (0.05±0.02) and day
3(0.19±0.01). There was statistical significance with the p value <0.01. There was also significant difference
between the groups and within the groups in ABPI scores in 3 days among patients with type 2 DM which
is significant at <0.05.

Conclusion: In the light of present study result, it depicted that the Buerger Allen exercise improve lower
extremity perfusion among patient with type 2 diabetes mellitus.

Keywords: Buerger Allen exercise, Lower extremity perfusion, Type 2 diabetes mellitus.

Introduction prevalence of diabetes is high 20% which is double the

national average of 8%. As compared the prevalence in
Diabetic mellitus is a group of metabolic disease
Thiruvananthapuram was 17%, in Hyderabad and New
in which defects in insulin secretion or action result in
Delhi 15%, in Nagpur 4% and in Dibrugarh 3%.2
elevated blood glucose (hyperglycemia). In 2017, The
WHO global report on diabetes demonstrates that the Diabetic foot complication is a major cause
number of adults living with diabetes is 422 million of disability, reduced quality of life, prolonged
adults. 1.6 million deaths are directly attributed to hospitalization, financial loss, lower limb amputation
diabetes each year. Type 2 DM accounts for around 90% and mortality rate. 3,4 People with diabetes develop foot
of all diabetes worldwide.1 Reports of type 2 diabetes ulcers because of neuropathy, vascular insufficiency
in children have increased globally. Diabetes currently and impaired wound healing. 5 Nearly 90% of diabetes
affects more than 62 million Indians, which is more than relayed lower limb amputations were preceded by foot
7.1% of adult population. The average age of onset is 42 ulcers.6 The value of these exercises had frequently been
years. Nearly 1 million Indians die due to diabetes every emphasized by Allen, many medical experts considered
year. Kerala is known as diabetes capital of India as them as important adjuvant treatment and postoperative
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 321
care for circulatory disturbances in the extremities.7,8 Methodology
The exercises involve the individual lying flat in bed
The present study was a quantitative quasi
with the legs elevated at 45 degrees until blanching
experimental two group pretest posttest design. The
occurs or for a maximum of 2 minutes. The patient then
study was done at Amrita Hospital, Kochi. The main
sits at the edge of the bed with the feet hanging down.
objective of the study was to evaluate the effectiveness
Further exercises include dorsiflex, plantar flex, then
of Burger Allen exercise on level of lower extremity
inward and outward movement of the feet, followed by
perfusion among patients with type 2 Diabetes Mellitus.
flexing and extending of the toes for 2 minutes. Finally
the individual lies supine with the feet covered with Selection method of the study participants: The
a warm blanket lasting 5 minutes. The whole cycle is study included all patients between 45-60 years with
repeated 3 to 6 times each session, and the complete Type 2 Diabetes Mellitus and whose ABPI score was
sequence is repeated 2- 4 times a day.9 0.9 -0.4. The sample size was obtained using Master
software based on previous article conducted by John
The ankle brachial pressure index is a simple non-
J and Rathiga R on effectiveness of Buerger Allen
invasive and inexpensive diagnostic tool of choice
Exercise to improve the lower extremity perfusion
for diagnosing peripheral artery disease in diabetic
among patients with type 2 diabetes mellitus with -80%
patients. The ABPI is the ratio of the systolic blood
power, 95% Confidence interval minimum sample size
pressure in the angle to the systolic blood pressure in
10 in each group. Totally 100 samples were taken in
the arm. It is an objective indicator of arterial disease
which 50 are in experimental and 50 in control group
that allows the examiner to quantify the degree of
using convenience sampling technique. The study
stenosis. Doing exercise will help the patient to improve
excluded patients who are unconscious, disoriented,
the vascularization and at the same time it will help to
critically ill, on anti-coagulant therapy, on treatment of
improve the wound healing process.
deep vein thrombosis and also who are not willing to
People with long standing Diabetes mellitus participate. The ABPI score was obtained by dividing
develop complication of PAD, which leads to grave the highest ankle systolic pressure to the highest brachial
complications like gangrene in the lowerlimbs. The most systolic pressure. After obtaining written informed
common symptom is muscle pain in the lower limbs on consent, the ABPI was measured in each subjects and
exercise. Indiabetes, pain perception may be blunted those subjects whose ABPI score was between 0.9 to
by the presence of peripheral neuropathy. Therefore, a 0.4 had been given the Buerger Allen Exercise for 12-13
patient with diabetes ismore likely to present with an minutes on three days. On the third day again the ankle
ischemic ulcer or gangrene. The use of ankle-brachial- brachial pressure index was calculated. Ethical clearance
pressure index in the clinic and bedside provide a had been obtained from the Thesis review committee of
measure of blood flow to the ankle. This could help early AIMS and research Committee of Amrita College of
detection,initiate early therapy and may thus reduce the Nursing.
risk of critical limb ischemia and limbloss.
Software Used for Data Entry, Compilation and
Buerger Allen Exercise is one of the intervention to Statistical Analysis: Microsoft Excel spread sheet was
stimulate the development of collateral circulation in the used for data entry and data analysis was done using
legs. Primary care providers should focus on prevention the SPSS 20.0 version. In this study the quantitative
by early recognition and prevention of PAD to those data were expressed in terms of descriptive statistics.
at increased risk. An awareness of diagnostic and Paired t-test had been used for comparing statistical
treatment strategies will enable primary care provide significant to compare the pre- test and post–test scores
providers to educate patients. This will help to improve of ankle brachial pressure index among Type 2 Diabetic
both concordance with treatment and disease outcome. Mellitus patients. Chi-Square test was used to find
Considering the above factors and review of literature, out the association between ABPI score and selected
the investigator felt that all patients with diabetes demographic variables.
mellitus should do the
Ethical consideration: The project has been
Buerger Allen Exercise to improve lower extremity approved by the ethics committee of the institution.
perfusion. Informed consent was obtained from the participants
before initiating the study.
322 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Results for more than 11 years. Whereas in the control group,

the average age is 55.30+- 4.58, 34 (68%) were males,
In the study, the average age of experimental group
41 (82%) had education upto secondary level, 26 (52%)
is 55.30 +- 4.58. 36 (72%) were males, almost 45 (90%)
were unemployed, 31 (62%) were moderate workers,
had education up to secondary level, 32 (64%) subjects
almost 45 (90%) were following non vegetarian diet, 34
were employed, 23 (46%) were doing sedentary and
(68%) had no ill habits.
moderate work each, 46 (92%) were non- vegetarian diet,
29 (58%) had no ill habits and 33 (66%) had type 2 DM

Figure 1: Frequency and percentages distribution of BMI among patients with Diabetes mellitus in control
and experimental group. N = 100

In the present study, the result shows that BMI In experimental group, 18(36%) were overweight and
category in control group were 2(4%) underweight, 7(14%) were obese.
15(30%) normal, 30(60%) overweight and 3(6%) obese.

Table 1: Comparison of mean, median and standard deviation of clinical variables among patients with
diabetes mellitus in control and experimental group. N=100

Group Clinical Parameters Mean Median Standard Deviation (SD)

Height 159.24 158 6.14
Control Group Weight 64.96 65 9.95
BMI 25.56 25.8 3.10
Height 159.24 160 5.17
Experimental Group Weight 64.48 60 11.71
BMI 25.42 24.69 4.33
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 323
The above table shows that among the control the mean and standard deviation of height, weight and
group the mean and standard deviation of height, BMI is (159.24±5.17), (64.48±11.71) and (25.42±4.33)
weight and BMI is (159.24± 6.14), (64.96± 9.95) and respectively.
(25.56± 3.10) respectively. In the experimental group

Table 2: Mean and standard deviation of Ankle brachial pressure index among control and experimental
group. N=100

ABPI Score Mean Standard Deviation F p- value

Day 1 0.07 0.01 4.44 0.00**
Day 2 0.05 0.02 2.88 0.01*
Day 3 0.19 0.01 0.60 0.00**

Data present in the table shows that mean and 3(0.19±0.01). There was statistical significance with the
standard deviation of ABPI score among both groups p value <0.01.
on Day 1(0.07±0.01), day 2 (0.05±0.02) and day

Table 3: Comparison of ABPI scores among patient with diabetes mellitus in between and within the control
and experimental groups. N=100

Variables Days Mean Sum of square df F p-value

Between groups 0.135 0.13 1
Day 1 45.55 0.000*
Within groups 0.003 0.29 98
Between groups 0.064 0.06 1
ABPI score Day 2 6.68 0.01*
Within groups 0.009 0.93 98
Between groups 0.984 0.98 1
Day 3 349.92 0.000*
Within groups 0.003 0.27 98

The table 3 depicts the significant difference diet, 29 (58%) had no ill habits and 33 (66%) had type2
between the groups and within the groups in ABPI DM for more than 11 years. Whereas in the control group,
scores in 3 days among patients with type 2 DM which the average age is 55.30+- 4.58, 34 (68%) were males,
is significant at <0.05. There was no association between 41 (82%) had education upto secondary level, 26 (52%)
the demographic variables and the ABPI score were unemployed, 31 (62%) were moderate workers,
almost 45 (90%) were following non vegetarian diet, 34
Discussion (68%) had no ill habits.
Diabetes is a complex metabolic disease. A Non Another study conducted by M. Vijayabarathi (2013)
pharmacological natural approach is needed to overcome on effectiveness of buergerallen exercise on wound
that problem. Burger’s Allen exercise is a simple, which healing process among the diabetic foot ulcer patients
is easy to do, have no notable side effects and most admitted in diabetology department which results
acceptable one to reduce Diabetes mellitus. showed that in considering the age wise distribution,
In the present study, the average age of experimental 36.7% of subjects were in 50 to 60 years of age, in
group is 55.30 +- 4.58. 36 (72%) were males, almost 45 the experimental group. In the control group 33.3% of
(90%) had education up to secondary level, 32 (64%) subjects were more than 60 years of age. In the sex wise
subjects were employed, 23 (46%) were doing sedentary distribution, females were high in both experimental
and moderate work each, 46 (92%) were non- vegetarian and control group as 80.0% and 83.3%.In Experimental
324 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
group majority was educated up to primary education from CVA, 04/30 (13.3%) were suffering from CAD,
50.0% (15) and in Control group 63.3% (19) equally and 30/60 (50%) of patients were not suffering from any
educated up to primary education and High School. comorbid illness.13
When considering the type of family most of them
belong to nuclear family in both the groups. In both the In the present study, the significant difference
groups when considering the education status most of between the groups and within the groups in ABPI
the subjects had only primary education.10 scores in 3 days among patients with type 2 DM which
is significant at <0.05.
The present study shows that 30 (60%) subjects are
overweight in control group whereas in the experimental Jemcy John and A Rathinga conducted a research
group most of the subjects 22 (44%) have normal BMI. study showed a significant improvement in the lower
extremity perfusion after the Buerger Allen exercise.
Leelavathi M. (2015) conducted a study on Data depicts that the mean post- test ankle brachial index
effectiveness buerger’sallen exercise on improving score was higher than the mean pre-test ankle brachial
lower extremity perfusion among patients with diabetes index score. The calculated t value was greater than the
mellitus which inferred that most of the patients with table value. The computed t value shows that there was
diabetes mellitus had B.M.I. of 25-29 (43.3%, 43.3%). a significant difference between the two mean ankle
Increased BMI was associated with increased prevalence brachial index score.14
of diabetes mellitus. An increase in body fat is generally
associated with increased risk of metabolic diseases Mellisha MS conducted a study on effectiveness of
such as type II diabetes mellitus.11 buergerallen exercise on lower extremity perfusion and
pain among patients with type 2 diabetes mellitus showed
Data present in the table shows that mean and that in the experimental group, the mean score of level of
standard deviation of ABPI score among both groups lower extremity pain was reduced from 4.33 to 1.30. The
on Day 1(0.07±0.01), day 2 (0.05±0.02) and day reduction of pain was statistically significant difference
3(0.19±0.01). There was statistical significance with the at 1% level of significance (p=0.001). The mean score
p value <0.01. of level of lower extremity perfusion was increased
from 44.50 to 52 and it showed a statistically significant
Dr. Aruna S, Thenmozhi P (2015) conducted a study difference at 1% level of significance (p=0.001).15
on effectiveness of allenbuerger exercise in preventing
peripheral arterial disease among people with type 2 The above finding clearly indicates that the
diabetes mellitus. Experimental Research Design with Buergerallen exercise was found to be an effective on
30 samples in experimental group and 30 samples in lower extremity perfusion among patients with type 2
control group were selected by using random sampling Diabetic Mellitus.
technique at Kuthambakkam village. The findings of the
study revealed that there is a significant improvement Conclusion
in Ankle-Brachial index Score in preventing peripheral The study concluded that the study participants
arterial disease among people with Diabetes Mellitus got benefited by Allen Buerger exercise in preventing
in experimental group after receiving Allen Buerger Peripheral Arterial Disease among patients with type
exercise at the level of P<0.05. Independent t test 2 Diabetic Mellitus. Nurses plays a significant role in
revealed that there is significant difference between the preventing Peripheral Arterial Disease there by reducing
experimental group and control group in preventing the risk of amputation and restore normal function of
peripheral arterial disease among people with Diabetes the extremity by encouraging them to do the exercise
Mellitus at the level of P<0.05.12 which will help to improve the quality of life. It also
Anju Kumari, Kanika Rai, Vinay Kumari, Dr Jyoti suggests that Buerger’s exercises could be an alternative
Sarin conducted a study on effectiveness of buergerallen procedure on improving peripheral circulation.
exercise on foot perfusion among patients with diabetes Conflict of Interest: There is no conflict of interest
mellitus showed that (50%) patients were suffering from for the study.
comorbid illness in which 56.6% were suffering from
hypertension, 8/30 (26.6%) were suffering from Chronic Source of Interest: Not a funded study.
Kidney Disease (CKD), 1/30 (3.33%) was suffering
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 325

References 10. Vijayabarathi. Buerger Allen Exercise

for Type 2 Diabetes Mellitus foot ulcer
1. World Health Organization (WHO). Diabetes
patients. International Journal of Innovative
fact sheet 2017 [internet]. Geneva: WHO; 2017.
Research in Science.2014;3(12):2319-8753
Available from: www.who.int/diabetes/en/
Available from: http://repository-tnmgrmu.
2. Mohan V, Sandeep S, Deepa R, Shah B, ac.in/9541/1/300116314vijaya_barathi.pdf
Varghese C. Epidemiology of type 2 diabetes:
11. Leelavathi M. Effectiveness of buerger’s allen
Indian scenario. Indian J Med Res. Mar
exercise on improving the lower extremity perfusion
2007;125(3):217-230. Available from: http://
among patients with Diabetes Mellitus admitted
admin.indiaenvironmentportal.org.in/files/file/
at Apollo Hospitals. The Tamil Nadu Dr. M.G.R
type%202%20diabetes.pdf
University; 2018. Available from: http://repository-
3. Boulton A J M, Vileikyte L, Ragnarson-Tennvall tnmgrmu.ac.in/1937/1/3001128leelavathim.pdf
G Apelqvist J. The Global Burden of Diabetic
12. S Aruna, Thenmozhi P. Effectiveness of
Foot Disease. 2005;366: 1719-24. Available from:
allenbuerger exercise in preventing peripheral
http://dx.doi.org/10.1016/S0140-6736(05)67698-2
arterial disease among people with type 2 diabetes
4. Health Promotion and Administration, Ministry mellitus. International Journal of Pharma and Bio
of Health and Welfare Diabetes; 2014. Available Sciences. 2015;6(2):966-70. Available from: https://
from: http://www.hpa.gov.tw/BHPNet/Web/ www.researchgate.net/publication/283021440_
HealthTopic/Topic.aspx?id=201409290001 Effectiveness_of_allen_buerger_exercise_in_
5. Harrington C, Zagari M, Corea J, Klitenic, J. A preventing_peripheral_arterial_disease_among_
Cost Analysis of Diabetic Lower-Extremity Ulcers. people_with_type_II_diabetes_mellitus
Diabetes Care. 2000; 23: 1333-38. Available from: 13. Kumari A, Rai K, Kumari V et.al. A study to assess
https://pdfs.semanticscholar.org/4aab/50a2b2131b the effectiveness of Buerger Allen exercise on foot
8ac45e11d575c0fed6814ac712.pdf perfusion among patients with diabetes mellitus
6. Alvarsson A, Sandgren B, Wendel C, Alvarsson admitted in selected hospital of Ambala, Haryana.
M, Brismar, K. A Retrospective Analysis of Int J Health Sci Res. 2019; 9(1):112-119. Available
Amputation Rates in Diabetic Patients: Can Lower from:http://www.ijhsr.org/IJHSR_Vol.9_Issue.1_
Extremity Amputations Be Further Prevented? Jan2019/18.pdf
Cardiovascular Diabetology.2012; 11:1-11. 14. John J, Rathiga A. Effectiveness of Buerger
Available from:http://dx.doi.org/10.1186/1475- Allen Exercise to improve the lower extremity
2840-11-18 perfusion among patients with Type 2 Diabetes
7. Bernheim A R, London I M. Arteriosclerosis and Mellitus. International journal of current research
Thromboangiitis Obliterans. JAMA.1937;108: and academic review. 2015 April; 3(4):358-66.
2102-09. Available from: http://dx.doi.org/10.1001/ Available from: http://www.ijcrar.com/vol-3-4/
jama.1937.02780250016005 Jemcy%20John%20and%20A.Rathiga.pdf
8. Edwards L, Crisenberry H. Vascular Disorders of 15. Mellisha MS. Effectiveness of Buerger Allen
the Extremities: A Discussion of Nursing Care. Exercise on Lower Extremity Perfusion and Pain
American Journal of Nursing. 1938;38:13-17. among Patients with Type 2 Diabetes Mellitus in
Available from: http://dx.doi.org/10.2307/3414247 Selected Hospitals in Chennai. International Journal
9. Bottomley J M. The Insensitive Foot. In: Timothy, of Science and Research (IJSR). 2016;5(7):1822-6.
L.K., John, O.B. and Michael, L.M., Eds., Geriatric Available from: https://pdfs.semanticscholar.org/
Rehabilitation Manual, Churchill Livingstone, 0b1a/2a1a06a4b05c0983fa3a782c1ed8548ab273.
Edinburgh. 2007;2:333-43. Available from:http:// pdf
dx.doi.org/10.1016/B978-0-443-10233-2.50058-4
326 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

A Glimpse of Manual Scavanging in India

Shailla Cannie1, Aasavri Cannie2

1Dean, Faculty of Nursing, Shri Mata Vaishno Devi University & Principal, Shri Mata Vaishno Devi College of
Nursing, Kakryal, Katra, 2Second year MBBS Student, The University of Georgia, Tiblisi, Georgia

Abstract
Across India, manual scavenging and its allied forms—the manual cleaning of dry latrines, sewers, manholes
and septic tanks, abstraction of debris from sewage canals and any interaction with excreta—are openly
prevalent, defined as a “cultural vocation”. “In India, every five days, a manual scavenger dies in a sewer,
septic tank or a manhole,” the report verbally expressed. However, its scope was constrained as its primary
source of data was statistics from NCSK, which has disarrayed information organised arbitrarily. The few key
features of the Act Prohibits the expression or maintenance of insanitary toilets, Prohibits the engagement
or employment of anyone as a manual scavenger, Violations could result in a years’ imprisonment or a fine
of INR 50,000 or both. The press Information Bureau, Government of India, Ministry of Social Justice and
Empowerment has verbally expressed that a Task Force was constituted for carrying out a National Survey
of manual scavengers in 2018 in 170 identified districts of 18 states. The right technology is considered as
one of the solution to eradicate this scourge. In spite of that, the social and gender issues should be abolished
by educating pupil about this ill.

Keywords: Manual scavengers, manholes, insanitary latrines, health issues.

Introduction The data from the National Commission for Safai

Karmacharis (NCSK) revealed appalling facts on the
Across India, manual scavenging and its allied
pattern of the deaths of manual scavengers from January
forms—the manual cleaning of dry latrines, sewers,
2017 to September 2018 and were widely shared by
manholes and septic tanks, abstraction of debris from
media houses and convivial media users. “In India,
sewage canals and any interaction with excreta—are
every five days, a manual scavenger dies in a sewer,
openly prevalent, defined as a “cultural vocation”
septic tank or a manhole,” the report verbally expressed.
annexed to a few make-believe lower castes—Hindu
However, its scope was constrained as its primary source
Dalits, a few Dalit Muslims and some converted Dalit
of data was statistics from NCSK, which has disarrayed
Christians. In India, this affair is hazardous, unsafe,
information organised arbitrarily.
unsanitary, degraded and above all, illicitly proscribed
by Parliament a few years ago. The level of susceptibility
increases as we peregrinate from rural to urban areas.
However, reports designate that these days; there is
incremented fatality in rural India, as well.1

Corresponding Author:
Dr. Shailla Cannie
Dean, Faculty of Nursing, Shri Mata Vaishno Devi
University, Principal, Shri Mata Vaishno Devi College
of Nursing, Kakryal, Katra, J & K, India–182320
e-mail: [email protected]
Mob. No.: 9796800101
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 327
Manual Scavenger at work–A bitter truth of the commencement of this Act or any time thereafter,
reality: The two major Acts have been since 1993 by by an individual or a local authority or an agency or a
Parliament to ban and control manual scavenging. One contractor for manually cleaning carrying, disposing of
of the Act passed by Narsimha Rao Government in or otherwise handling in any manner, human excreta in
1993 created a history in the legislation banning manual an insanitary latrine or in an open drain or pit into which
scavenging altogether and aimed at rehabilitation of the human excreta from the insanitary latrines is disposed
scavengers followed by passing of another Act in 2013 of, or railway track or in such other spaces or premises,
by UPA II after it was reported that manual scavenging as the central government or a state government may
still persists despite a slow progress.2 notify, before the excreta fully decomposes in such
manner as may be prescribed, and the expression
According to the India census of 2011, there are ‘manual scavenging’ shall be construed accordingly.5
more than 2.6 million dry latrines in the country. Along
with that toilets with human excreta flushed in drains The prohibition of Employment of Manual
is 13, 14,652 and 7, 94,390 dry latrines are cleaned Scavengers and their Rehabilitation Act, 2013, defines a
manually. It has as well been identified that seventy manual scavenger as an individual employed by a local
three percent of these are in rural areas and twenty seven authority or agency for manually cleaning, carrying and
in urban areas. disposing of human excreta from insanitary latrines.2

The few key features of the Act are Categories of Sanitation Workers: A caste
predicated and hereditary vocation, which is bequeathed,
Prohibits the expression or maintenance of insanitary as a legacy from one generation to the next; “manual
toilets scavenging” has been an age-old routine for this
Prohibits the engagement or employment of anyone community, which is untouched by technological
as a manual scavenger advancement in sanitary practices.

Violations could result in a years’ imprisonment or i. Sewer Cleaners: These cleaners are involved in
a fine of INR 50,000 or both unblocking and cleaning of the permissive wastewater
drains. The work is need based (pluvial season)
Prohibits a person from being engaged or employed and infrequently for preventive maintenance. The
for hazardous cleaning of a sewer or a septic tank3 sewer gas is a complex amalgamation of toxic and
non toxic flatulency engendered and accumulated
Offences under Act are cognizable and non-bailable in sewage system by the decomposition of organic
calls for a survey of manual of scavengers in urban home or industrial waste.
and rural areas within a time limit framework. While
the Act is encouraging in that it focuses on the duty of ii. Latrine Cleaners: They are involved in cleaning
official to ensure its implementation, it does not outline the process of evacuating dry/single-pit latrines
administrative measures beyond conduct rules that can preferably in rural areas. The process involves daily
be imposed if officials do not implement the Act. amassment and convey/evacuating of faecal matter.
iii. Faecal Sludge Handling: The scavengers muddled
The mundane accidents include falls/slips fire or
in faecal sludge by emptying, collecting and
explosion, oxygen depletion, heat stress, drowning,
transporting human waste from septic tanks. The
asphyxiation arising from gas, gas poisoning, vapour
work is carried out on demand. The frequency of
and entrapment by free flowing solids. Amongst these
de-sludging ranges from six months to 10 years.
hazardous gases etc are facilely overlooked or neglected
leading to earnest causalities.4 India does not even have categorical licit
provisions cognate to the management of faecal
Definition: Manual scavenging refers to the unsafe sludge, additionally called septage in municipal
and manual removal of raw (fresh and untreated) human parlance, albeit a number of laws cover sanitation
excreta from buckets or other containers that are used as accommodations and environmental regulations.6
toilets or from the pits of simple pit latrines.
iv. Railway Cleaners: These employees cleans the
According to the Indian Law, 1993, Manual human excreta i.e. remains of a train that has ended
scavengers means a person engaged or employed at its journey, leftover food, packets and paper boxes
328 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
from the track as well as cleaning of the railway Onetime cash assistance has been relinquished to 8438
toilets. All these activities are carried out several identified manual scavengers.11
times a day. These workers are employed by
private contractors to whom the India Railways has Schemes Available for Manual Scavengers: The
outsourced. Most of the time when the water doesn’t National Safai Karamcharis Finance and Development
get the job done or the drains get clogged, the cleaners Corporation (A Government of India undertaking the
have to scoop up the excreta with ply boards using Ministry of Social Justice and Empowerment) introduced
their bare hands without any precautions.7 Self Employment Scheme for Rehabilitation of Manual
Scavengers (SRMS) and their dependents in alternative
v. Treatment Plant Workers: Treatment plant occupations by 2009. According to the updated number
workers maintain and operate sewage and faecal announced by States/UTs, 1.18 lakh manual scavengers
sludge treatment plants on a quotidian footing. and their dependents in 18 States/UTs were determined.
Workers are mostly in urban areas spread across One from each family of the identified manual scavenger
India – working in the 527 STPs/FSTPs.8 is eligible for receiving cash assistance of Rs. 40000
vi. Community and Public Toilet Cleaners: These immediately after their identification. The beneficiary is
workers are engaged in maintaining the public sanctioned to withdraw an amount of Rs. 7000 maximum
toilets on daily basis. The workers belong to the rural in monthly instalments.
and urban areas of slums and public convenience
The quantum of loan upto a maximum cost of Rs.
shelters. The task of these cleaners (halalkhors) is
10 lacs is permissible under this scheme and a sum of
still the same as of colonial era.9
Rs. 15 lacs in case of sanitation related projects such as
Statistics on Manual Scavengers in India: vaccum loader, suction machine with vehicle, garbage
According to the findings of the socio-economic and disposal vehicle etc. which are immensely compatible
caste census, 2011, the Ministry of Rural Development for target group with high success rate and income. The
(Government of India) has revealed that that a paramount moratorium period is of two years. The repayment mode
number of manual scavengers were analyzed in the state is of five years including the period of moratorium for
of Maharashtra followed by Madhya Pradesh at second the projects upto five years.12
position. The other states in the line of higher number
are Jammu and Kashmir, Karnataka, Tripura, Punjab, Beneficiaries can as well avail the facility of
Uttar Pradesh, Daman and Diu, Bihar. The census subsequent loan from banks, if needed without capital
has as well acknowledged that Tamil Nadu, Kerela, and interest subsidy.
Goa, Andhra Pradesh, Telengana, Gujrat, Assam and The training is administered to the beneficiaries for
Manipur have no manual scavengers. These statistics are gaining new skills and entrepreneurship capabilities. The
based on the number of households in the states. This training is being provided by govt. agencies/Institutions
survey communicates that India has 18.06 lakh manual along with the reputed specialized training agencies.
scavengers in the country.10 The training is given as per their level of education and
The press Information Bureau, Government of aptitude.12
India, Ministry of Social Justice and Empowerment has Remedies: The solution, it seems, is a public-private
verbally expressed that a Task Force was constituted for partnership. Collaboration would work best because it
carrying out a National Survey of manual scavengers would ravage the mafia of private cleaners, making them
in 2018 in 170 identified districts of 18 states. The accountable
national Survey concluded in 163 of the 170 identified
districts. A total of 50,644 persons registered themselves It was also found that some scavengers have
in the survey camps. It was claimed that 20,596 endeavoured to challenge their social and economic
persons have been accepted after identification with status by transmuting their jobs. But determinately,
subsequent verification as manual scavengers. Data of they have to return to their pristine profession because
the identified manual scavengers is being digitized in of a social boycott and the lack of foothold from both
National Safaikaramcharis Finance and Development private and governmental agencies. The law and order
Corporation. Besides that the data of remaining 11,757 machinery has additionally proved inefficient.
manual scavengers were digitized upto October 2018.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 329
Eradication of manual scavenging needs to 4. MitraArun, Manual Scavenging in India, Daily
be worked out on war footing. A mission for total Excelsior Newspaper, 2019
eradication of manual scavenging and rehabilitation of 5. The Employment of Manual Scavengers and
manual scavengers needs to be set up and implemented Construction of Dry latrines (Prohibition) Act
by the government. 1993, Ministry of Housing and Urban Poverty
Alleviation, Govt. of India
The right technology is considered as one of
the solution to eradicate this scourge. In spite of that, 6. Rohilla Suresh, Luther Bhitush, etal, Urban shit:
the social and gender issues should be abolished by where does it all go, Down to Earth, 2016
educating pupil about this ill. 7. Roy Sidhartha, The not-so-swachh life of the
Railways’ cleaners, The Hindu, 2016, https://www.
The sewage handlers come across with multiple thehindu.com/news/national/The-not-so-swachh-
health issues such as respiratory and skin diseases, life-of-the-Railways%E2%80%99-cleaners/
anaemia, jaundice, carbon monoxide poisoning and article14623426.ece
sometimes leads to death. The health issues should be
8. BakshiAnahitaa, The Nine Kinds of Manual
taken care by the agency and safety equipments to be
Scavenging in India, The Wire, 2018, https://
provided before handling. Vaccination against hepatitis
thewire.in/labour/manual-scavenging-sanitation-
A, E-Coli, Rotovirus, Norovirus must be administered to
workers
these workers to avoid deaths at young age of their life.
9. DarokarShailesh Kumar, Manual Scavengers:
The construction of toilets under Swachh Bharat A blind Spot in Urban Development Discourse,
Mission on a large-scale was built under single pit toilets Engage, 2018;53: 22 https://www.epw.in/engage/
but the cleaning of these excreta is carried out by manual article/manual-scavengers-blind-spot-urban-
scavengers. Therefore, a technology based structure development-discourse
should be introduced to dispose of waste and reduce the 10. India-18.06 lakh manual scavengers, Maharashtra
figures of manual scavengers. tops manual scavenging ststes# WTF news,
Ethical Clearance: Nil Kractivist.org,2017, https://kractivist.org/india-
18-06-lakh-manual-scavengers-maharashtra-tops-
Source of Funding: Self manual-scavenging-states-wtfnews
11. GehlotThaawarchand, Government is keen to
Conflict of Interest: Nil
eradicate Press Information Bureau, Government of
References India, Ministry of Social Justice & Empowerment,
2018, http://pib.nic.in/newsite/PrintRelease.
1. Swaroop Kanthi, India’s Manual Scavengers: Ugly aspx?relid=184118
truths of unsanitary sanitation work an open secret;
12. National Safai Karamcharis Finance &
law needs better enforcement, Firstpost, 2019
Development Corporation, (A Government of
2. Mishra Neeraj, Manual Scavenging: Lies, Damned India undertaking under the Ministry of Social
Lies and Numbers, Indian Legal Stories that Count, Justice & Empowerment), https://nskfdc.nic.in/en/
2019 content/revised-srms/self-employment-scheme-
3. United Nations of India, Breaking Free: rehabilitation-manual-scavengers-srms
Rehabilitating Manual Sacvengers, 2013. https://
in.one.un.org/page/breaking-free-rehabilitating-
manual-scavengers
330 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Out of Pocket Spending for Natal Care Services:

A Comparative Analysis among High and
Less developed States in India

A.K. Ravisankar

Assistant Professor, Department of Population Studies, Annamalai University, Tamil Nadu

Abstract
In this paper attempt is made to assess the expenditure incurred on natal health care services in India at two
different socio-economic settings. Data for the analyses are drawn from the 71st round of NSSO held in
2014. A logistic regression model used to assess the determinants such as socio-economic and demographic
indicators on expenditure incurred for natal care services. It is found that a major proportion of respondents
spent money for their natal care however a wide difference was noticed between high and low HDI states
in India. The average amount spent from their pockets for natal care services was Rs.6,685/- for high HDI
states. It was almost double times higher than the low HDI sates’ expenditure incurred for natal care (Rs.
3,400). The results of the logistic regression analysis on expenditure incurred for natal care is positively
and significantly associated with all the socio-economic, demographic variables (except age, religion). In
India, the natal health care services are offered free, yet many families’ average out of pocket natal health
care expenditure incurred was relatively high, however, a wide variation is witnessed among high and low
HDI states. Hence, it is suggested to increase the share of state’s expenditure on healthcare, especially those
states which are socially and economically backward states, to reduce the state differences in the country on
health outcomes.

Keywords: Natal care, out-of-packet expenditure, wealth index, Human Development Index.

Introduction expenditure4. The total health expenditure constituted

4.1 percent of GDP of India (2009), with private and
In many developing countries, household out-
public sectors accounting for 78 percent and 20 percent
of-pocket (OOP) spending on health constitutes a
respectively5. These additional expenses not only deter
significant share of total health care expenditure. The
women from accessing health care services but also push
WHO estimates, that globally, private expenditure on
households further into poverty6,7,8,9. Peters estimated
health in most countries is approximately 1.5 to 3.0
that a quarter of the Indian population fall into poverty as
percent of their Gross Domestic Product1. In much of
a direct result of the medical expenses incurred through
the Asian region, public funding of healthcare is low,
hospitalisation10.
forcing most households to pay essential healthcare
bills out of their pockets. These payments hit the poor The expenses incurred during child bearing also
particularly hard3. Globally, the affordability costs of varied with the place of antenatal care (ANC), indicating
treatment are known to be a major barrier in accessing that the contact with private facility at any stage of
essential care, potentially imposing considerable burdens pregnancy will increase cost per delivery11. Studies
on households2. on OOPE12, 13 established the fact that out of pocket
expenditure on health care services is a significant factor
The progress in improving maternal health, as
in choice of the institutional facility for ante-natal and
envisaged in the UN MDGs, critically depends on
delivery care in India. Van DE and others found that
the availability, affordability and effective use of
Out of pocket payment is the main source of financing
reproductive health services3. In India, out-of-pocket
health care throughout Asia, more than 72 percent of
expenses made up over 70 percent of the total health
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 331
expenditure on health care is financed by out of pocket viz Kerala, Punjab, Himachal Pradesh, Maharashtra and
in India14. Haryana. The bottom five HDI states were grouped as
Low HDI states such as Orissa, Bihar, Chhattisgarh,
Studies conducted by Mukherjee et al. (2013) Madhya Pradesh and Jharkhand. Totally 7,004 women
and Douangvichit et al. (2012) on OOP expenditure (3285 from High HDI states and 3719 from Low HDI
consistently report higher expenditure for deliveries states) who had get pregnancy during the last 365 days
conducted in private health care centres and for were considered for this analysis.
complicated deliveries and caesarean deliveries 15, 16.
There are some hidden costs like - transportation cost, Background characteristics of the sample
medicines, and other expenses, which also affect the population: Age distribution of the sample population
utilisation of reproductive health care services. Some discloses a slight difference between high and low HDI
studies found that cost of travel, drugs, and hike in states. The proportion of ST population among low
fees structure are negatively related with utilisation of HDI states was three time higher than the high HDI
health care services17. Saraswati Kerketta (2015) found states (19.5 and 6.4 percent respectively). The illiterate
that there were differentials between public and private proportion was around four times higher among low
health facilities in terms of out of pocket expenditure on HDI states than the low HDI states (30.7 and 8.3 percent
maternal care services in India18. Under this backdrop respectively). The regular wages/salary earning people
here an attempt is made to assess the expenditure incurred was relatively high in high HDI states (42.7 percent)
on natal health care services in India at two different than the low HDI states (29.9 percent). More than one-
socio-economic settings. The specific objectives of the third of the high HDI states’ respondents were fall in the
research paper are richest wealth (35.8 percent) whereas this proportion for
low HDI states was just 5.6 percent.
• to understand the socio, economic and demographic
characteristics of the study population in high and Payments incurred for Natal care: It is inferred
less developed states that there is wide difference was noticed between high
HDI states and low HDI states with regard to pocket
• to examine the expenditure pattern of the respondents
payments on natal care services. Of the 3,094 households
on natal care services at two different HDI settings
who made payment for natal care in the high HDI states,
• to explore the relationships between socio-economic little less than one-fifth of the households spent up to
and other characteristics of households and natal 1,500 rupees for natal care (19.0 percent) and at the same
health care expenditures in different settings of India time more than two-fifth of the households in this group
Data Method: Data for the analyses are drawn spent above 5,000 rupees for natal care services (46.0
from the 71st round of the National Sample Service percent). The corresponding percentage for the low HDI
Organization held in 2014. Though the survey covered states was 36.3 percent and 23.8 percent respectively.
the whole of the Indian Union, this study made an attempt Overall, the average amount spent from their pockets for
to classify the states into two different socio-economic natal care services for high HDI states was Rs. 6,685. It
settings by using the 2011 Human Development Index. was almost double times higher than the low HDI sates’
The top five HDI states were grouped as High HDI states expenditure incurred for natal care (Rs. 3,400).

Table No. 1: Percentage distribution of women by payments incurred for Natal care in High and Low HDI states

High HDI Low HDI

Expenditure Incurred (in Rs.)
% Total % Total
Total expenditure incurred on Natal care*** 427.687
Up to 1,500 19.0 588 36.3 1148
1,501-3,000 16.5 512 23.2 732
3,001-5,000 18.5 572 16.8 530
Above 5000 46.0 1422 23.8 751
Total 100.0 3094 100.0 3161
Average amount spent (in Rs.) 6685.86 3400.70
***Refers to significant at 1% level (chi-square results–Expenditure incurred and different HDI states)
332 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Socio-economic and demographic determinants percent respectively. A similar increase also noticed
of out of pocket payments for Natal care services: among the low HDI states; however the proportions
Irrespective of age groups, more than two-fifth of the were ranged between 13.1 percent in poorest group to
high HDI states’ households was spent above 5,000 38.8 percent for richest group among rural women and
rupees for natal care from their pockets. It ranges from it ranged from 22.4 to 67.9 percent respectively. The
51.5 percent among 30-34 age group to 42.5 percent bivariate analysis shows that the women’s age, place of
among 20-24 age group. On contrast, less than one-fourth residence, caste, educational status, occupation, wealth
of the households in the low HDI states incurred above index and outcome of pregnancy are is significantly
5,000 rupees for natal car, irrespective of age groups. It associated with the expenditure incurred for natal care
is inferred that while age increases, the amount spent for both among high HDI states and low HDI states. It
natal care also increase. However, a wide variation was is inferred from the analysis on average expenditure
witnessed between high and low HDI states. incurred for natal care that Kerala state stood at top with
Rs. 9,114/- which is the highest spending state among
Amongst the socio-economic characteristics, place high HDI state. The lowest amount spent for natal care
of residence has been found to have the strongest among the high HDI state was Himachal Pradesh with
association with the pocket payment for natal health care Rs. 3,929/-. On contrast, the maximum amount spent
services. More than half of the urban women who fall in for natal care services among low HDI state was Orissa
the high HDI states were spent above 5,000 rupees for with Rs. 4,187/- The least amount was recorded by
natal care (52.8 percent). On contrast, just one-third of the Chhattisgarh with Rs. 2,393/‑.
respondents in the low HDI states were paid above 5,000
rupees for natal care services (32.7 percent). Religion In order to determine the association between each
of the respondents and the pattern of payment incurred independent variable and the expenditure incurred for
for natal care analysis show a strong association among natal care, two statistics of the model are used. The
the high and low HDI states. Caste of the respondents results of the logistic regression model (separately for
can also be an important determinant of the expenditure HDI groups as well for rural and urban) comparing
incurred for natal health care. Both at high and low HDI households who spent less money (less than 1,500/‑)
states, ST population spent for natal care was quite low with those of household spent more money (above
than the rest of other caste population. However a wide 1,500/‑) (Less money = 0; More money = 1).
difference was noticed between high and low HDI states’
sample population. As educational level of respondents The results of the logistic regression analysis on less
increases, their amount incurred for natal care also money spent with those of more money spent for natal
increases, irrespective of HDI status. However, a wide care show that households which spent more money
difference was noticed between high and low HDI states. is positively and significantly associated with caste,
A similar observation was noticed with respondents’ educational status, wealth index and states variables
occupational status at both the HDI settings and at the among rural sector both at high and low HDI states. All
same time a wide difference also noticed between high the variables the odds increase with the categories of
and low HDI states. a variable when compared to the respective variable’s
reference category, indicating an increase in expenditure
There is a steady increase in proportion of rural incurred when improving the background conditions
women who spent more money (above Rs.5,000) from of women. This model (rural) also shows that the age,
22.7 percent among poorest wealth index women to 34.2 religion, and occupation were insignificantly determining
percent among women living at middle wealth index then the expenditure incurred for natal care services both
to 53.2 percent among richest wealth index women in at high and low HDI states. A similar observation was
the high HDI states. The corresponding figures for urban noticed for urban high HDI states.
high HDI states were 34.7 percent, 48.2 percent and 72.6
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 333
Table 2: Odds ratios from logistic regression examining the effect of selected background variables on
expenditure incurred for natal care by place of residence

Rural Urban
SED High HDI States Low HDI States High HDI States Low HDI States
Sig. Exp (B) Sig. Exp (B) Sig. Exp (B) Sig. Exp (B)
Caste *** *** ** **
ST (ref) .000 1.000 .000 1.000 .002 1.000 .009 1.000
SC .000 2.398 .001 1.695 .368 1.413 .748 1.105
OBC .000 2.776 .001 1.570 .002 3.340 .021 1.917
Others .000 3.158 .000 2.213 .079 1.936 .031 1.936
Edu. Status ** *** *** ***
Illiterates (Ref) .001 1.000 .000 1.000 .000 1.000 .000 1.000
Primary .420 1.206 .040 1.293 .889 .954 .956 .988
Middle/Sec .205 1.317 .000 2.183 .048 1.845 .002 1.876
Hr Sec/Diploma .001 2.354 .000 2.668 .027 2.133 .030 1.750
Degree .001 3.030 .000 4.491 .000 5.292 .000 3.298
Wealth Index *** *** *** ****
Poorest .000 1.000 .002 1.000 .001 1.000 .001 1.000
Poorer .557 1.144 .000 1.569 .072 1.541 .392 .870
Middle .105 1.450 .033 1.369 .068 1.570 .019 1.773
Richer .002 1.948 .003 1.599 .002 2.339 .001 2.931
Richest .000 2.558 .036 1.665 .000 5.050 .187 1.713
States *** *** *** NS
Bihar .000 1.000 .000 1.000 .000 1.000 .051 1.000
Jharkhand .001 2.737 .000 .450 .000 5.185 .753 1.078
Orissa .093 .670 .000 1.811 .163 1.749 .095 1.514
Chhattisgarh .000 2.393 .086 .700 .000 5.175 .294 .762
Madhya Pradesh .000 3.763 .896 .982 .000 4.589 .198 .789
Constant .004 .278 .033 .551 .022 .210 .378 .659
-2 Log likelihood 1553.277(a) 2437.426(a) 954.515(a) 1253.497(a)
***, and ** denotes significant at 1% and 5% probability level respectively. NS- Not Significant

Conclusion particular attention should be paid to women living in

low standard of living condition. In the light of the above
Though Government of India has been running lot of
discussion it can be suggested that poor people can be
schemes for availing free of cost maternal health services
protected from maternal health expenditures by reducing
but still one has to pay from their pocket as medical
a health system’s dependence on out-of-pocket payments
expenses. This paper also found that the average out
and to develop social insurance system. In addition, IEC
of pocket natal health care expenditure incurred during
activities must be given more emphasis, so that the under
delivery was relatively high particularly for high HDI
served population may also make the use of currently
states. In the multivariate regression analysis, as in the
running health schemes, which may reduce the burden
bivariate analysis, women’s caste, education, and wealth
of expenditure. Apart from that the incentives provided
index variables are continued to be strong predictors of
to the beneficiaries’ mothers must be revised from time
the expenditure incurred for natal health care services.
to time based on inflation and growth rate. Finally, this
Above all, it is found from the analysis that there is a
research finding suggest to increase the share of state’s
wide variation between two different socio-economic
expenditure on healthcare, especially those states which
settings on payments incurred for natal care. Hence,
334 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
are socially and economically backward states, to reduce 8. Balarajan Y, Selvaraj S, Subramanian SV. Health
the state differences in the country on health outcomes. care and equity in India, Lancet. 2011; 377:
505‑515.
Ethical Clearance: Not Applicable
9. Mohanty SK, Srivastava A. Out-of-pocket
Source of Funding: Self expenditure on institutional delivery in India,
Health Policy and Planning. 2012. (published
Conflict of Interest: Nil online PMID: 22709923).
10. Peters DH, Yazbeck AS, Sharma RR, Ramana
References
GNV, Pritchett LH, Wagstaff A. Better health
1 WHO. 2014, Global Health Expenditure Database. systems for India’s Poor: Findings, analysis, and
www. http://apps.who.int/nha/database options, Human Development Network, Health,
2. Rannan-Eliya RP, Anuranga J, Chandrasiri R, Nutrition and Population Series, Washington DC:
Hafez G, Kasthuri R, Wickramasinghe, Jayanthan. The World Bank. 2002.
Impact of out-of-pocket expenditures on families 11. Levin A, Dymatraczenko TT, McEuen M,
and barriers to use of maternal and child health Ssengooba F, Mangani R, Van Dyck G. Costs of
services in Asia and the Pacific: Evidence maternal health care services in three Anglophone
from national household surveys of healthcare African Countries. Int J Health Plann Manag.,
use and expenditures—summary technical 2013.
report Mandaluyong City, Philippines: Asian 12. Ellis RP, Alam M, Gupta I. Health Insurance in
Development Bank. 2012. India: Prognosis and Prospectus. Economic and
3. Goldie SJ, Sweet S, Carvalho N, Natchu UCM, Political Weekly. 2000; 35(4):207-17.
Hu D. Alternative strategies to reduce maternal 13. Devadasan N, Criel B, Van DW, Ranson K, Vander
mortality in India: A cost effectiveness analysis, SP. Indian community health insurance schemes
PLoS Medicine.2010; 7(4): e1000264. doi:10.1371 provide partial protection against catastrophic
/journal.pmed.1000264) health expenditure. BMC Health Serv Res.,
4. Reddy KS. India’s Aspirations for Universal Health 2007;43.
Coverage. New England Journal of Medicine. 14. Van DE, O’Donnell O, Rannan ER, Somanathan A,
2015; 373: 1-5. Adhikari S, Garg C, et al. Catastrophic payments
5. Ravisankar AK, Devanathan R. Share of Public for health care in Asia. Health Economics, 2007;
and Private Health Facilities: A Study among 16(11):1159-84.
Hospitalised Cases at Two Different Socio 15. Mukherjee S, Singh A, Chandra R. Maternity or
Economic Settings of Indian States, International catastrophe: a study of household expenditure
Journal of Scientific and Research Publications, on maternal health care in India. Health, 2013;
2017: 7(1):190-196. 5(1):109–18.
6. Selvaraj S, Karan A. Deepening health insecurity in 16. Douangvichit D, Liabsuetrakul T, McNeil E. Health
India: evidence from national sample surveys since care expenditure for hospital-based delivery care in
1980s. Economic & Political Weekly. 2009; 44, Lao PDR. BMC Res Notes., 2012.
55–60.
17. Yoder RA. Are people willing and able to pay
7. Devanathan R, Ravisankar, AK. Maternal health for health services? Social Science and Medicine.
spending characteristics of households in India: A 1989; 29(1):35-42.
regional Analysis, International Research Journal
18. Golechha M. Healthcare agenda for the Indian
of Human Resources and Social Sciences, 2016;
government. Indian J Med Res., 2015; 141: 151-
3(12).
153.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 335

Current Research in Neuropathology and Pharmacotherapy of

Alzheimer’s Disease: A Review

Amit Yadav1, Prabhat Kumar Upadhyay2, Manish Kumar3,

Vishal Kumar Vishwakarma4, A. Pandurangan3, Pradeep Mishra1
1Rsearch
Scholar, M.M. College of Pharmacy, Maharishi Markandeshwar (Deemed to be University),
Mullana, Ambala, Haryana, India, 2Associate Professor, Institute of Pharmaceutical Research,
GLA University, Mathura, Uttar Pradesh, 3Professor, M.M. College of Pharmacy, Maharishi Markandeshwar
(Deemed to be University), Mullana, Ambala, Haryana, 4Lecturer, Department of Pharmacology,
All India Institute of Medical sciences, New Delhi, India

Abstract
Background: Alzheimer’s disease (AD), a category of neurological degeneration generally seen in elderly
people which is reflected by memory loss and affecting daily living activities.

Method: The data has been accessed from scopus, pubmed, science-direct and google-scholar which is
included in this article.

The literature provide the information about pathological alterations of Alzheimer disease emphasizing on
formation of neuritic plaques, beta amyloid protein, neurofibrillary tangle and also updates therapeutics used
in Alzheimer’s disease including cholinesterase inhibitors, ACE inhibitors, NMDA receptor antagonists,
secretase inhibitors and anti-inflammatory drugs, herbal drugs and other naturals.

Results: The research on neuropathology and diagnosis of Alzheimer’s disease are determinants of this
study. The pathophysiology, diagnosis using biomarkers and therapeutics of disease has been summarized.

Conclusion: The aim of this review paper is to focus on how diagnosis and pharmacotherapy of Alzheimer’s
disease useful for researchers engaged in the experimental research.

Keywords: Alzheimer’s disease, β-amyloid precursor protein, neurofibrillary tangles, Acetylcholinesterase

inhibitors, Secretase inhibitors, biomarkers.

Introduction loss and cognitive impairment which affect daily living

activities. With an increase in the geriatric population
Alzheimer’s disease (AD) is approved as a chronic,
in India, quantities of AD patients are increasing step
irreversible neurodegenerative disorder in many countries
by step (1). The neuropathologists had distinguished
which produces various cognitive impairments in old
64 instances of amyloid plaques and NFTs, a cause of
people. Alzheimer’s disease (AD) is indicated by memory
disease, at the time of Dr. Alois Alzheimer, in autopsied
brains of AD individuals (2). The extracellular deposition
of Ab called Amyloid plaques; saw in parenchymatous
Corresponding Author:
cells of brain and furthermore in cerebral blood vessels
Dr. Manish Kumar called cerebral amyloid angiopathy (CAA) (3).
M.M. College of Pharmacy, Maharishi Markandeshwar
(Deemed to be University), Mullana, Ambala, Haryana, Currently such medications are approved by
India USFDA (US Food and Drug Administration), including
e-mail: [email protected] five medications those are utilized for the treatment
Tel.: +91-7017548594 of cognitive manifestations of AD. NMDA receptor
336 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
antagonist–memantine (Namenda) donepezil (Aricept), pathophysiology of AD when neuropathological features
AChEIs –rivastigmine (Exelon), tacrine (Cognex) and of this disease observed and described by amyloidal
galantamine (Razadyne, Reminyl) are drug of choice as plaques and hyperphophorylated NFTs and different
per indications(4). hypotheses have been proposed (5) (Fig.-1). In last
decade, it has been suggested that commonly used Ab
Pathophysiology of Alzheimer’s Disease: In 1907, hypotheses is responsible for complex pathophysiology
AD is known to treat subsequent to recognizing the of growing disease (6).

Fig. 1: Various pathophysiological processes causing Alzheimer’s disease (AD)

In late stage, development of amyloid plaques is Early Detection Strategies via Biomarkers: The
appeared in the older age of patients (7). The breakdown of magnetic resonance imaging and fluorodeoxy-glucose
APP is occurred by α-secretase which is further by action positron emission tomography determine hippocampus
of β-and γ-secretases in amyloid cascade hypothesis (8). atrophy and cortical hypo-metabolism in AD progression.
The activities of neurons and their related astrocytes Advancements in science, radiology and system biology
are responsible for production of Ab42 oligomers. promotes use of biomarkers in AD research (14).
The cytokines like IL-1b, TNF-a, and IFN-g stimulate
neighbour astrocyte-neuron which produces Ab42 Biomarkers Using Cerebrospinal Fluid: Scientists
oligomer (9). Working of neuron–astrocyte complex is have determined levels of Ab-42 peptide by knowing
affected by oligodendroglia (OLGs) which are destroyed and total phosphorylated Tau protein (t-tau and p-Tau)
by Ab oligomers (10). The aggregation of Ab oligomers and by estimating cerebrospinal liquid (CSF) which
also induces degeneration in neurons of AD patients is responsible for neurodegeneration in AD. All three
(11). It was proposed that receptor pharmacology of Ab parameters have been proposed as one of the prevailing
activates neuroprotectiion mediating Ab42 monomers biomarkers for this disease which is independent of the
through signaling pathways of mediating receptors (12). apo-lipoprotein E (APOE) genotype (15). The accuracy in
AD symptoms and combining CSF Ab with either t-tau
Use of Biomarkers in alzheimer’s Disease: The or p-tau level(16).
cholinergic hypothesis of AD mechanism stipulates
that most of cognitive manifestations are a result of Biomarkers Using Imaging Techniques: Beta-
cholinergic dysfunction (13). amyloid load in the brain can be estimated through
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 337
positron emission tomography (PET) using amyloid angiotensin II. Another possibility is that angiotensin II
ligands such as Pittsburgh compound B (PiB), florbetapir is converted to angiotensin III after that to angiotensin
(AV-45). Amyloid PET is considered a strong biomarker IV. Angiotensin IV binds at AT4 receptor sites, which
which was incorporated in 2011 and re-evaluated by are most predominant in the neocortex, hippocampus,
National Institute on Aging-Alzheimer’s Association and other areas and improves learning and memory (28).
diagnostic criteria for AD. In spite of being an amazing
screening instrument in clinical trials, there is as yet Nonsteroidal Anti-inflammatory Drugs: Most
limited evidence as a diagnostic tool for AD in clinical researches on nonsteroidal anti-inflammatory drugs
practice (17). have concentrated on prevention instead of treatment
of AD(29). Animal models have exhibited that anti-
Biomarkers Using Genetic Screening: Early inflammatory cyclooxygenase-2 (COX-2) inhibitors
AD was related with special autosomal dominant (Rofecoxib) reduced oxidative stress yet nonspecific
mutations in amyloid precursor protein (APP), and/ COX inhibitors (Flurbiprofen and Ibuprofen) (30).
or presenilin 1 (PSEN1), or presenilin 2 (PSEN2). At
present, genetic testing for both PSEN1 and PSEN2 lay Secretase Inhibitors: Secretases are enzymes
down in one family member with early-beginning of forms plaques by breaking APP of cell membranes into
AD18. Lanoisele´e et al. observed the occurrence of AD, βA fragment. Memoquin, an example of β-secretase
proposing potential advantage of screening non-familial inhibitors reduce βA production by inhibiting AChE and
cases of AD for these mutations19. Late-onset AD is limits tau hyperphosphorylation in early developmental
most normally connected with APOE4 allele which is stage (31).
situated on chromosome 19q13.2 including regulation Herbal Drug Treatment:
of Ab aggregation and clearance (20). Besides, carriers
of this allele have a lower onset of disease and more Polyphenols e.g. Resveratrol found in red wine,
hippocampal atrophy in dose-dependent manner (21). peanuts and other plants, has been used to reduce
oxidative stress, inflammation, βA and protect DNA
Strategies Used for Treatment of AD: Currently thus, decrease in cell death. A moderate utilization of
available medications N-methyl d-aspartate receptor red wine decreases the danger of growing AD (32).
antagonist (Memantine), acetylcholinesterase inhibitors
(Rivastigmine, Galantamine, Donepezil) in the various Curcumin obtained from turmeric is used in
stages of disease(22). In AD, deletion of amyloid beta AD treatment. Curcumin has neuroprotective, anti-
protein deposition is one of the most favorable targets for inflammatory, antioxidant activities and cause inhibition
treatment. Anticholinesterases- The drugs can change of βA formation and clearance of existing βA (33).
cholinergic neurotransmission, have been approved from
regulatory authorities for Alzheimer’s therapy (23). Three Ashwagandha (also known as Withania somnifera)
ChEIs like Donepezil, Rivastigmine and Galantamine. proposed to have neuroprotective, anti-inflammatory,
Donepezil and Galantamine are usually used to get antioxidant, AChE inhibitoy, βA inhibitory activities
patients with mild to moderate AD. Rivastigmine inhibits which decrease in cell death34. It has been found that
both Acetyl cholinesterase and Butyryl cholinesterase its oral use reversed damage to hippocampus and
associating the degradation of Acetyl choline(24). brain cortex by diminishing neurite atrophy, restoring
NMDA receptor antagonist (Memantine) Memantine synapses and improving memory in mice (35).
is a newer medication used in treatment of moderate to Nutrients and Hormones:
severe dementia. Its mechanism of action is a voltage-
dependent, low-moderate affinity, uncompetitive Alpha-lipoic acid acts as a prevailing micronutrient
NMDA receptor antagonism(25). Memantine blocks with various pharmacological and antioxidant
abnormal glutamate activity which causes neuronal cell properties(36). LA has been proposed to have anti-
death and cognitive dysfunction(26). dementia in AD by altering antioxidant protective
enzymes37.
Angiotensin-converting Enzyme (ACE)
inhibitors: It has been seen that ACE inhibitors Polyunsaturated fatty acids like omega 3-fatty
decrease aggravation in brains of AD patients (27). The acids (FAs), docosahexaenoic acid (DHA) found in high
mechanism includes transformation angiotensin I to levels in the mammalian brain, neuronal membranes and
338 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
myelin sheath. Their actions were observed by enhanced acetylcholinesterase; AChEIs, acetylcholinesterase
receptor binding and function of ion channels(38). The inhibitor; ApoE, apolipoprotein-E; βA, beta amyloid;
cognitive impairment occurs due to diminished serum β-APP, β-amyloid precursor protein; NMDA, N-methyl
DHA levels which obstruct learning and memory(39). As d-aspartate.
a result, the scientists have explored possibility of DHA
supplement utilization may decrease risk of progression Ethical Clearance: There is no need of Ethical
of AD(40). Clearance for publishing this review article.

Vitamin B12 and folate in low levels are shown Conflict of Interest: The authors have no conflicting
to result into cognitive decline. AD patients have high interests in writing this paper.
levels of homocysteine which need to become low. Source of Funding: Self.
Homocysteine levels seem to relate with aging but not
with cognition. A combination of vitamins B12 and B 6 References
and folate brought down homocysteine in people with
mild to moderate AD(41). 1. Apostolova, L. G., Alzheimer Disease. Continuum
(Minneap Minn). 2016, 22, 419-434.
Retinol commonly known as Vitamin A is essential 2. Pietrzik, C., Behl, C., Concepts for the treatment
for learning, memory and cognition. Vitamin A levels of Alzheimer’s disease: molecular mechanisms
in the brain decline in AD people, therefore its need to and clinical application. Int J Exp Pathol. 2005, 86,
improve. A metabolite of vitamin A, retinoic acid is 173–185.
known to slow cell death and protect from βA(42). Lithium
3. Anand R., Gill, K. D., Mahdi, A. A., Therapeutics
Compounds are prescribed for some neurodegenerative
of Alzheimer’s disease: past, present and future.
disorders. Enhancement of bcl-2 levels (neuroprotective
Neuropharmacology. 2014, 76, 27-50.
protein) in hippocampus and frontal cortex of the rat has
been observed. It also inhibits GSK-3, which is involved 4. Aisen, P. S., Cummings, J., Schneider, L. S.,
in increasing levels of phosphorylated tau and believed Symptomatic and Nonamyloid/Tau Based
to be a factor prompting βA plaques and cell death (43). Pharmacologic Treatment for Alzheimer Disease.
Cold Spring Harb Perspect Med. 2012, 2, a006395.
Melatonin has antioxidant, anticancer properties 5. Kurz, A., Perneczky, R., Novel insights for
and also protects mitochondria against tau tangles and the treatment of Alzheimer’s disease. Prog
also reduces βA toxic effects (44). Neuropsychopharmacol Biol Psychiatry. 2011, 35,
373–379.
Conclusion
6. Castello, M. A., Soriano, S., On the origin of
The evidences have been proposed to suggest that Alzheimer’s disease. Trials and tribulations of the
Aβ has pivotal role in the pathogenesis of AD, which amyloid hypothesis. Ageing Res Rev. 2014, 13,
involves many complex secondary events in the disease. 10-12. 7. Cheignon, C., Tomas, M., Bonnefont-
Novel developments like radiology, chemistry and Rousselot, D., Faller, P., Hureau, C., Collin, F.,
system biology involved use of biomarkers to identify Oxidative stress and the amyloid beta peptide in
mechanism. Enormous development has proposed to Alzheimer’s disease. Redox Biol. 2018, 1, 450-
make various strategies for AD treatment including 464.
anti-inflammatory, antiamyloid, secretase inhibitor, 8. Chow, V. W., Mattson, M. P., Wong, P. C.,
antihypertensive, cholinesterase inhibitor, and some Gleichmann, M., An Overview of APP Processing
natural nutrients and hormones. Enzymes and Products. Neuromolecular Med.
In this paper, authors have discussed the current 2010, 12, 1-12.
research on diagnosis and pharmacotherapy of 9. Dal Pra, I., Chiarini, A., Gui, L., Chakravarthy, B.,
Alzheimer’s disease which may be fruitful for researchers Pacchiana, R., Gardenal, E., et al., Do astrocytes
engaged in the experimental research. collaborate with neurons in spreading the
‘‘infectious’’ Ab and tau 644 drivers of Alzheimer’s
Abbreviations: AD, Alzheimer’s disease; ACh, disease? Neuroscientist. 2015, 21, 9-29.
acetylcholine; AChRs, acetylcholine receptors; AChEs,
10. Rosenmann, H., Immunotherapy for targeting tau
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 339
pathology in Alzheimers disease and tauopathies. 20. Liu, C. C, Liu, C. C., Kanekiyo, T., Xu, H., Bu,
Curr Alzheimer Res. 2013, 10, 217-228. G., Apolipoprotein E and Alzheimer disease: risk,
11. Vromman, A., Trabelsi, N., Rouxel, C., Béréziat, mechanisms, and therapy. Nat Rev Neurol. 2013, 9,
G., Limon, I., Blaise, R., β-Amyloid context 106-118.
intensifies vascular smooth muscle cells induced 21. Hostage, C. A., Roy, C. K., Doraiswamy, P. M.,
inflammatory response and de-differentiation. Petrella, J. R., Dissecting the gene dose-effects
Aging Cell. 2013, 12, 358-369. of the APOE epsilon4 and epsilon2 alleles on
12. Armato, U., Chakravarthy, B., Pacchiana, R., hippocampal volumes in aging and Alzheimer’s
Whitfield, J. F., Alzheimer’s disease: an update of disease. PLoS One. 2013, 8, e54483.
the roles of receptors, astrocytes and primary cilia 22. Lleó, A., Current Therapeutic Options for
(review). Int J Mol Med. 2013, 31, 3-10. Alzheimer’s Disease. Curr Genomics. 2007, 8,
13. Ferreira-Vieira, T. H., Guimaraes, I. M., Silva, F. 550–558.
R., Ribeiro, F. M., Alzheimer’s Disease: Targeting 23. Arendt, T., Bigl V., Arendt, A., Tennstedt, A.,
the Cholinergic System. Curr Neuropharmacol. Loss of neurons in the nucleus basalis of Meynert
2016, 14, 101–115. in Alzheimer’s disease, paralysis agitans and
14. Frisoni, G. B., Visser, P. J., Biomarkers for Korsakoff’s Disease. Acta Neuropathol. 1983, 61,
Alzheimer’s disease: a controversial topic. Lancet 101-108.
Neurol. 2015, 14, 781-783. 24. Colović, M. B., Krstić, D. Z., Lazarević-Pašti, T. D,
15. Lautner, R., Palmqvist, S., Mattsson, N., Bondžić, A. M., Vasić, V. M., Acetylcholinesterase
Andreasson, U., Wallin, A., Palsson, E., et al., inhibitors: pharmacology and toxicology. Curr
Apolipoprotein E genotype and the diagnostic Neuropharmacol. 2013, 11, 315-35.
accuracy of cerebrospinal fluid biomarkers for 25. Carvajal, F. J., Mattison, H. A., Cerpa, W., Role
Alzheimer disease. JAMA Psychiatry. 2014, 71, of NMDA Receptor-Mediated Glutamatergic
1183-1191. Signaling in Chronic and Acute Neuropathologies.
16. Dubois, B., Feldman, H. H., Jacova, C., Hampel, Neural Plast. 2016; 2016: 2701526.
H., Molinuevo, J. L, Blennow, K., et al., Advancing 26. Rogawski, M. A., Wenk, G. L. The
research diagnostic criteria for Alzheimer’s disease: neuropharmacological basis for the use of
the IWG-2 criteria. Lancet Neurol. 2014, 13, 614- memantine in the treatment of Alzheimer’s disease.
629. CNS Drug Rev. 2003, 9, 275-308.
17. Johnson, K. A., Minoshima, S., Bohnen, N. I., 27. Wolfel, E. E., Effects of ACE inhibitor therapy
Donohoe, K. J., Foster, N. L., Herscovitch, P., et on quality of life in patients with heart failure.
al., Appropriate use criteria for amyloid PET: a Pharmacotherapy. 1998, 18, 1323-1334.
report of the Amyloid Imaging Task Force (AIT), 28. Sink, K. M,, Leng, X., Williamson, J., Kritchevsky,
the Society of Nuclear Medicine and Molecular S. B., Yaffe, K., Kuller, L., Yasar, S., Atkinson, H.,
Imaging (SNMMI) and the Alzheimer Association Robbins, M., Psaty, B., Goff, D. C., Angiotensin
(AA). Alzheimers Dement. 2013, 9, 1-16. Converting Enzyme Inhibitors and Cognitive
18. Sassi, C., Guerreiro, R., Gibbs, R., Ding, J., Lupton, Decline in Older Adults with Hypertension: Results
M. K., Troakes, C., Investigating the role of rare from the Cardiovascular Health Study. Arch Intern
coding variability in Mendelian dementia genes Med. 2009, 169, 1195-1202.
(APP, PSEN1, PSEN2, GRN, MAPT, and PRNP) 29. Ong, C. K., Lirk, P., Tan, C. H., Seymour, R. A.,
in late-onset Alzheimer’s disease. Neurobiol Aging. An evidence-based update on nonsteroidal anti-
2014, 35, 2881.e1-2881.e6. inflammatory drugs. Clin Med Res. 2007, 5, 19-34.
19. Lanoisele´e, H. M., Nicolas, G., Wallon, D., 30. Umar, A., Boisseau, M., Yusup, A., Upur, H.,
Rovelet-Lecrux, A., Lacour, M., Rousseau, S., et Bégaud, B., Moore, N., Interactions between
al., APP, PSEN1, and PSEN2 mutations in early- aspirin and COX-2 inhibitors or NSAIDs in a rat
onset Alzheimer disease: a genetic screening study thrombosis model. Fundam Clin Pharmacol. 2004,
of familial and sporadic cases. PLoS Med. 2017, 18, 559-563.
14, e1002270.
340 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
31. Ghosh, A. K., Tang, J., Prospects of β-Secretase chain PUFAs differentially affect hippocampal
Inhibitors for the Treatment of Alzheimer’s muscarinic 1 and serotonergic 1A receptors in
Disease. Chem Med Chem. 2015, 10, 1463-1466. experimental cerebral hypoperfusion. Brain Res.
32. Upadhyay, S,, Dixit, M., Role of Polyphenols and 2002, 954, 32-41.
Other Phytochemicals on Molecular Signaling. 39. Tully, A. M., Roche, H. M., Doyle, R., Fallon, C.,
Oxid Med Cell Longev. 2015, 2015, 504253. Bruce, I., Lawlor, B., Coakley, D., Gibney, M. J.,
33. Amalraj, A., Pius, A., Gopi, S., Gopi, S., Biological Low serum cholesteryl esterdocosahexaenoic acid
activities of curcuminoids, other biomolecules from levels in Alzheimer’s disease: A casecontrol study.
turmeric and their derivatives - A review. J Tradit Br J Nutr. 2003, 89, 483-489.
Complement Med. 2016, 7, 205-233. 40. Cunnane, S. C, Plourde, M., Pifferi, F., Begin,
34. Kurapati, K. R., Atluri, V. S., Samikkannu, T., M., Feart, C., Barberger-Gateau, P., (2009) Fish,
Nair, M. P. Ashwagandha (Withania somnifera) docosahexaenoic acid and Alzheimer’s disease.
reverses β-amyloid1-42 induced toxicity in human Prog Lipid Res. 2009, 48, 239-256.
neuronal cells: implications in HIV-associated 41. Reay, J. L., Smith, M. A., Riby, L. M., B vitamins
neurocognitive disorders (HAND). PLoS One. and cognitive performance in older adults: review.
2013, 8, e77624. ISRN Nutr. 2013, 2013: 650983.
35. Kuboyama, T., Tohda, C., Komatsu, K., Neuritic 42. Watson, J., Lee, M., Garcia-Casal, M. N.,
regeneration and synaptic reconstruction induced Consequences of Inadequate Intakes of Vitamin A,
by withanolide A. Br J Pharmacol. 2005, 144, 961- Vitamin B12, Vitamin D, Calcium, Iron, and Folate
971. in Older Persons. Curr Geriatr Rep. 2018, 7, 103-
36. Packer, L., Witt, E. H., Tritschler, H. J., Alpha- 113.
lipoic acid as a biological antioxidant. Free Radic 43. Forlenza, O. V, De-Paula, V. J., Diniz, B. S.,
Biol Med. 1995, 19, 227–250. Neuroprotective effects of lithium: implications for
37. Maczurek, A., Hager, K., Kenklies, M., Sharman, the treatment of Alzheimer’s disease and related
M., Martins, R., Engel, J., Carlson, D. A., Münch, neurodegenerative disorders. ACS Chem Neurosci.
G., Lipoic acid as an anti-inflammatory and 2014, 5, 443-450.
neuroprotective treatment for Alzheimer’s disease. 44. Cardinali, D. P, Vigo, D. E., Olivar, N., Vidal, M.
Adv Drug Deliv Rev. 2008, 60, 1463-1470. F., Brusco, L. I., Melatonin Therapy in Patients
38. Farkas, E., de Wilde, M. C., Kiliaan, A. J., Meijer, with Alzheimer’s Disease. Antioxidants (Basel).
J., Keijser, J. N., Luiten, P. G., Dietary long 2014, 3, 245-77.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 341

In Vitro Anticancer Study of

Bioactive Compound Isolated from Musa Extract
(Musa Acuminata)

Arunava Das1, J. Bindhu2, P. Deepesh3, G. Shanmuga Priya3, S. Soundariya3

1AssociateProfessor, 2Research Associate cum Assistant Professor, 3III Year Biotech Students, Molecular
Diagnostics and Bacterial Pathogenomics Research Laboratory, Department of Biotechnology, Bannari Amman
Institute Technology, Sathyamangalam, Erode District, Tamil Nadu, India

Abstract
Banana tree being one of the most economically important tree worldwide is cut once the fruits are harvested.
However other parts of the tree are used in medicine worldwide. In this study, the flower extract of Musa
acuminatais extracted by maceration with methanol and the phenolic and aliphatic compounds present
in the flower extract is identified using GC-MS analysis. Phytochemical screening of the banana extract
showed the presence of alkaloids, phlobatanning, triterpanoids, flavanoids, lipids, steroids and terpenoids.
Potent antibacterial activity is observed from the flower extract against the tested gram positive and negative
bacteria. Anticancer activity of the flower extract is assessed on the cervical cancer cell line HeLa. MTT
assay is used to evaluate the antiproliferative effects. This study concluded that the economically important
Musa acuminatais widely used in anticancer studies worldwide.

Keywords: Musaacuminata, Phenolic compounds, GC-MS analysis, Phytochemical screening, Antibacterial

activity, MTT assay.

Introduction recognized as a tropical fruit.[2] Almost every part of

banana plant has got its own significant use that is useful
Recently, Musa sp, (Musaceae) also known as
to mankind in many aspects. Being highly polymorphous
Banana has evolved to be one of the largest herbaceous
Musa acuminata is spindly plants that are grown in
flowering plant recognized by the world. Musa sp, being
clumps. Musa species is widely used in medicinal and
a most popular fruit are widely exported to a number
traditional food. The optimum temperature for the
of industrialized countries [1]. Tropical and sub-tropical
growth of Musa acuminata is 80˚F (26.67℃) and the
regions of the world consume more banana in common.
optimum mean rainfall is 4 in (10 cm) per month.
Having south western pacific as native, banana is
Being under the kingdom Plantae and coming under
the order Zingiberales it belongs to the family Musaceae
having genus Musa has a wide range of sub species.
Corresponding Author: It is a perennial monocotyledonous herb. Musa is an
Arunava Das bisexual flower having each spathe encloses 2 rows of
Associate Professor, Molecular Diagnostics and flowers, upper spathe enclosing male flowers, lower
Bacterial Pathogenomics Research Laboratory, spathe enclosing female flowers, and few middle spathe
Department of Biotechnology, Bannari Amman with bisexual flowers. The flowers are tricarpellary,
Institute Technology, Sathyamangalam-638401, Erode syncarpous, ovary inferior, placentation axile, style
District, Tamil Nadu, India long, stigma capitated. [3] It takes approximately 28 days
e-mail: [email protected] for Musa acuminata for anthesis, 2 to 3 weeks after
Phone: 9751882590 plantation.
342 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
It has high protective action and is widely used to Test for phlobatannins: 10 ml of aqueous
prevent food spoilage. The blossoms of banana to a extract of flower was boiled with 1% HCl. Presence of
wide extent is considered as a vegetable and is cooked phlobatannins was indicated by the thick red precipitate
in various dishes [4]. It is helpful in muscle contraction deposition in the bottom.[12]
and response of nerve cells. The banana also enables
Test for triterpenoids: Salkawasaki Test was used
the stabilization of blood pressure. Being known for its
to indicate Triterpenoids in the extract in which 2 ml of
eternal evergreen, Musa species, are widely used for
extract was taken and 5 drops of concentrated sulphuric
ornamental purposes.
acid was added, shaken and allowed to stand. Presence
Musa species, highly known for its medicinal of triterpenoids was indicated by the appearance of
purposes is beneficial to mankind. Heart pain, asthma, greenish blue colour.[12]
endocrine problem like diabetes can be treated by the
Test for flavonoids: Alkaline reagent was used to
flowers of banana. Stomach cramps and diarrhoea can be
indicate the presence of flavanoids in the extract. To
treated by consuming banana leaves. Menses pain and
1 ml of the extract few drops (3 drops) of 10%NaOH
bleeding due to menopause can be reduced by the uptake
solution was added, flavonoids was indicated by intense
of banana leaves by women. Infantile malnutrition and
yellow colour, which disappeared on addition of a few
weak body can be suppressed with the help of banana
drops of dilute acid.[12]
blossoms. Antioxidants are components that reduce
the oxidative stress level by prevention of free radicals Test for lipids: To 10 ml of the extract 0.5 N
from damaging DNA, proteins and lipids. Being a alcoholic potassium hydroxide was added along with
weak primary antioxidant source, Musa acuminata has a drop of phenolphthalein. The mixtures were heated
proven to be a powerful secondary antioxidant source[5]. on water bath for 1 hour. The presence of lipids was
Ascorbic acid, beta carotene, phenolic groups, dopamine indicated by the formation of foam or soapy layer.[12]
are the antioxidant compounds found in Musa acuminata.
Being a good source of bioactive phytochemicals Musa Test for steroids: To 5 ml of aqueous extract 2 ml
acuminata provide opportunities for functional food of chloroform and few drops of concentrated H2SO4
industry. was added. The presence of steroids was indicated by
the appearance of red colour in the upper layer while
Methodology yellow with greenish fluorescence appears in the H2SO4
layer.[12]
Identification and Handling of Sample: Arid
flowers of Musa acuminata were collected from Test for terpenoids: To 1 ml of the aqueous extract
Sathyamangalam forest. Using plastic bags, the flowers 1 ml of chloroform was added and mixed well and left
collected were transferred to lab. The powdered and for 5 minutes, 1ml concentrated H2SO4 was added after
sieved arid flowers are finely powered and is stored in 5 minutes. The presence of terpenoids was indicated by
the Non-toxic- polyethylene bag. the appearance of greyish layer.[12]

Plant Extract Preparation: 10 gm powder mass Antioxidant Assay: The antioxidant capacity of
was extracted using 200 ml Methanol solvent. Dark Musa acuminata was identified through 2,2-Diphenyl-
maceration for 72 hours at 27˚C was considered for 1-picryhydrazyl (DPPH) assay. Equal volumes samples
the extraction process and muslin cloth was used for at different concentrations were with 0.1 mM of
filtration. The pasty layer of extract was formed after DPPH. Then the mixture was stored in dark place for
the filtrate was condensed at 45˚C which were used for 30 minutes. The colour change from violet to yellow
further assays. indicated the presence of antioxidants. Quantification
was calculated by absorbance. The absorbance was
Phytochemical Screening: performed in triplicates. Ascorbic acid was used as the
standard to compare with samples and IC50 (inhibition
Test for alkaloids: To 3 ml of the extract 1 ml of
concentration) was calculated for both sample and
Mayer’s reagent was added and shaken well, presence
standard. The percentage of inhibition was calculated
of Alkaloids was indicated by the white precipitate at
using the following formula.
the bottom.[12]
% of inhibition = [A0-A1/A0] × 100
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 343
Where A0 is absorbance of control (i.e., DPPH performed with an in vitro Cytotoxicity test method. The
solution without sample) and A1 is absorbance of culture medium from the Hela cells was replaced with
sample or standard (i.e., DPPH solution with sample/ fresh medium. The triplicates of the test sample were
standard)[12] added on the cells. Incubation at 37°C for 18 hr was
done. After incubation MTT (1 mg/ml) were added in
GC-MS: The sample was subjected to GC-MS the wells and incubation was done for 4 h. DMSO were
analysis to quantify the number of molecules and added in the wells after incubation and read at 570 nm
its structures. The analysis was carried out using using photometer. Cytotoxicity and cell viability were
GCMS (Perkin Elmer model: Clarus 680) and also it calculated by
is equipped with mass spectrometer (Clarus 600(EI)
analysed using (TurboMassver5.4.2) software. Fused Cytotoxicity = [(Control-Treated)/Control]×100
silica which is packed with Elite-5MS. At a constant
flow rate about 1 ml/min, carrier gas such as helium Cell Viability = (Treated/Control)×100
was used to separate the components. The temperature
of the injector was adjusted to 260˚C while performing
Result and Discussion
the experiment. The extract sample of 1µL was injected The chemical composition of the extract was
was into the equipment the temperature of the oven studied using GC-MS analysis. The peak was identified
were 60˚C(2mins); followed by 300˚C at the rate of as pentanoic acid, 2-(aminooxy)- an aromatic phenolic
10˚Cmin-1; and 300˚C for 6 mins. The conditions of the group of salicylic acid at a retention time of 26.508. The
mass detector were: the temperature of transfer line was next compound was identified as 1,3-bis-t-butylperoxy-
240˚C: and ionization mode electron impact at 70 eV, phthalan belonging to aromatic phenolic group of
the duration time of scan interval is 0.2 sec and scan salicylic acid giving a peak at 27.663 retention time. The
interval is 0.1 sec. The fragments from 40 to 600 Da. next peak was observed at 29.364 retention time which
The spectrum of components was corresponding to the was identified as 1,2-pentanediol, 5-(6-bromodecahydro-
database of the spectrum of established components 2-hydroxy-2,5,5a,8a-tetramethyl-1-naphthalenyl)-3-
gathered in the GC-MS NIST library. methylene that belongs to the aromatic phenolic groups
of salicylic acid. The final peak was observed at 29.544
Antibacterial Assay: Antibacterial activity was retention time and the compound was identified as
determined by agar well-diffusion method. Swabbing carpesterol dehydrate an aromatic phenolic group of
using sterile cotton swabs was done on Nutrient agar salicylic acid compound.[6] The GCMS analysis result
(NA) plates with 8 hour old-broth culture of different for major phytocomponents inMusa acuminata flower is
bacteria such as Streptococcus agalactiae, Bacillus given in Table 1. Chromatogram of compounds present
cereus, Staphylococcus aureus, Enterobacteraerogenes, in Musa acuminatais represented in Figure 1.
Eschericia coli, Bacillus subtilis. In each of these plates
wells (10 mm diameter and about 2 cm a part) were The crude extract of Musa acuminata was obtained
made using sterile gel puncher. From the methanolic from maceration with 80% methanol. Antibacterial
flower extract 1 mg/ml concentration of stock solution assay of the flower extract against gram positive and
was prepared.30 µl of varying concentrations of flower negative bacteria were determined by the formation of
solvent extracts were added by sterile micropipette into zone of inhibition around the wells. The negative control
the wells and allowed to diffuse at room temperature (methanol) showed zero zone of inhibition. Larger zones
for 2 hrs. Inoculums without plant extract were set up of inhibition were observed on the plates with 20 μg/
for control experiments. Incubation of the plates is ml of Ampicillin (antibiotic) to the methanolic extract
done at 37˚C for 18-24 h for bacterial pathogen. The tested. The zone of inhibition of S.aureus shows greater
zone of inhibition was observed and the diameter of the diameter of 10mm over the flower extract while the zone
inhibition zone (mm) was measured and the experiment of inhibition of other bacterial strains ranges from 5mm
was also calculated. Triplicates were maintained and the to 8mm. The antibacterial activity that is the formation of
experiment was repeated thrice, for each replicates the the zone of inhibition in the agar well diffusion method
readings were taken in three different and the average is due to the presence of active compounds in the flower
values were recorded. extract.[7-12]Different Bacteria and its zone of inhibition
is tabulated in Table 2.The phytochemical constituents
Cytotoxic assay (MTT method): The sample was of Musa acuminataflower extract is tabulated in Table 3.
344 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
The MTT assay resulted in the sample showed Slight on a dose-dependent manner against the extracts from
to Severe Cytotoxic reactivity to Hela cells. The cell rhizome of Musa acuminata.[16-17] The control gave no
death was increased with increase in concentration on cytotoxic reactivity.The activity of sample at different
the sample. Another experimental study of anthocyanin concentrations against the cells are displayed in Figure
extracted from Musa acuminata bract showed a strong 2, the cytotoxicity is represented in Figure 3 and the
anticancer activity against of MCF-7 cell lines(Breast cytotoxic reactivity of Musa acuminata flower extract
cancer)[13-15]. Another experimental result tested against displayed in Table 4.
carcinoma of cervix (HeLa) showed increased effect

Table 1: GCMS analysis result for major phytocomponentsinMusaacuminata flower

(RT- Retention Time)

Molecular Molecular
RT Compound Name Peak Area Molecular Structure
Formula Weight

1-adamantanemethylamine, alpha.-
25.933 C12 H 21 N 179 3.555
methyl-

7-hydroxy-3-(1,1-dimethylprop-2-
26.108 C14 H14 O3 230 4.025
enyl)coumarin

26.508 pentanoic acid, 2-(aminooxy)- C5 H11O3 N 133 10.832

27.663 1,3-bis-t-butylperoxy-phthalan C16 H 24 O5 296 5.798

1,2-pentanediol,
5-(6-bromodecahydro-2-
29.364 C24 H39 O5 Br 486 18.411
hydroxy-2,5,5a,8a-tetramethyl-1-
naphthalenyl)-3-methylene

29.544 Carpesterol Dehydrate C37 H52 O3 544 57.378

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 345

Figure 1: Chromatogram of compounds present in Musa acuminata

Table 2: Different Bacteria and its zone of inhibition

Microorganism Zone of Inhibition in Extracts (mm) Zone of Inhibition in Ampicillin (mm)

Streptococcus agalactiae 6 8
Bacillus cereus 5.4 7.1
Staphylococcus aureus 10 12
Enterobacteraerogenes 7 8.1
Eschericia coli 6.6 7.9
Bacillus subtilis 8 9

Table 3:The phytochemical constituents of Musa acuminataflower extract

Phytochemicalconstituents Presence
Alkaloids +
Phlobatannins +
Triterpenoids +
Flavonoids +
Lipids +
Steroids +
Terpenoids +
(+ present)

Table 4: Cytotoxic reactivity of Musa acuminata flower extract

Vol (µl) Cytotoxicity (%) Cell Viability (%) Cytotoxic Reactivity

5 16.2 83.8 Slight
25 22.8 72.8 Mild
50 33.2 66.8 Mild
75 59.5 40.5 Moderate
100 71.9 28.1 Severe
346 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Figure 2: Hela cells reactions at different sample concentrations.

Figure 3: Cell death percentage of Hela cells against Musa acuminata

Conclusion some bacteria. Further Musa extracts acts as good

antioxidant sources. Musa extracts are also involved in
This study shows us the compounds present in
anticancer studies in medicinal field.
Musa acuminata. Musa acuminata is rich in phenolic
compounds as per this study. Phytochemical study of Acknowledgement: Authors gratefully
the extract revealed the presence of certain group of acknowledge AICTE, New Delhi, sponsored Molecular
compounds. Musa acuminata acts as good antimicrobial Diagnostics and Bacterial Pathogenomics Research
agent since it shows a significant inhibition zone against Laboratory, Department of Biotechnology and Bannari
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 347
Amman Institute of Technology, for providing an 8. Martin, G., Baurens, F. C., Droc, G., Rouard, M.,
ambient environment for the successful completion of Cenci, A., Kilian, A., & Carreel, F. Improvement of
the project. the banana “Musa acuminata” reference sequence
using NGS data and semi-automated bioinformatics
Ethical Clearance: Ethical approval is taken from method; BMC genomics.2016:17, 243.
IEC. This work is carried out by following the strict
9. Oliveira, L., Freire, C. S. R., Silvestre, A. J.
guidelines of IEC.
D., Cordeiro, N., Torres, I. C., & Evtuguin,
Source of Funding: Nil D. Sterylglucosides from banana plant Musa
acuminata Collavarcavendish; Industrial Crops and
Conflict of Interest: Nil Products.2005:22, 187-192.
10. Sagrin, M. S., & Chong, G. H. Effects of drying
Reference
temperature on the chemical and physical properties
1. Brat, P., Yahia, A., Chillet, M., Bugaud, C., Bakry, of Musa acuminata Colla (AAA Group) leaves;
F., Reynes, M., & Brillouet, J. M. Influence of Industrial Crops and Products. 2013:45, 430-434.
cultivar, growth altitude and maturity stage on 11. Shian, T. E., & Abdullah, A. Antioxidant
banana volatile compound composition; Fruits. properties of three banana cultivars (Musa
2004:59, 75-82. acuminata ‘Berangan’,‘Mas’ and ‘Raja’) extracts;
2. China, R., Dutta, S., Sen, S., Chakrabarti, R., SainsMalaysiana. 2012:41, 319-324.
Bhowmik, D., Ghosh, S., & Dhar, P. In vitro 12. Sumathy, V., Lachumy, S. J., Zakaria, Z.,
antioxidant activity of different cultivars of banana & Sasidharan, S. In vitro bioactivity and
flower (Musa paradicicus L.) extracts available in phytochemical screening of Musa acuminata
India;Journal of food science. 2011:76, 1297-1299. flower; Pharmacologyonline. 2011:2, 118-127.
3. D’hont, A., Denoeud, F., Aury, J. M., Baurens, 13. Veneziano, A., Vacca, G., Arana, S., De Simone,
F. C., Carreel, F., Garsmeur, O., & Da Silva, C. F., & Rastrelli, L. Determination of carbendazim,
The banana (Musa acuminata) genome and the thiabendazole and thiophanate-methyl in banana
evolution of monocotyledonous plants; Nature. (Musa acuminata) samples imported to Italy; Food
2012:488, 213. chemistry. 2004:3, 383-386.
4. Jourda, C., Cardi, C., Bocs, S., Garsmeur, O., 14. Vilela, C., Santos, S. A., Villaverde, J. J., Oliveira,
D’Hont, A., & Yahiaoui, N. Expansion of L., Nunes, A., Cordeiro, N., & Silvestre, A. J.
banana (Musa acuminata) gene families involved Lipophilic phytochemicals from banana fruits of
in ethylene biosynthesis and signalling after several Musa species; Food chemistry. 2014:162,
lineage‐specific whole‐genome duplications; New 247-252.
Phytologist. 2014:202, 986-1000.
15. Villaverde, J. J., Oliveira, L., Vilela, C., Domingues,
5. Karuppiah, P., & Mustaffa, M. Antibacterial and R. M., Freitas, N., Cordeiro, N., & Silvestre, A. J.
antioxidant activities of Musa sp. leaf extracts High valuable compounds from the unripe peel of
against multidrug resistant clinical pathogens several Musa species cultivated in Madeira Island
causing nosocomial infection; Asian Pacific journal (Portugal); Industrial crops and products. 2013:42,
of tropical biomedicine. 2013:3, 737-742. 507-512.
6. Marikkar, J. M. N., Tan, S. J., Salleh, A., Azrina, 16. Adinarayana, Kps., Ajay Babu P. Anti-oxidant
A., & Shukri, M. A. M. Evaluation of banana activity and cytotoxicity of ethanolic extracts from
(Musa sp.) flowers of selected varieties for their rhizome of Musa acuminata; Natural Science.
antioxidative and anti-hyperglycemic potentials; 2011:3,291-294.
International Food Research Journal. 2016:23,
17. Jenshi Roobha, J., Saravanakumar, M., Aravindhan,
1988-1995.
K. M., & Suganyadevi, P. In vitro evaluation of
7. Martin, G., Baurens, F. C., Cardi, C., Aury, J. M., anticancer property of anthocyanin extract from
& D’Hont, A. The complete chloroplast genome of Musa acuminate bract; Research in Pharmacy.
banana (Musa acuminata, Zingiberales): insight into 2011:1, 17-21.
plastid monocotyledon evolution; PloS one.2013:8,
67350.
348 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Optimized Feature Selection and Classification in

Microarray Gene Expression Cancer Data

B. Lakshmanan1, T. Jenitha1
1Department of Computer Science and Engineering, Mepco Schlenk Engineering College,
Sivakasi, Tamil Nadu, India

Abstract
Cancer classification can be performed by Microarray Gene Expression data which comprises of thousands
of genes and small number of samples. Gene expression data is efficient method for finding which gene
causes cancer in human being. In this work, formulate hybrid model containing filter approach, the wrapper
approach and partial least square method that used to select the optimized features form the high dimensional
dataset. Filter approach uses mutual information, wrapper approach uses genetic algorithm and partial least
square method uses t-score estimation for feature selection mechanism. With the reduced dimension of
features, classification is performed on the reduced data set to classify the samples into normal or abnormal.
To attain the improved classification accuracy both the feature selection and the dimension reduction is
performed. By using feature selection technique most possibly cancer related genes from huge microarray
gene expression data are selected. The trained classifier model is tested with benchmark cancer dataset
which consists of colon cancer dataset comprises 62 samples, 40 of which are tumor and 22 are normal with
2000 genes and the prostate cancer dataset comprises 136 samples, 59 of which is normal and 75 are tumor
with 12,600 genes. The proposed model achieves accuracy of 92.7% for wrapper approach with optimal
features and also outperforms other two approaches with respect to accuracy and time complexity.

Keywords: Partial least squares, Feature selection, Mutual Information, Cancer classification, t-score,
genetic Algorithm, Support vector machine.

Introduction Major feature selection algorithms are the filter model,

the wrapper model and partial least square method. The
In Human being, Gene expression is the process by
filter model approach depends on general characteristics
which information from a gene is used in the synthesis of
of the training data to select some features/genes without
a functional gene product. Measuring gene expression is
involving any learning algorithm, therefore it does not
an important part of many life sciences, as the ability to
inherit any bias of learning algorithm. The wrapper
quantify the level at which a particular gene is expressed
model approach requires one predetermined learning
within a cell, organism or tissue can provide a lot of
algorithm in feature selection and uses its performance
valuable information. Gene expression profiles based on
to evaluate and determine which features are selected.
microarray data are recognized as potential diagnostic
As for each new subset of features, the wrapper model
indices of cancer.
needs to learn a hypothesis (or a classifier). It tends to
Feature selection used for microarray gene give superior performance as it finds features better
expression data is called gene selection. Apart from curse suited to the predetermined learning algorithm, but it
of dimensionality there are many other problems faced also tend to be more computationally expensive.
during gene selection for prediction or classification.
Partial least squares (PLS) technique is another
The major problems are mislabeled or redundant or
dimension reduction method that is used widely for the
noisy data, problem of cross-platform comparisons,
gene expression data based cancer classification. PLS
bias problem and difficulty in biological information
is the best method to handle the high-dimension-small-
retrieval.
sample-size problem. This kind of problem can be well
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 349
handled with partial least squares method and with the Forward feature selection algorithm1
using the
t-scores calculated for the feature selection is also used mutual information method to measure the relation
for dimension reduction. among features. The optimal feature set given to train
the LS-SVM classifier and results good accuracy.
To combine the advantages of above approaches,
algorithms in a hybrid model have recently been E Alba et al., proposed the hybridization of Particle
proposed to deal with high dimensional data. In these Swarm Optimization, a Genetic Algorithm and the
algorithms, first, a goodness measure of feature subsets Support Vector Machine (PSO/GA/SVM) to find few
based on data characteristics is used to choose best genes with high classification rates2. In order to overcome
subsets for a given cardinality and then cross validation the local optimum problem in GA,it is combined with
was exploited to decide a final best subset across PSO and SVM to find a better optimal solution.
different cardinalities. These algorithms mainly focus
on combining filter and wrapper algorithms along with Correlation-based Feature Subset Selection (CRFS)
partial least square to achieve best possible performance approach3 in which two correlation measures are used
with a particular learning algorithm at the same time for feature selection ie., feature-class correlation and
complexity of computational algorithms. feature-feature correlation. Initially, N numbers of
features are combined as possible combinations of feature
In this work proposes a new filter-based feature subsets using heuristic-based best-first search, then each
selection method uses mutual information (MI) to subset is evaluated with the two correlation measures.
evaluate the dependence between features and output The subset that has lesser feature-feature correlation
classes. The most relevant features are retained and used and higher feature-class correlation compared to other
to construct classifiers for respective classes. feature subsets is considered as the selected significant
feature subset for the classification task.
In the second method, the selection and classification
of gene subsets is performed, the selection is performed Mutual Information-based Feature Selection (MIFS)
by a genetic algorithm, and the classification of the method4 is used to determine the relevancy between
subsets feature is made with a support vector machine the individual feature and the target-class. The features
and is validated using a cross-validation method. having similar information are considered as redundant
features that are to be removed and this method shows
In the third method, Partial least squares technique good accuracy results.
uses t-score estimation for dimension reduction in the
gene expression data. In this technique, T-scores of the Particle swarm optimization (PSO)-based feature
genes are calculated and the individual genes satisfying selection method5, in which the feature subsets generated
a particular threshold value will be made into a subset of by PSO are evaluated using supervised learning
genes that contributes to the classification. This subset algorithm and results good accuracy.
is provided as the input for the dimension reduction that
further reduces the dimension of the genes. The reduced Mutual information-based max-relevancy min-
subset of data is given to classifier for identifying the redundancy (MRMR) feature selection6,the mutual
cancer and non-cancer samples. information is computed between the individual feature
and target-class, and to identify the redundant feature,
The paper is organized as follows. In section II, the mutually exclusive condition is applied to get good
we present the related work to our proposed system, accuracy.
In Section III, the materials and method. Results and
performance evaluation of the work are provided in Conditional mutual info maximization (CMIM)7
Section IV. Finally section V concludes the proposed method that recursively chooses the features that have
work. maximum mutual information with the target-class for
classification.
Related Work: Feature selection is a technique
for eliminating irrelevant and redundant features and Materials and Method
selecting the most optimal subset of features that This section provides the description of the
produce a better characterization of patterns belonging proposed system. The system design is shown in Fig. 1.
to different classes. The framework contains three main components. The
modules are described here.
350 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Dataset: The genomics dataset8 are collected from Some of the gene names included in the 2000 genes
publicly available website which consists of colon and that provides the expression levels are H55933, R85482
prostrate cancer data. X63432, L28809, J02763, T63508, U14973

Figure 1: Overall System Design

Mutual Information: In feature selection, a feature Procedure:

is relevant to the class if it contains important information
about the class; otherwise it is irrelevant or redundant. Input: Feature set F = {fi, i = 1, ….., n} ∈ D
Since mutual information is good at quantifying the Output: S //Selected feature subset
amount of information shared between two random
variables, it is often used as a criterion to evaluate the Step 1: Initialize set S = ∅
relevance between a feature and a class label.
Step 2: Calculate amount of information for each
Under this context, features with high predictive feature fi with respect to the class
power are the ones that have larger mutual information
I(C; f). On the contrary, in the case of I(C; f) equal to Step 3: Select the feature fi which has the maximum
zero, the feature f and the Class C are proven to be mutual information.
independent of each other. This means that feature f Step 4: Add the feature fi to the set S
contributes redundancy to the classification.
Genetic search: A genetic algorithm is a type of
Mutual information is a symmetric measure of the local search method. It mimics evolution by taking a
relationship between two random variables. population of strings, which encode possible solutions,
I(f , C) = H(f ) + H(C) − H(f , C)  (1) and combines them based on fitness function to produce
individuals that more fit.
where, H(f) and H(C) are the entropies of f and C
There are five phases Initial population, Fitness
Function, Selection, Cross over, Mutation
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 351
Procedure: the covariance between the predictor variables higher
the amount of information provided by the features. The
Step 1: Encoding of the problem in a binary string
formula for calculating the covariance and reducing the
Step 2: Random generation of a population dimension is provided.

Step 3: Calculate fitness of each solution w1 = arg max(Cov(Xw, y))

Step 4: Select pairs of parent strings based on fitness The objective function is provided above and using
the covariance it is calculated.
Step 5: Generate new string with crossover and
mutation until a new population has been produced. Classification

Repeat step 2 to 5 until satisfying solution is obtained Input: S // Selected feature subset,

T-score feature selection: Gene selection is the Output: Class labels

initial process of preselecting the genes by finding the
Various classifiers such as SVM, Decision tree C4.5,
score. The score is calculated for each gene by using the
Naïve Bayes are used for the identification of unknown
mean, variance and number of samples. Calculating the
class labels.
t-score provides the information about the informative
genes and also about the irrelevant genes. Results and Discussions
Steps: This part discusses the results of the each component
1. Initially split the dataset according to their class of the system and provides the performance evaluation
labels. of the implemented methodologies.

2
2. Calculate mean x , variance s k and also number of Feature Selection:
samples in each class N k . 1. Mutual Information:
3. Calculate the t-statistics score for each gene and the Table I: Filter approach based on mutual
formula is given as information

t= x −x
0 1 Index Attribute Index Mutual Information
s02 s12 1 249 0.348689
+
N 0 N1 2 1042 0.344656
3 258 0.329303
Where k = 0, 1 that represents the various classes. 4 399 0.293341
For each gene t-score value is calculated and the results 5 493 0.283547
are provided using the t-score value about eliminating the
6 513 0.283547
irrelevant genes and identifying the informative genes.
7 1771 0.283547
Therefore the feature selection method is for calculating
8 377 0.232417
the score and identifying the best scored features. With
9 1772 0.232417
the best scores subset of features is formed.
......... ....... .........

Dimension Reduction 200 1567 0.86545

Dimension reduction plays an important role Table I shows the results of selected features (Top
in analyzing the suitable subset of data that helps in 200) by using mutual information based feature selection
handling the data in a batter way. Reducing the features method.
alone doesn’t provide the better classification results
but also in the formation of informative subset of Table II shows the results that comparing them with
original data. PLS calculates the covariance between the various classifier such as decision tree, Naïve bayes and
predictor variables and the response variables. Higher Random forest with the accuracy of the feature selected
by the filter approach.
352 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table II: Classification for filter approach data particular number of informative genes can be
identified and also irrelevant genes can be identified.
Classifier Training set Testing set Accuracy The calculated T-score value is shown in Table III.
75 25 86.3871
Decision tree 60 40 84 Dimension Reduction
(C4.5) 40 60 75.6757 Dimension Reduction is done after the feature
80 20 87.09677 selection method is performed. Using the t-statistics
75 25 87.0968 value the features are selected from the large number of
60 40 64 genes. Informative genes can be identified using the high
Naive Bayes
40 60 70.2703 t-score value and the irrelevant genes can be identified
80 20 91.67 by the low t-score value. PLS method is used for the
75 25 98.3871 dimension reduction and the dimension is reduced using
60 40 72 the covariance value calculated between the predictor
Random forest
40 60 70.2703 variables.
80 20 91.667
Performance Analysis and Evaluation: The
2. Genetic Approach: Genetic Algorithm combined performance analysis is done by calculating the accuracy.
with decision tree, in order to select a small subset
tp + tn
of genes ie., 8 features that allows enhancing the Accuracy a =
classification accuracy of 92.70% tp + tn + fp + fn

Table III: T-Score Values The table IV shows the performance analysis of
various classifiers performed on colon cancer and
Gene Names T-Score Value prostate cancer dataset. Here method adopted for feature
H55933 0.005846 selection and dimensionality reduction is partial least
H54676 0.015935 square (t-score calculation).
X55715 0.051163
D45887 -0.0123282 Table IV: Performance analysis
T57882 0.042118
Accuracy for colon Accuracy for
R50864 0.033315 Classifier
cancer prostate cancer
X02152 0.024249 SVM 93.5% 92.8%
U20982 -0.017666 Decision Tree 91.25% 90.6%
X66363 0.012090 Naïve Bayes 88.5% 87.2%
M86842 0.015174 Random Forest 92.4% 94.2 %

3. T-Score Feature Selection: Genes are selected The Accuracy value for Filter approach, Wrapper
using the T-score value for each gene. Using the approach and T-score estimation is shown in table V.
T-score value calculated for each gene present in the

Table V: Comparison of Filter, Wrapper and PLS approach

Method Important Features Selected Number of Features Accuracy (%) (C4.5)

Mutual information
N1=249, 1042, 258, 399, 493, 513, 1771,, ......1567 200 87.09677
(Filter approach)
Genetic algorithm
N2=51, 575, 633, 870, 1244, 1310, 1742, 1952 8 92.70968
(Wrapper approach)
T-score Estimation
- 100 91.25
(Partial Least Square)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 353

Conclusion and Future Work 4. Battiti R. Using mutual information for selecting
features in supervised neural net learning. IEEE
The proposed work uses a hybrid technique which
Transactions on Neural Networks. 1994.5(4):537-
uses filter based approach, Wrapper based method,
550.
Partial least square method. Classification is performed
on reduced gene subsets and is validated using a cross- 5. Xue B, Zhang M, Browne W N.Particle swarm
validation method. optimization for feature selection in classification:
A multi-objective approach. IEEE Transactions on
Although the proposed MIFS (Mutual information Cybernetics. 2013.43(6):1656-1671.
based feature selection) has shown encouraging 6. Peng H, Long F, Ding C. Feature selection based
performance, it could be further enhanced by optimising on mutual information criteria of max-dependency,
the search strategy .In this work, wrapper approach max-relevance, and min-redundancy. IEEE
outperforms other two approaches. In future research Transactions on Pattern Analysis and Machine
the combination of other techniques of feature selection Intelligence. 2005.27(8):1226-1238.
will be used, as other local search method (Ant Colony
7. Fleuret F. Fast binary feature selection with
Optimization, Particle Swarm Optimization) or other
conditional mutual information. The Journal of
techniques of data mining, the goal is to maximize the
Machine Learning Research. 2004.5:1531-1555.
classification accuracy and minimize the number of
genes for further analysis. 8. Available from: http://genomicspubs.princeton.
edu/oncology/affydata/index.html [Internet].
Acknowledgements: We thank Management, 9. Liu J X, Xu Y, Zheng C H, Wang Y, Yang J Y.
Principal, HOD (CSE) of Mepco Schlenk Engineering Characteristic Gene Selection via Weighting
College for providing Infrastructure and other Principal Components by Singular Values. Plos
computational facilities to carry out this research work; One. 2012.7(7):1-10.doi.org/10.1371/journal.pone.
Princeton University Gene Expression Project for 0038873.
providing the dataset.
10. Cai D, He X, Han J.AN Efficient Algorithm
Conflict of Interest: Nil For Large Scale Discriminant Analysis. IEEE
Transactions on Knowledge and Data Engineering.
Source of Funding: Mepco Schlenk Engineering 2008.20(1):1-12.
College, Sivakasi.
11. Pavithra D, Lakshmanan B. Feature Selection and
Ethical Clearance: No Human or Animal Subject Classification in Gene Expression Cancer data.
is involved in this research. IEEE sponsored International Conference on
Computational Intelligence in Data Science. 2017.
References 12. Gayathri D, Lakshmanan B. Mining of Gene
1. Amiri F, Rezaei Yousefi, Lucas C, Shakery A, Expression Data for Cancer Classification.
Yazdani N.Mutual information-based feature International Journal of Emerging Trends in
selection for intrusion detection systems. J. Netw. Science and Technology. 2016.3(1).793-799.
Comput. Appl. 2011.34(4):1184–1199. 13. Gupta A, Jayaraman V K, Kulkarni B D. Feature
2. Alba E, Garcıa-Nieto J, Jourdan L, Talbi E G.Gene selection for cancer classification using ant colony
selection in cancer classification using PSO/SVM optimization and support vector machines.in
and GA/SVM hybrid algorithms. in Proc. Congress Analysis of Biological Data: A Soft Computing
Evolutionary Compution. 2007:284–290. Approach. World Scientific. 2007.259–280.

3. Hall M. Correlation-based feature selection for 14. Liu H, Motoda H. Feature selection for knowledge
discrete and numeric class machine learning. discovery and data mining. Kluwer Academic
Proceedings of the Seventeenth International Publishers. 1998.
Conference on Machine Learning. 2000:359–366. 15. Kohavi R, John G. Wrappers for feature subset
selection. Artificial Intelligence. 1997.273–324.
354 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Evaluation of Autonomic Dysfunction in Underweight,

Normal Weight, Overweight and Obese Patients with Chronic
Obstructive Pulmonary Disease

Desai Nabil1, Jyoti Ganai2, Shobitha M.3, Nabi N.4

1Senior
Lecturer, Mahatma Gandhi Physiotherapy College, Gujarat University, 2Assist. Prof. Dept. of
Physiotherapy, 3Professor and HOD Physiology, 4Demonstrator-MD Pharmacology, Hamdard Institute of Medical
Sciences and Research, Jamia Hamdard, New Delhi

Abstract
Background: Though there are several studies available on effects of obesity on cardiac autonomic
dysfunction and effects of COPD on cardiac autonomic dysfunction separately but search on combined
effect of obesity and COPD on cardiac autonomic dysfunction fails to produce results. Therefore there was a
need to evaluate the changes in autonomic dysfunction with increasing BMI in patients with COPD.

Objective: The aims of this study were 1) to compare autonomic dysfunction in patients with COPD with
increasing BMI, 2) to correlate autonomic dysfunction in patients with COPD with increasing BMI.

Methodology: In the present study, 42 subjects were categorized into underweight, normal weight,
overweight and obese category. Non invasive cardiac autonomic function tests were carried out in these
subjects.

Results: The mean ± SD age of underweight, normal weight, overweight, and obese patients with COPD
were 57.667 ± 5.1640, 61.007 ±8.8991, 55.800±6.6106 and 56.200±7.1204 respectively. It was found that
there was no correlation between BMI and autonomic dysfunction responses in patients with COPD. All
four cardiac autonomic function test came out to be non significant statistically [Karl Pearson correlation (r),
ns- p >0.05]. Multiple comparisons between underweight, normal weight, overweight, and obese patients
with COPD for cardiac autonomic responses, FEV1, PEF were statistically non significant.

Conclusion: In present study, although the results have shown that there was definite autonomic neuropathy
in patients with COPD with increasing BMI, there was no significant difference in autonomic dysfunction
with increasing BMI in patients with COPD.

Keywords: Forced expiratory volume (FEV1), Peak expiratory flow rate (PEF), Obesity, Chronic Obstructive
Pulmonary Disease.

Introduction common consequence and has been shown to negatively

affect the cardiovascular and autonomic nervous system.
The chronic obstructive pulmonary disease (COPD) 3, 4
Previous studies have demonstrated that COPD
is characterized by persistent airflow limitation that is
patients have depressed heart rate variability (HRV),
usually progressive and associated with an enhanced
indicating increased sympathetic activity at rest5,6 and
chronic inflammation response of the airways. It has
Bronchoconstriction, hypoxia, hypercapnia, weight
been estimated that in 2030, COPD will become the
loss and systemic inflammation are other associated
third biggest cause of death.1,2
features.7, 8 Studies on adults show that the HRV is
Previous studies show that in COPD patients, decreased in overweight young adults especially men
cardiovascular autonomic neuropathy (CAN) is a indicating sympathovagal imbalance. No changes were
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 355
observed in HRV in underweight group. Changes in the 1. Valsalva maneuver: The heart rate response to
autonomic nervous activity begin in the overweight and valsalva maneuver i.e forced expiration against
may become more prominent in the obese thus indicating resistance to assess baroreceptor integrity was
increased cardiovascular risk. 9 But the number of assessed. The valsalva ratio was calculated as
studies that analysed the autonomic functions in obese the ratio of longest R-R interval after maneuver
adult population is still limited. to shortest R-R interval during maneuver. 16

Available data suggests that obesity is more 2. Heart rate variation (HRV) with respiration was
prevalent in patients with COPD than in the general measured in supine position. Resting ECG was
population, depending on the severity of chronic airflow recorded and baseline heart rate was measured.
limitation. 10, 11 Obesity is an independent risk factor for The subject was asked to breathe in deeply
cardiovascular disease and mortality12,15. Autonomic at a rate of 6 breaths per minute allowing 5
neuropathy is another complication in obese patients.16,17 seconds each of inspiration and expiration.
But limited literature is available to examine the relation The expiratory (E) to inspiratory (I) ratio was
between increasing body mass index (BMI) and cardiac calculated as the sum of 6 longest R-R interval,
autonomic function tests in patients with COPD. Hence, divided by 6 shortest R-R intervals. 16
this study on the evaluation and correlation of autonomic B. Sympathetic function tests:
function in the underweight, normal weight, overweight
and obese patients with COPD was undertaken 1. Cold pressor test (CPT): Subject was asked to
immerse his hand in cold water maintained at 4-6
Materials and Method degree Celsius and blood pressure measurement
was made from other arm. Failure of systolic
Subjects: 42 COPD subjects on the basis of BMI BP to rise by 16-20 mm Hg and diastolic BP
were categorized into 6 underweight, 26 normal weight,5 by 12-15 mmHg was indication of autonomic
overweight and 5 obese category. Written informed neuropathy.16, 17
consent was taken from the subjects and approval
was obtained from the Institutional ethical committee. 2. Blood pressure response to standing:
Procedures followed were in accordance with the ethical After blood pressure measurement in supine
standards of the responsible committee on human position the subject was made to stand. Blood
experimentation (institutional and national). pressure was recorded in 30 second interval.
Difference between readings of blood pressure
Parameters Measured: Autonomic function in lying position and then after standing was
tests were employed to evaluate the integrity of both calculated.16,17
parasympathetic and sympathetic innervations of the
Statistical Analysis: SPSS 21.0 software and graph
heart in all the groups.
pad prism 3.0 for windows were used. Co-efficient
(A) Parasympathetic Function Tests: Blood of correlation in bivariate relationship was obtained
pressure was recorded from OMERON digital using the Karl Pearson correlation test. The autonomic
sphygmomanometer and heart rate beat to beat responses were compared between underweight, normal
changes can be measured from a continuous running weight, overweight and obese COPD using the multiple
ECG record (lead II). analysis of variance (MANOVA Tukey). A “p” value of
<0.005 was considered as statistically significant.

Result
Table 1: Frequency of different responses to tests of autonomic dysfunction according to severity of COPD

Test Under Weight N=6 Normal Weight N=26 Over Weight N= 5 Obese N=5
Valsalva ratio <1.20- abnormal, 1.20-1.45, borderline, and >1.45-normal
Abnormal 2(33%) 8(31%) 3(60%) 1(20%)
Borderline 1(17%) 11(42%) 2(40%) 3(60%)
Normal 3(50%) 7(27%) 0(0) 1(20%)
356 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Test Under Weight N=6 Normal Weight N=26 Over Weight N= 5 Obese N=5
Heart rate variation (HRV) after deep breathing <10 beats- abnormal, 10-15 beats –borderline, and >15 beats –normal
Abnormal 6(100%) 10(38%) 3(60%) 3(60%)
Borderline 0 11(42%) 1(20%) 2(20%)
Normal 0 5(19%) 1(20%) 0
BP response to posture change
Abnormal 1(17%) 1(4%) 0 0
Borderline 2(33%) 8(30%) 2(40%) 0
Normal 3(60%) 17(67%) 3(60) 5 (100%)
BP response to Cold pressor test
Abnormal 3(50%) 18(70%) 3(60%) 18(70%)
Normal 3(50%) 8(30%) 2(40%) 8(30%)

Table 2: Correlation between BMI and autonomic tests responses

BMI
Pearson Correlation P Value Significance
Valsalva Maneuver -.17 .28 NS
Heart rate variation after deep breathing -.05 .75 NS
FEV1 .01 .97 NS
PEF .19 .23 NS
SBP to posture change -.25 .12 NS
DBP to posture change -.08 .61 NS
SBP to cold pressor test -.02 .90 NS
DBP to cold pressor test -.08 .60 NS

SBP- Systolic blood pressure, DBP- Diastolic blood between BMI and autonomic dysfunction responses in
pressure, FEV1- Forced expiratory volume in 1 second, patients with COPD. [Karl Pearson correlation (r), ns- p
PEF-Peak expiratory flow rate. There were no correlation >0.05] given in Table 2.

Table 3: Between groups MANOVA analysis

Group Mean Std. Deviation F value P Value

1 1.3427 .38015
2 1.2440 .12442
Valsalva Maneuver 0.572 0.637
3 1.1580 .06058
4 1.3533 .20906
1 12.846 7.8470
2 8.600 4.0373
Heart rate variation after deep breathing 1.46 0.24
3 11.800 7.3959
4 6.950 2.1107
1 37.62 10.534
2 40.60 13.939
FEV1 0.599 0.62
3 44.00 13.435
4 43.17 18.192
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 357

Group Mean Std. Deviation F value P Value

1 34.50 12.791
2 45.60 16.319
PEF 1.039 0.386
3 40.00 9.055
4 40.33 21.528
1 9.54 7.223
2 6.60 2.408
SBP to posture change 0.316 0.814
3 8.60 5.550
4 10.17 8.010
1 5.69 4.028
2 4.40 2.881
DBP to posture change 0.451 0.718
3 6.80 7.791
4 8.33 12.258
1 12.50 9.378
2 15.00 9.618
SBP to cold pressor test 0.275 0.843
3 15.80 6.979
4 15.17 13.630
1 7.15 5.548
2 5.80 2.775
DBP to cold pressor test 0.177 0.911
3 5.80 3.271
4 6.67 4.676

Multiple comparisons between underweight, normal Wu J et al compared autonomic dysfunction in

weight, overweight, and obese patients with COPD underweight, normal weight, overweight and obese
for cardiac autonomic responses. FEV1, PEF were adults. The study compared HRV (hear rate variation
statistically non-significant (MANOVA Tukey, P>0.05) during forced breathing) and HF (high frequency
given in table-3. spectrum) power and correlated SDNN (the standard
deviation of the average NN intervals) autonomic
Discussion dysfunction in underweight, normal weight, overweight
The role of BMI in the pathogenesis of COPD is not and obese adults. HRV and HF power were statistically
clear. In previous researches it has been found that both, significant for obese (p=o.o1) but there were non-
parasympathetic as well as sympathetic divisions have significant results for underweight and overweight
been found to be affected in the adult obese population (P= 0.86, 0.15 respectively). There was no significant
as compared to the non- obese adult population.16,17 independent correlation of SDNN with underweight
Whereas Chabra S K et al reported a reduction in both (p=0.41), overweight (p =0.80) and obesity (p= 0.43)
parasympathetic and sympathetic function in subjects group. It was concluded that underweight was not a
with normal BMI with or without hypoxemia.4 Among correlate of any indices of Cardiac autonomic function
patients 21.4% had no evidence of autonomic neuropathy (CAF) but over weight and obesity were independently
while 28.6% had early neuropathy and 28% had definite associated factors of altered CAF.18
neuropathy. The relationship between autonomic In our present study, we compared autonomic
neuropathy and BMI was not given by Chabra S K et dysfunction in underweight, normal weight, overweight
al. The results of the present study found that there was and obese COPD population. Parasympathetic function
definite autonomic neuropathy in normal weight COPD tests were statistically non- significant between
population similar to Chhabra S K et al. Amongst all underweight, normal weight, overweight, and obese
the groups of COPD population in our study 90% have COPD patients (P-0.64, P-0.24 respectively, table-3).
definite or early autonomic neuropathy and 10% have no Sympathetic function tests i.e BP response to postural
evidence of autonomic neuropathy (Table-1). change and BP response to cold pressor tests also were
358 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
statistically non-significant between underweight, there was definite autonomic neuropathy in patients with
normal weight, overweight and obese COPD patients. COPD with increasing BMI, there was no significant
(P-0.8, P-0.84, table-4). We also found non- significant difference in autonomic dysfunction with increasing
correlation between BMI and autonomic function tests BMI in patients with COPD. Furthermore, in several
(table-2) studies we found that irrespective of the stages of the
disease, underweight was an independent risk factor for
In present study most of the underweight COPD cardiovascular complication and mortality. In mild and
population have definite or borderline autonomic moderate COPD the best prognosis is found in normal
neuropathy (table-1) which was different from the results weight or over weight subjects. In severe COPD, over
of study of W u J et al. 18 This may be the reason that COPD weight, and obesity, is associated with better survival
patients have enhanced sympathetic tone at rest and are (obesity paradox, prognostic). Therefore we suggest that
less able to respond to sympathetic and parasympathetic patients with COPD in the normal to overweight range
stimuli in comparison to healthy persons. Previous study have better prognosis.
show that resting muscle sympathetic nerve activity is
significantly higher in patients with COPD as compared Limitations of the Study: Our study was
to age and sex matched healthy control subjects. 11 constrained by the small size of the sample available.
The morbidly obese were not included in our study.
Studies show that plasma nor-epinephrine was
elevated in patients with emphysema compared with Conflict of Interest: The authors do not have any
healthy controls. Altered lung inflation reflexes may conflicts of interest to declare.
also mediate sympathetic activation in COPD.19,20
Sympathetic activation with its chronotropic effects may Acknowledgement: The authors acknowledge all
be responsible for elevated heart rate response seen in the technical help rendered by the lab technicians.
COPD patients.20 Source of Funding: Self and with Institutional
In underweight COPD patients, neuro-humoral facilities available.
activation caused by sympathetic activation may be
a cause of skeletal muscle dysfunction. This seems
References
to involve the diaphragm and accessory respiratory 1. Salvi S.COPD: The Textbook of pulmonary and
muscles, with aggravation of ventilation disturbances critical care Med.vol 2,ed: Jindal S K, Jaypee
characteristic for COPD. Chronic hypoxemia seems to publications, 2011;971-974.
play a role in sympathetic activation, even in healthy 2. Rennard S., Pathogenesis of chronic obstructive
subjects.21 pulmonary disease. Pneumonol. Alergol. Pol. 2011,
79, 2: 132–138.
The results of this study show that there was non-
significant (weak positive, r-0.006) correlation for FEV1 3. Volterrani M., Scalvini S., Lanframchi P.,
and PEF with increasing BMI [ FEV1(P-0.62, P-0.97), MazzueroG., Colombo R., Clark a.l. et al.,
PEF(P-0.39,P-0.23) respectively, table-2]. Lad U et al Decreased Heart Rate Variability in Patients With
found in their study that there was positive correlation in Obstructive Pulmonary Disease. Chest 1994, 106,
underweight male and female with FEV1 and overweight 1432–1437.
male, and female had negative correlation with FEV1.21 4. Chhabra SK. De s. Cardiovascular autonomic
neuropathy in chronic obstructive pulmonary
Conclusion disease, Respir Med. 2005; 99: 126-133
There were several studies available on effects of 5. Gunduz H., Talay F., Arinc H., Oyildirim S.,
obesity on cardiac autonomic dysfunction and effects of Akdemir K., Yolcu M. et al., Heart rate variability
COPD on cardiac autonomic dysfunction. But till date and heart rate turbulence in patients with chronic
no study is available on combined effects of obesity and obstructive pulmonary disease. Cardiol J 2009, 16
COPD on cardiac autonomic dysfunction. Therefore (6): 553–9.
present study was done on evaluation of autonomic 6. Tukek T., Yildiz P., Atilgan D., Tuzcu V., Eren
dysfunction with increasing BMI in patients with COPD. M, Erk O. et al., Effect of diurnal variability of
In present study, although the results have shown that heart rate on development of arrhythmia in patients
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 359
with chronic obstructive pulmonary disease. Int J cardiovascular disease: the Framingham study.
Cardiol 2003 April, 88 (23):199–206. Clinics in Endocrinology and Metabolism 1976; 5,
7. Stein PK, Nelson P, Rottman JN, Howard D, Ward 367-374.
SM, Kleiger RE, et al. Heart rate variability reflects 15. Drenick, E J., Bale, G S., Seltzer, F. & Johnson,
severity of COPD in PiZ α1-antitrypsin deficiency. D. G. Excessive mortality and causes of death
Chest. 1998; 113:327–33. in morbidly obese men. Journal of the American
8. Stewart AG, Waterhouse JC, Howard P. Medical Association 1980; 243, 443-445.
Cardiovascular autonomic nerve function in 16. Quadri R, Maule S, Flecchia D, Veglio M, Rovera
patients with hypoxaemic chronic obstructive L, Rosa C, Zanone M, Fonzo D. Autonomic nervous
pulmonary disease. Eur Respir J.1991; 4:1207–14. system activity in obese subjects before and after
9. Pushpa krishna, deepa rao and vishal v. navekar. caloric restriction. Funct Neurol. 1990; 5(3):273-
Cardiac autonomic activity in overweight and 276
underweight young adults. Indian J Physiol 17. Valensi P, Thi BN, Lormeau B, Paries J, Attali JR.
Pharmacol 2013; 57(2) : 146–152. Cardiac autonomic function in obese patients. Int J
10. Poulain M, Doucet M, Major GC, et al. The Obes Relat Metab Disord. 1995 ;19(2):113-118.
effect of obesity on chronic respiratory diseases: 18. Wu J-S, Lu FH, Yang Y-C, Lin T-S, Huang
pathophysiology and therapeutic strategies. CMAJ Y-H, et al. Epidemiological evidence of altered
2006; 174:1293–9. cardiac autonomic function in overweight but
11. Schokker DF, Visscher TL, Nooyens AC, et not underweight subjects. International journal of
al. Prevalence of overweight and obesity in the Obesity 2008; 32, 788-794.
Netherlands. Obes Rev 2007;8:101–8. 19. Seals D.R., Suwarno N.O., Dempsey J.A., Influence
12. Hubert, H. B.,Feinleib, M., McNamara, P.M & of lung volume on sympathetic nerve discharge in
Castelli, W.P Obesity is an independent risk factor nocturnal humans, Circ Res 1990; 67: 130–141.
for cardiovascular disease: a 26-years follow up 20. Heidl S., Lehnert M., Criée C.P., Hasenfuss G.,
of participants in the Framingham Heart Study. Andreas S., Marked sympathetic activation in
Circulation 1983; 67, 968-977. patients with chronic respiratory failure, Am J Crit
13. Garrison, R J., Feinleib, M., Castelli, W.P & Care Med 2001; 164: 597–601.
McNamara, P.M. Cigarette smoking as a confounder 21. Lad U., Jaltade VG., LAD S, Satyanarayana P.,
of the relationship between relative weight and long Correlation between body mass index (BMI),
term mortality. Journal of the American Medical body fat percentage amd pulmonary functions in
Association 1983; 249, 2199-2203. underweight, overweight and normal adolescents.
14. Gordon, T. & Kannel, W.B Obesity and J of Clin and Dign Res 2012; 6(3): 350-353.
360 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Effect of Exercise Program in

Reducing Risk of Fall in Elderly People

Elizabeth J. Shende1, Pranjali M. Gosavi2, S. Anandh3, Yogita A. Pawar1

1Final
Year, 2Assistant Professor, 3Professor, Faculty of Physiotherapy,
Krishna Institute of Medical Sciences Deemed to be University, Karad, Maharashtra, India

Abstract
Objective: To study the Effect of Exercise Program in reducing risk of fall in elderly subject.

Materials and Method: Total 30 elderly subjects(10 males and 20 females) aged above 60 years were having
problem with flexibility, balance and high risk of fall were selected for the assessment of their flexibility, gait
and balance. Subjects who are bed ridden, having neurological conditions, Psychiatry condition and visual
deficit were excluded from the study. Outcome measures used were Morse fall risk assessment tool, Timed
up and go test, Functional reach test, Functional gait assessment.

Conclusion: The present study provided evidence to conclude that the exercise programme was significantly
effective in improving strength, flexibility and balance along with reducing risk of fall in elderly population.

Keywords: Fall, Elderly subject, flexibility, balance, gait, strength, exercise.

Introduction perceived to play an significant role in falls experienced

by the elderly population.[1]
Fall is defined as unintentionally coming to rest on
the ground or other level with or without consciousness. Walking difficulty is very common problem
Falls are faced by elderly population. Balance in elderly experienced in older adults which leads to loss of
is affected by both diseases as well as age related issues independence. Multiple changes in different systems of
along with problems like cognitive impairment, various body contribute to change in walking pattern in elderly.
medications and environmental changes all appear to The disability of gait is a gradual process. This group
contribute to the increase risk of falls.[1] of age related deficits results in inefficient gait. Body
mechanics are altered starting with flexed trunk posture,
Falls among elderly is a major public issue interfering
decreased hip extension in mild to late stance, decreased
with social essential. It has various physical, medical,
ankle plantar flexion at power push off and movement
psychological, social and economic consequences.
control is disturbed like reduced rate of forward
This include disability and deformity,fear of repeated
momentum, stride length and time variability, and
falls,direct costs of medical care associated with injuries
timing issues, and difficulty in transitioning from stance
and loss of potential income. The environment is
to swing. Reduced hip extension causes blocking of the
mechanical accumulation of potential energy in the limb
tissue during stance phase with release during swing to
fuel the limb forward movement, while also eliminating
Corresponding Author:
the hip extension. The loss of motor skills, high energy
Pranjali M. Gosavi cost of walking is major factor contributing in the age-
Assistant Professor, Faculty of Physiotherapy, Krishna related decline in physical function and activity for older
Institute of Medical Sciences Deemed to be University, adults.[2]
Karad, Maharashtra, India
e-mail:[email protected] The risk factor contributing to falls can be classified
Contact No: 8446575499 into two categories.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 361
Intrinsic and Extrinsic factors. Intrinsic factors Fall in older age population are related to socio
typically includes Age, Gender, Poor balance, Weakness, economic, environment, behavioral and biological
Mobility whereas on the other hand extrinsic factors factors. Socioeconomic factors like low income &
include Poor lighting, Slippery surface, Obstacles etc.[3] education levels, inadequate housing and lack of social.
Environment al factors like poor building design,
Gait is one of the basic component to determine slippery floors. Biological factors like age, chronic
independency of function. Many physical therapy illness. Behavioral factors like excess alcohol intake,
interventions are therefore, directed to restore and lack of exercise and inappropriate foot.[8]
improve subject ambulation status.[4]

Various studies have been shown the effects of

Materials and Methodology
various physical exercise programs on the functional Study Type: Experimental
capacity of older subject. Resistance training, endurance
training, balance training and combination of this Study Design: Pre and post
exercise have beneficial effects on certain functional Sampling Method: Simple random sampling
parameters in frail elderly subject.[5]
Sample Size: 30
Studies on resistance training have shown that this
type of exercise program can improve neuromuscular Study Duration: 6 months
activity, muscle mass, strength, power and functional
capacity as well as improve cardiovascular function. [5] Place of Study: Karad

Balance training is another type of exercise Participants: Total 30 elderly subjects (10 males and
intervention which can help to prevent fall. [5] 20 females) aged above 60 years were having problem
with flexibility, balance and high risk of fall were selected
Exercise intervention include gait training, resistance for the assessment of their flexibility, gait and balance.
exercise and balance training where resistance training Subjects who are bed ridden, having neurological
has positive effects on the strength and bone density.[6,7] conditions, psychiatry condition and visual deficit were
excluded from the study. Outcome measures used were
Resistance exercises can be used for strengthening Morse fall risk assessment tool, Timed up and go test,
weak lower limb musculature as they function as prime Functional reach test, Functional gait assessment. Each
movers of the limbs, also act as synergists to stabilize and every elderly person was approached and informed
the trunk, and sometimes act as antagonists, which help consent was taken from the individuals, willing to
to decelerate limb. Exercises to improve muscle strength participate. They were explained about the procedure
and power helps in enhancing the ability of a weak lower of the study and then were assessed for flexibility,
limb musculature, like the plantar flexors of ankle. This gait and balance using the outcome measure, after the
helps in aiding the ground reaction forces. [2] demographic data from the individuals was collected.
Stretching exercises aiding joint range of Outcome Measures: Outcome measures used were
motion(ROM) helps in maintaining the postures of Morse fall risk assessment tool, Timed up and go test,
the limbs or trunk. Secondly the desired length of Functional reach test, Functional gait assessment. After
muscles can be obtained for optimal activation during the selection of appropriate candidates fulfilling the
dorsiflexion and in heel strike a appropriate lengthening criteria they were asked to fill the questionnaire to record
of the calf muscles is needed to facilitate activation and the number of falls prior starting the treatment. Subjects
lastly for appropriate movement-related feedback to the were asked to perform the set of exercises according to
nervous system.[2] the set protocol. The set of exercises were practiced for 1
A multi-component exercise intervention program month and follow up was done for 5 months. The results
that consists of strength, endurance, and balance training gained after completing the 6 month protocol were
appears to be the best strategy for improving gait, noted by Morse fall risk assessment tool, time up go test,
balance, and strength, as well as reducing the rate of functional reach test. The change in individual’s number
falls in elderly individuals and consequently maintaining of falls was noted by the pre and post answers noted in
their functional capacity during aging.[5] the questionnaire.
362 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Statistical Analysis: Within group comparison ASSESSMENT showed significant improvement within
statistical analysis of all pre and post interventional the group(p=<0.0001). The statistical analysis for
values was done by paried ‘t’ test. The statistical analysis TIMED UP GO TEST showed significant improvement
for MORSE FALL ASSESSMENT TOOL showed within the group(p=<0.0001). The statistical analysis
significant improvement within the group(p=<0.0001). for FUNCTIONAL REACH TEST showed significant
The statistical analysis for FUCNTIONAL GAIT improvement within the group (p=<0.0001).

Table 1: Baseline Parameters

Parameters Pre Post t value p value Inference

Timed up go test 3.773 ± 2.087 5.333 ± 2.705 9.252 < 0.0001 Significant
Functional reach test 5.427 ± 0.8542 5.830 ± 0.9692 8.003 < 0.0001 Significant
Functional gait assessment 22.567± 4.006 20.5± 3.138 4.821 < 0.0001 Significant
Morse fall risk assessment tool 48.5±21.502 39.667±19.517 7.737 < 0.0001 Significant

Discussion appropriate candidates fulfilling the criteria they were

asked to fill the questionnaire to record the number of
This study “effect of exercise program in reducing
falls prior starting the treatment. Subjects were asked to
risk of fall in elderly subject” was conducted among
perform the set of exercises according the set protocol.
elderly population in Karad. As risk of fall increases
This set of exercises were practiced for 1 month and
among elderly subject due various factors, prevalence of
follow up was done for 5 months . The results gained
falls is 30% in elderly population. Previously the studies
after completing the 6 month protocol were noted
have been conducted on the fall prevention. Until now,
by Morse fall risk assessment tool, time up go test,
there was no study done to find the effect of exercise in
functional reach test. The change in individual’s number
reducing risk of fall in elderly subject.
of falls was noted by the pre and post answers noted in
Aim was to study the Effect of Exercise Program the questionnaire.
in reducing risk of fall in elderly subject. Objectives
were to determine the effect of exercise program in Conclusion
reducing risk of fall. Inclusion criteria were age group of In this study the exercise programme was
60 years and above, both Male and female with history significantly effective in improving strength, flexibility
of fall. Exclusion criteria were bed ridden patient, and balance along with reducing risk of fall in elderly
existing Neurological condition, Patient with Psychiatry population.
condition and Subject with visual deficit.
Hence Alternative hypothesis is proved.
Total 30 elderly subjects (10 males and 20 females)
aged above 60 years were having problem with Conflict of Interest: The authors declare that there
flexibility, balance and high risk of fall were selected are no conflicts of interest concerning the content of the
for the assessment of their flexibility, gait and balance. present study.
Subjects who are bed ridden, having neurological
Source of Funding: This study was self funded.
conditions, Psychiatry condition and visual deficit were
excluded from the study. Outcome measures used were Ethical Clearance: The study was approved by the
Morse fall risk assessment tool, Timed up and go test, institutional ethical committee of KIMSDU.
Functional reach test, Functional gait assessment.
References
They were explained about the study and treatment
protocol. Written consent was taken from the subjects. 1. Kenneth James, Jacqueline Gouldbourne, Chloe
They were given the questionnaire to fill and tests were Morris, et al; Falls and Fall Prevention in the
taken to find out the risk of fall. After the selection of Elderly: Insights from Jamaica; 2009: 1-46
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 363
2. Brach JS, Van Swearingen JM; Interventions 14. Kerrigan D, Todd MK, Della Croce U, Lipsitz
to Improve Walking in Older Adults. Current LA, Collins JJ. Biomechanical gait alterations
translational geriatrics and experimental independent of speed in the healthy elderly:
gerontology reports; 2013, Dec 1;2(4): 230-8. evidence for specific limiting impairments. Arch
3. NarinderkaurMultani; Principles of geriatric Phys Med Rehabil. 1998; 79(3):317–322.
physiotherapy. 15. DeVita P, Hortobagyi T. Age Causes a
4. O’sullivan SB, Schmitz TJ, Fulk G; Physical Redistribution of Joint Torques and Powers During
Rehabilitation; FA Davis; 2013 Jul 23. Gait. J Appl Physiol. 2000; 88:1804–1811.
5. Cadore EL, Rodriguez-Manas L, Sinclair A, et al; 16. Paillard T, Lafont C, Costes-Salon MC,Riviere
Effects of Different Exercise Interventions on Risk D, Dupui P; Effects of brisk walking on static and
of Falls, Gait Ability, and Balance in Physically dynamic balance, locomotion, body composition,
Frail Older Adults: A Systematic Review; RA 2013 and aerobic capacity in ageing healthy active men.
Apr 1;16(2): 105-14 International journal of sports medicine. 2004 oct;
25(07) 539-46.
6. Barbosa AP, Teixeira TG, Orlandi B, et al; Level of
physical activity and quality of life: a comparative 17. Bell JA, Talbot- Stern JK, Hennessy A;
study among the elderly of rural and urban areas; Characteristics and outcomes of older patients
2015 Dec; 18(4): 743-54. presenting to the emergency department after a
fall: a retrospective analysis; Medical Journal of
7. Claudine Barrett and Peter Smerdely; A comparison
Australia. 2000;173:179-182.
of community-based resistance exercise and
flexibility exercise for seniors; AJOP; 2002 Jan 18. Gillespie LD, Gillespie WJ, Robertson MC, et al:
1;48(3): 215-9 Interventions for preventing falls in elderly people.
Cochrane Database Syst Rev 2001;3:CD000340
8. Nelson Sousa, Romeu Mendes, Silva A, et al;
Combined exercise is more effective than aerobic 19. Province MA, Hadley EC, Hornbrook MC, et al:
exercise in the improvement of fall risk factors: A The effects of exercise on falls in elderly patients:
randomized controlled trail in community-dwelling A preplanned metaanalysis of the FICSIT trials.
older men; clinical reh; 2017, Apr; 31(4):478-86 JAMA 1995; 273:1341–7
9. WHO Global Report on Fall Prevention in Older 20. Gabell A, Simons MA, Nayak USL: Falls in the
Age. healthy elderly: Predisposing causes. Ergonomics
1985;28:965–75
10. Cesari M, Kritchevsky S, Bauer DC, et al.
Prognostic value of usual gait speed in well- 21. Owings TM, Pavol MJ, Foley KT, et al: Measures
functioning older subject--results from the Health, of postural stability are not predictors of recovery
Aging and Body Composition Study. J Am Geriatr from large postural disturbances in healthy older
Soc. 2005; 53(10):1675–1680. adults. J Am Geriatr Soc 2000;48:42–50
11. Guralnik JM, Ferrucci L, Pieper C, et al. Lower 22. Shimada H, Obuchi S, Kamide N, etal: Relationship
extremity function and subsequent disability: with the dynamic balance function during standing
consistency across studies, predictive models, and and walking. Am J Phys Med Rehabil 2003;-
value of gait speed alone compared with the short 82:511‑6.
physical performance battery. J Gerontol Med Sci. 23. Rubenstein LZ, Josephson KR. The epidemiology
2000; 55A:M221–M231. of falls and syncope. Clin Geriatr Med 2002; 18:
12. Ferrucci L, Baninelli S, Benvenuti E, et al. 141–58.
Subsystems contributing to the decline in ability to 24. Rubenstein LZ, Josephson KR, Robbins AS. Falls
walk: Bridging the gap between epidemiology and in the nursing home. Ann Intern Med 1994; 121:
geriatric practice in the In CHIANTI study. J Am 442–51.
Geriatr Soc. 2000; 48(12):1618–1625. 25. Tinetti ME, Williams TF, Mayewski R. Fall risk
13. McGibbon CA, Krebs D. Age-related changes in index for elderly patients based on number of
lower trunk coordination and energy transfer during chronic disabilities. Am J Med 1986; 80: 429.
gait. J Neurophysiol. 2001; 85:1923–1931.
364 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Regenerative Endodontics-The Future?

A Questionnaire Based Study

Farhan Ariwala1, Mahalaxmi Yelapure2, Mithra N. Hegde3, Darshana Devadiga4, Upasana5

1II-MDS, 2Reader, 3Head
of the Department, 4Reader, 5Lecturer,
Department of Conservative Dentistry and Endodontics, ABSMIDS, Mangaluru

Abstract
Introduction: Regenerative Endodontics is a fast growing field in dentistry showing highly favourable
clinical outcomes. It encompasses various procedures that serve as a better alternative to traditional root
canal therapy as well as more aggressive treatments such as surgical endodontics. The knowledge and skill
of the practitioner plays a pivotal role in the success of any regenerative procedure.

Aim: The purpose of this survey is to evaluate knowledge, attitudes and practice of regenerative endodontics
among the dental Interns, dental postgraduates and dental practitioners in mangaluru.

Materials and Method: An online questionnaire comprising of 20 questions was distributed amongst the
dental professionals of Manguluru. A total of 448 dental professionals responded over a period of 1 month.
Their responses were collected and tabulated to interpret the data and obtain the results.

Results: A total of 448 replies were received, with the majority of the correspondents belonging to the
dental post graduates (41.5%). The majority (97%) of the participants of this survey had come across the
term ‘Regenerative Endodontics’, but only 41 out of the 448 had reported performing any regenerative
endodontic procedure.

Conclusion: Regenerative endodontic Procedures have shown favourable results in various studies. It can
be used as a valuable tool for any dental professional. But, as seen in this study, the knowledge levels as well
as attitudes amongst the dental fraternity needs to improve so as to allow the incorporation of regenerative
endodontics into clinical practice.

Keywords: Regenerative, Survey, Knowledge.

Introduction apexification procedures amongst researchers and

clinicians.[1]
Regenerative endodontic procedures(REP’s) were
proposed to overcome the drawbacks related to the Regenerative endodontic procedures can be defined
clinical management of necrotic immature permanent as biologically based procedures designed to replace
teeth and are gaining prominence over traditional damaged structures, including dentin and root structures,
as well as cells of the pulp-dentin complex.[2]

In other words, regenerative endodontics is a broad

Corresponding Author:
term encompassing various procedures such as pulp
Dr. Farhan Ariwala
revascularisation, apexogenesis, pulp implantation,
II MDS, Department of Conservative Dentistry and
three-dimensional cell printing etc.[2]
Endodontics, ABSMIDS, Mangaluru
Address: 301, Plama Citius, University Road, The success of regenerative endodontics, like any
Deralakatte, Mangalore-575018 other dental procedure, depends upon the knowledge
e-mail: [email protected] and skill of the practitioner. Although, regenerative
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 365
procedures are highly technique sensitive and require a of mangaluru digitally. This was done by distributing the
systematic protocol to be followed. link to the questionnaire. https://docs.google.com/forms/
d/e/1FAIpQLScxYl8XLC4yK2PsDovd4hQHqSQMcY
Hence, the knowledge of the practitioner regarding tTULLYucTErJCZ_buKiQ/viewform#start=openform
these procedures is of paramount importance. Since
very few studies have been conducted in this regard Printed copies of the questionnaire were also
and little information about this is available, the aim used and were circulated individually amongst the
of this survey is to evaluate knowledge, attitudes and practitioners. Only dental interns, dental post graduates
practice of regenerative endodontics among the dental and dental practitioners were provided with the
Interns, dental postgraduates and dental practitioners in questionnaire. Responses to both the online form as well
mangaluru. as the hard copy of the questionnaire were accepted for
a period of 1 month.
Materials and Method
All the data was then collected and tabulated. This
The study undertaken was a questionnaire- was later analysed to obtain the results of the survey.
based survey to evaluate the awareness and attitudes
towards regenerative endodontics, with a questionnaire Results
comprising of 20 questions. Out of this, 15 questions
were framed to evaluate the knowledge and awareness A total of 448 replies were received for the
of dental professionals towards REP’s, while 5 were survey, both online and offline. Out of this, most of the
framed to reveal their attitudes towards the same. correspondents were the dental postgraduates (41.5%),
followed by the dental practitioners (31.9%) and then
The questions were arranged systematically to the dental interns (26.6%).
evaluate the awareness, knowledge and attitudes of the
dental practitioners in the region of Mangaluru, towards The age of the participants ranged from 21 to 52
regenerative endodontic procedures. years, with an average age of 27 years. Amongst the
dental practitioners, the average number of years of
Using ‘Google Docs’, an online questionnaire was practice was 7.5 years.
created to be distributed amongst the dental professionals

Table 1: Questions drafted so as to determine the knowledge levels of the various participants in the field of
regenerative endodontics

Response
Question
Yes No Not Sure
Do you think Regenerative procedures can serve as a practical and
292(65.2%) 66(14.7%) 90(20.1%)
feasible replacement for more aggressive treatment protocols?
Do you think regenerative procedures can serve as an alternative to
128(28.6%) 186(41.5%) 134(29.9%)
implants?
Single visit procedure is recommended for regenerative endodontic
26(5.8%) 338(75.4%) 84(18.8%)
treatment.
Leaching of Sodium Hypochlorite (NaOCl) into the periapical space has
289(64.5%) 42(9.4%) 117(26.1%)
a detrimental effect on revascularisation procedures.
The use of Ethylene-Diamine-Tetra-acetic acid (EDTA) is
recommended along with Sodium Hypochlorite (NaOCl) during 161(35.9%) 108(24.1%) 179(40%)
revitalisation procedures.
Revascularisation procedures performed on teeth with a large apical
foramen diameter are more successful than teeth with a small apical 172(38.4%) 102(22.8%) 174(38.8%)
foramen.
Should revascularisation be performed on deciduous teeth? 30(6.7%) 288(64.3%) 130(29%)
366 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 2: The technical aspects of regenerative procedures was inquired with these following questions.

Table 3: The scope and future aspects of REP’s, according to the participants, was Questioned.

Discussion Endodontics. Few of the correspondents also believed

direct pulp capping (20.2%) and apexification (9.6%) to
In this survey, 97% (435) of the correspondents
be regenerative procedures, but, even though they fulfil
had come across the term ‘Regenerative Endodontics’.
the criteria stipulated for regenerative procedures of
This showed a high awareness amongst the population
growth of tooth structures, they are not considered under
of dentists in mangaluru. In a similar study conducted
the umbrella of regenerative endodontics.
amongst dental residents in selected hospitals within
Nigeria, 91.2% (114) of the participants had come across A total of 41(9.1%) respondents reported practicing
the term regenerative endodontics.[3] regenerative procedures, with apexogenesis (18) and pulp
revascularisation (14) the most practiced procedures.
Pulp revascularisation and apexogenesis were the 2
procedures (88.2% & 78.3% respectively) most recognised A total of 292(65%) of the respondents believed
in this study to fall under the term of Regenerative that REP’s can replace more aggressive treatment
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 367
modalities. This is supported by available literature, Sodium hypochlorite has a detrimental effect on
displaying a high success rate for procedures such as the stem cells. [12,16] The majority of the correspondents
pulp revascularisation and apexogenesis. A cohort study were aware of this fact, with 289(64.5%) believing that
investigated 20 cases of regenerative endodontic therapy leaching of sodium hypochlorite into the periapical
for immature permanent teeth with necrotic pulps and space is harmful for the regenerative procedure. Out of
showed that the success or survival rate of treated teeth those who did not agree to the same, the majority of the
was 100% in terms of regression of clinical symptoms/ correspondents belonged to the group of dental interns.
signs and resolution of apical periodontitis or retention
of teeth. [4] In a study conducted by martin et al. (2014), the
use of 17% EDTA resulted in increased survival and
But, it is also important to view the failures for DSPP expression, partially reversing the deleterious
REP’s. A study conducted by song et.al (2017) showed effects of NaOCl. [12] This study showed that the highest
the presence of Revascularisation Associated Intra-Canal awareness regarding this information existed amongst
Calcifications in 62% of the cases under the study.[5] the post graduates. As the speciality of the participants
were not recorded, the awareness amongst the various
When it came to REP’s serving as an alternative specialities could not be determined.
to implants, the majority of the correspondents (71%)
were sceptical towards it’s ability for the same. The Teeth with pre-operative apical diameters wider
current philosophy in tissue engineering is developing/ than 1 mm have been reported to show a greater increase
regenerating a whole new organ. This can be achieved in root thickness, length, and apical narrowing. This
either by seeding tooth germ cells in a tooth shaped finding suggests that revascularization of necrotic
scaffold or recreating the tooth germ from detached pulps with fully formed (closed) apices might require
mesenchymal and epithelial cells.[6] But, this technology instrumentation of the tooth apex to approximately 1 to
is still in its infancy. This may also explain why 332 2mm in apical diameter to allow systemic bleeding into
of the total correspondents believed that it would take root canal systems. [13]There was reduced knowledge
atleast 20 years for a tooth developed in a lab to be regarding this fact, as only 154(35%) correspondents
implanted in the oral cavity. were aware of it. Again, the post graduates showed the
highest awareness regarding the same.
A multiple visit protocol using a tri-antibiotic paste
may be a better treatment option for teeth with complete The most recognised scaffold, in this survey, to be
pulpal necrosis, during revascularisation procedures.[7] used during REP’s was Platelet Rich Fibrin. A study
338(75.4%) of the respondents also believed the same, comparing platelet rich plasma (PRP), platelet rich
as they did not believe single visit endodontics is fibrin (PRF) and blood clot, showed that PRF had a
recommended for regenerative procedures. Shin et al. huge potential to accelerate the growth characteristics in
had proposed a single visit procedure using an intra immature necrotic permanent teeth as compared to PRP
canal medicament,but it showed limited success.[7] and blood clot. [14]

Disinfection of the root canal space is paramount 227(50.7%) of the correspondents believed that the
towards the success of any Regenerative procedure. higher cost factor for regenerative procedures would be
Both irrigants as well as intra canal medicaments can its biggest obstacle.In a similar survey conducted by
be used.[8] The most recognised irrigant in the survey Utneja et al (2012), 74% of the participants believed that
was sodium hypochlorite and the most recognised intra the higher cost factor would be the biggest obstacle to
canal medicament was the triple antibiotic paste (TAP). regenerative procedures. [15]
Although TAP has been shown to be more effective
in eradicating bacteria,[9] it has the potential for tooth For those believing that complicated procedures
disco-loration, which results from contact between are the biggest obstacle for regenerative endodontics,
minocycline and the root canal walls during the REP.[10] the majority belonged to the practicing dentists (40%),
Exclusion of minocycline (known as double antibiotic which may indicate a lack of trust in such procedures by
paste) or substitution of minocycline by amoxicillin, practitioners.
doxycycline, clindamycin, tetracycline or cefaclor has
been reported to solve this problem.[11]
368 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Conclusion: Mahilod study 1: Comparison of radiographic and

survival outcomes of immature teeth treated with
Traditional root canal therapy of necrotic pulps is
either regenerative endodontics or apexification
mechanically and materially based. But, Regenerative
method—A retrospective study. J. Endod. 2012,
endodontic therapy is biologically based and intended
38, 1330–1336.
to promote the host’s natural wound healing process to
restore vitality, immunity, and sensitivity of tissue in the 5. Song M, Cao Y, Shin S, Shon W, Chugal N, Kim
canal space, that was destroyed by infection or trauma. R et al. Revascularization-associated Intracanal
Calcification: Assessment of Prevalence and
In order to harness this potential, the dental Contributing Factors. Journal of Endodontics.
practitioners need to be aware and well informed 2017;43(12):2025-2033.
regarding the same. This will allow the introduction of a 6. C U V, George J, John M, Nair M, S A. regenerative
new era in clinical endodontic dentistry, that will help in endodontics- treatment options and challeges to
preserving the vitality of the tooth. success. International Journal Of Oral Care and
In this study, the dental interns lacked knowledge Research. 2015;3(4):89-95.
regarding certain aspects of the regenerative endodontic 7. Shin SY, Albert JS, Mortman RE. One step
procedures. Training regarding the same can be done pulp revascularization treatment of an immature
so as to facilitate the incorporation of regenerative permanent tooth with chronic apical abscess: a case
endodontics in dental clinics. report. Int Endod J. 2009;42(12):1118–26.
8. Velmurugan N. Revascularisation of necrotic
A wider study group, incorporating a larger region
immature permanent teeth: An update. J Oper Dent
could be done in the future to analyse the trend of REP’s
Endod 2016;1(1): 18-24.
in today’s environment.
9. Windley W, Teixeira F, Levin L, Sigurdsson A,
Limitations: The study did not differentiate Trope M. Disinfec-tion of immature teeth with a
between the various specialities of the post graduates triple antibiotic paste. J Endod 2005;(6):439—43.
as well as the practitioners. Hence, knowledge levels 10. Reynolds K, Johnson JD, Cohenca N. Pulp
regarding REP’s between each speciality could not be revascularization of necrotic bilateral bicuspids
determined. The study also did not differentiate between using a modified novel technique to eliminate
general practitioners and dental specialists. potential coronal discolouration: a case report. Int
Endod J 2009;42(1):84—92.
Source of Funding: Self
11. Conde MC, Chisini LA, Sarkis-Onofre R, Schuch
Ethical Clearance: Not required HS, No¨r JE, Demarco FF. A scoping review of
root canal revascularization: relevant aspects for
Conflict of Interest: None
clinical success and tissue formation. Int Endod
J)2016;(October 22).
References
12. Martin D, De Almeida J, Henry M, Khaing Z,
1. Iwaya SI, Ikawa M, Kubota M. Revascularization Schmidt C, Teixeira F et al. Concentration-
of an immature permanent tooth with apical dependent Effect of Sodium Hypochlorite on Stem
periodontitis and sinus tract. Dent Traumatol Cells of Apical Papilla Survival and Differentiation.
2001;17(4):185—7. Journal of Endodontics. 2014;40(1):51-55.
2. Murray PE, Garcia-Godoy F, Hargreaves KM. 13. Estefan BS, El Batouty KM, Nagy MM, Diogenes
Regenerative endodontics: a review of current status A. Influence of age and apical diameter on the
and a call for action. J Endod 2007;33(4):377—90. success of endodontic regeneration procedures. J
3. M A, IMF b, A. A Survey of Knowledge and Practice Endod 2016;42(11):1620—5;
of Regenerative Endodontics Among Nigerian 14. Hotwani K, Sharma K. Platelet rich fibrin - a novel
Dental Residents. International Journal of Sciences: acumen into regenerative endodontic therapy.
Basic and Applied Research. 2014;14(1):75-85. Restorative Dentistry & Endodontics. 2014;39(1):1.
4. Jeeruphan, T.; Jantarat, J.; Yanpiset, K.; 15. Nawal R, Ansari M, Talwar S, Verma M, Utneja
Suwannapan, L.; Khewsawai, P.; Hargreaves, K.M. S. A survey of attitude and opinions of endodontic
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 369
residents towards regenerative endodontics. Journal 17. Lee B, Moon J, Chang H, Hwang I, Oh W, Hwang Y.
of Conservative Dentistry. 2013;16(4):314. A review of the regenerative endodontic treatment
16. Yildiz M, FatihOzcan S, T. Kahramanogullari procedure. Restorative Dentistry & Endodontics.
C, Tuna E. The Effect of Sodium Hypochlorite 2015;40(3):179.
Solutions on the Viability and In Vitro Regeneration
Capacity of the Tissue. The Natural Products
Journale. 2012;2(4):328-331.
370 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Breast Cancer Screening: Are ‘At Risk Population’ Known by

Public Health Nurse Practitioners?

G.M. Venkatesh1, M. Sundar2

1Assosicate Professor, 2Professor and Head, Department of Community Medicine,
Hassan Institute of Medical Sciences, Hassan

Abstract
Introduction: Health care providers, especially Public Health Nurse who come in regular contact with
women, can play an important role in providing the information regarding breast cancer. Hence this study
is undertaken to assess the knowledge of risk factors associated with breast cancer and screening for breast
cancer among Public Health nurse practitioners.

Method: This is a cross-sectional study designed to assess the Knowledge of risk factors associated with
breast cancer and screening for breast cancer among Public Health nurse practitioners working in the Health
centres of Dept of Community Medicine of Hassan Institute of Medical Sciences. All (30) Public Health
nurse practitioners in the Seven Primary care facilities participated in the study.

Results: Fourteen percent of Public Health Nurse knew that most common cancer among women was breast
cancer. However, 43% were aware that the obesity increased the risk of developing breast cancer. Whereas
60% were aware that nulliparity was a risk factor for developing breast cancer and 43% said having 2 or
more children decreased the risk of developing breast cancer. However, 33% knew breast feeding was
protective against breast cancer. Moreover, early menstruation and late menarche were known to be risk
factors by 20% each, and 33% knew physical activity could be a preventive factor for Breast cancer. 96%
were aware that a lump in the breast was a sign of breast cancer and 56% said discharge from the nipple was
also a sign of cancer in the breast. All 100% knew that Breast Self-Examination was a screening method and
only 20% were aware that clinical examination was also a method for identification of breast cancer.

Conclusion: District Health Authorities should periodically train public health nurses to improve their
knowledge regarding risk factors, early signs and symptoms of breast cancer and method of cancer screening.
This intern would help them to educate, suspect, and detect the breast cancer among the risk population at
the earliest.

Keywords: Breast Cancer, Risk factors, Public Health Nurse.

Introduction standardised incidence rate of 46.3/100000 women and

age standardised mortality rate of 13/100000 women.
Breast cancer is the most common female cancer
While in India also it has now become the most common
in the world with an estimated 2.08 million (24.2%)
female cancer with 162 468 (27.7%) new cases reported
new cancer cases diagnosed in 2018. With age
in 2018. Whereas the age standardised incidence rate
was 24/100000 women, 87090 women died from breast
cancer in 2018 giving an age adjusted mortality rate
Corresponding Author:
of 13 per 100000 of population. And is estimated to
Dr. G.M. Venkatesh
increase to 261850 by 2040.1
Associate Professor, # 66 Doctors Quarters, Hassan
Institute of Medical Sciences, Hassan Breast cancer risk factors include increased age,
e-mail: [email protected] early menstrual period, late or no pregnancy, starting
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 371
menopause after age 55, not being physically active, (5), Masalehosahalli CHC (3), Nitturu PHC (4), Dudda
being overweight or obese after menopause, having CHC (3), Konanuru PHC (3)). All (30) Public Health
dense breast, using combination hormone therapy, taking nurse practitioners in the selected health facilities
oral contraceptives, personal history of breast cancer, participate in the study over a period of 2 months. A
family history of breast cancer, previous treatment using pretested questionnaire was used to collect the data. The
radiation therapy and alcohol consumption. 2-8 questionnaire included information on sociodemographic
profile of the study subjects, knowledge of breast cancer
Adequate knowledge about the signs and symptoms risk factors, knowledge of breast cancer signs and
and early breast cancer detection through breast self- symptoms, knowledge of Breast Self-Examination,
examination (BSE) or clinical breast examination Clinical Examination and Mammography. Data
(CBE) or mammogram, is crucial to reducing breast collection on Knowledge of breast cancer among the
cancer-related morbidity and mortality.9 Screening participants was assessed based on knowledge on risk
asymptomatic women by means of breast self- factors of breast cancer, signs and symptoms of breast
examination, clinical examination or mammography cancer and knowledge on BSE and CBE. The assessment
can play a significant role in decreasing breast-cancer is done by scoring breast cancer knowledge computed
mortality in developing countries.10 The Breast Health by giving “1” to the correct answer, and “0” for the
Global Initiative developed appropriate guidelines that wrong and ‘do not know’ answers. The data obtained
can be used in nations with limited health care resources was entered excel and analysed using epi info software.
to improve breast cancer outcomes.11 The data is display using tables and graphs.
Health care providers, especially Public Health
Nurse who come in regular contact with women, can play
Results
an important role in providing the information regarding Knowledge about the risk factors for breast
breast cancer.12 Empowering nurses with information cancer among the study participants: Thirteen percent
about early detection method and their related benefits of Public health nurse knew that most common cancer
could help in advancing their skills in performing among women was breast cancer and 36% said this
breast self-examination and expanding their role as cancer was inherited. However, 43% were aware that the
client educators.13 Education and awareness need to be obesity increased the risk of developing breast cancer
culturally appropriate and targeted towards the relevant and 30% were aware that the large breast increases the
risk population, because this may contribute towards risk of developing breast cancer. Whereas 60% were
an increase in early presentation so that highest benefit aware that nulliparity was a risk factor for developing
can be gained.14 The information obtained could help to breast cancer and 43% said having 2 or more children
initiate interventions to address the gaps in knowledge decreased the risk of developing breast cancer. However,
of Public Health Nurses towards breast cancer-related 33% knew breast feeding was protective against breast
risk factors, signs and symptoms and early breast cancer cancer. Moreover, early menstruation and late menarche
detection through breast self-examination (BSE) or were known to be risk factors by 20% each. However,
clinical breast examination (CBE). Hence this study 60% knew that advancing age was a risk factor for Breast
is undertaken to assess the knowledge of risk factors cancer and 66% knew consumption of alcohol can be a
associated with breast cancer and screening for breast risk factor for developing breast cancer but only 33%
cancer among Public Health nurse practitioners. knew that physical activity could be a preventive factor
for Breast cancer. (Table -1)
Methodology
Knowledge about signs and symptoms of Breast
This is a cross-sectional study designed to assess Cancer: 96% were aware that a lump in the breast was
the knowledge of, risk factors associated with breast a sign of breast cancer and 56% said discharge from the
cancer and screening for breast cancer among Public nipple was also a sign of cancer in the breast, whereas
Health nurse practitioner in the Health centres of Dept 80% of the Public health nurse said pain and swelling in
of Community Medicine of Hassan Institute of Medical the breast was also a sign of Breast Cancer. Dimpling
Sciences. We have seven Health Centre with following in the breast was understood to be a sign cancer among
number of Public Health Nurse Practitioners (Salagame 50% of Public health nurse and 46% were aware that
PHC (7), Krishna Urban PHC (5), Shantigrama CHC ulceration in the breast can be a sign of cancer. Only
372 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
30% knew that weight loss can also be a symptom of Knowledge about Screening Method: A large
cancer whereas a majority 63% were aware that the majority 100% knew that Breast Self-Examination was
change in the shape of the breast tissue can be a sign a screening method to appreciate sign of cancer and only
of cancer. A minimal 16% of Public health nurse had 20% were aware that clinical examination was also a
known that inversion of nipple can be a sign of cancer method for identification of breast cancer and none of
but 46% were aware that a lump in the arm pit could be them knew about mammography as a screening method
a sign of breast cancer. But very few 16% knew that the for identification of breast cancer. (Table 3).
dry skin on the nipple region can be a symptom of breast
cancer. (Table 2).

Table 1: Knowledge about risk factors of breast cancer among the study Participants

No (30) % Sd
1 Breast cancer is the most common cancers among women 4 13 1.4
2 Breast Cancer is an Inherited Disease 11 36 3.5
3 Being Overweight and Obese increase the risk of developing Breast Cancer 13 43 4.4
Breast cancer is more common among Nulliparity increased the risk of
4 18 60 5.9
developing Breast cancer
5 Large Breast increased the risk of Breast Cancer 9 30 2.9
6 Breastfeeding may decrease the risk of breast cancer development 10 33 3.5
7 Bearing two or more children decreases the risk of breast cancer 13 43 4.3
8 Early Menarche may increase the risk of breast cancer 6 20 2.1
9 Late menopause may increase the risk of breast cancer 6 20 2.1
10 Breast cancer risk increase with advancing age 18 60 5.9
11 Smoking and Alcohol consumption increase the risk of breast cancer 20 66 6.8
12 Does physical activity decrease the risk of developing breast cancer? 10 33 3.9

Table 2: Knowledge about Signs and Symptoms of Breast Cancer

No (30) % Sd
1 Lump in the breast 29 96 9.3
2 Discharge from the breast 17 56 5.5
3 Pain and Soreness in the breast 24 80 8
4 Dimpling in the breast 15 50 5.4
5 Ulceration in the breast 14 46 4.6
6 Weight loss 9 30 3.2
7 Change in the shape of the breast 19 63 6.7
8 Inversion in nipple 5 16 2.4
9 Lump Under Armpit 14 46 4.7
10 Dry Skin on Nipple region 5 16 1.8

Table 3: Knowledge about Screening Method

No (30) % Sd
1 Brest Self Examination 30 100 9.6
2 Clinical Breast Examination 6 20 2.6
3 Mammography 0 0 0
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 373

Discussion Knowledge about signs and symptoms of Breast

Cancer: 96% were aware that a lump in the breast was a
Breast cancer is the most common female cancer
sign of breast cancer, which is better than that of a finding
in the world as well as in India. Panieri E et al 2012.15
reported by Negalign Getahun et al 20 from china where
Opined that screening asymptomatic women by means
breast lump was the most commonly known symptom of
of breast self-examination, clinical examination or
cancer by 61.7% of the respondents. This may be because
mammography can play a significant role in early
of the recent experience of the public health nurses with
detection of breast cancer.13.
the cases in their field practice areas. Dimpling in the
Knowledge about the risk factors for breast breast was understood to be a sign of cancer among
cancer among the study participants: Only thirteen 50% of public health nurse and 46% were aware that
percent of Public health nurses knew that most common ulceration in the breast can be a sign of cancer. Similar
cancer among women was breast cancer. The study observations were reported by Andegiorgish et al 21 in
shows that our public health nurses are not oriented to their study, where more than 85% of the respondents
the problem of Cancer in their population and women stated that a lump in the breast, change in the size of the
cancer in particular. However, factors like multiparity, breast and discoloration/dimpling of the breasts are the
breast feeding and physical activity as protective factors major signs of breast cancer.
was not known by many. This shows that the respondents
Knowledge about Screening Method: All 100%
are not informed of the protective factors. Shuyuasa et
knew that Breast Self-Examination was a screening
al16 in their study found that the risk for breast cancer
method to appreciate sign of cancer and only few were
development among single was 49% more as compared
aware that clinical examination was also a method for
to the married women and also nulliparous woman had
identification of breast cancer, Santhana krishnan et
38% more risk as compared to women with 5 or more
al22 in their study among nursing staff reported that
children. A recent meta-analysis by Zhou Y et al17 in
73.2% mentioned BSE as a screening test and only 20%
2015 involving twenty-four articles with 13,907 breast
mentioned CBE as a diagnostic test. This observation is
cancer cases showed that breastfeeding was inversely
likely because of the training under non communicable
associated with the risk of breast cancer. Wherein the
disease programme initiative where predominantly
relative risk of breast cancer for the ever breastfeeding
teaching is about the signs and symptoms of breast
compared with never was 0.613 and an inverse
cancer and about breast self-examination.
association was found for the longest as compared with
the shortest duration of breastfeeding with the relative
Conclusion
risk of 0.471. Also, Pettapiece-Phillips R et al (2015)18
in their study reported that physical activity increases Our study revealed minimal awareness of risk factors
the expression of normal BRCA1 or BRCA2 gene and associated with breast cancer among respondents. The
their by mitigating inherited BRCA mutation. Our study study found that majority of the respondents answered
shows that the study population are poorly informed the most common symptom of breast cancer and were
about the association of mensuration on breast cancer. aware of breast-self-examination. So, we recommend that
This has been documented by shuyuasa et al16, that District Health Authorities to periodically train public
relative risks of breast cancer for women reporting health nurses to improve their knowledge regarding risk
menarche prior to the age of 13 years was twice as high factors, early signs and symptoms of breast cancer and
as that for those with menarche occurring after 16 years method of cancer screening. This intern would help them
of age. The author also recorded relative risk of 1.40 to educate, examine and detect the breast cancer among
for women reporting menopause at 50 years of age or the risk population at the earliest.
over, as compared to those reporting it prior to 50 years.
Conflict of Interest: None
Also 66% knew consumption of alcohol can be a risk
factor for developing breast cancer. This association Source of Funding: Self
was recorded by Romieu et al 2015 19 in their study,
wherein it was estimated that, for each 10 g/day increase Ethical Clearance: Ref No: IEC/HIMS/R70/21-
in alcohol intake the risk increased by 4.2%. 05-2019.
374 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

References 12. Thomas DB, Gao DL, Ray RM, Wang WW,
Allison CJ, Chen FL, et al. Randomized trial of
1. http://globocan.iarc.fr/Pages/fact_sheets_cancer.
breast self-examination in shanghai: final results. J
aspx. Source: Globocan 2018
Natl Cancer Inst 2002;94(19):1445–1457
2. http://www.cancer.org/cancer/breastcancer/
13. Collaborative Group on Hormonal Factors
detailedguide/breast-cancer-risk-factors
in Breast Cancer. Familial breast cancer:
3. Pharoah PD, Day NE, Duffy S, et al. Family history collaborative reanalysis of individual data from 52
and the risk of breast cancer: A systematic review epidemiological studies including 58,209 women
and meta- analysis. Int J Cancer 1997; 71:800-09 with breast cancer and 101,986 women without the
4. Collaborative Group on Hormonal Factors in disease. Lancet. 2001;358(9291):1389–99
Breast Cancer. Menarche, menopause, and breast 14. Stockton D, Davies T, Day N, McCann J.
cancer risk: individual participant meta-analysis, Retrospective study of reasons for improved
including 118,964 women with breast cancer from survival in patient with breast cancer in east
117 epidemiological studies. Lancet Oncol 2012; Anglia: earlier diagnosis or better treatment. BMJ.
13:1141-51 1997;314:472–5.
5. Vrieling A, Buck K, Kaaks R, et al. Adult weight 15. Panieri E1. Breast cancer screening in developing
gain in relation to breast cancer risk by estrogen countries. Best Pract Res Clin Obstet Gynaecol.
and progesterone receptor status: a meta-analysis. 2012 Apr;26(2):283-90
Breast Cancer Res Treat 2010; 123:641-49
16. Shuyuasa, Bbrian- macmahon. Lactation and
6. Ewertz M, Duffy SW, Adami HO, et al. Age at Reproductive Histories of Breast Cancer Patients
first birth, parity and risk of breast cancer: a meta- in Tokyo, Japan. Bull. World Health Org 1970, 42,
analysis of 8 studies from the Nordic countries. Int 195-204
J Cancer 1990;15;46:597-603
17. Zhou Y, Chen J, Li Q, Huang W, Lan H, Jiang
7. Collaborative Group on Hormonal Factors in H. Association between breastfeeding and breast
Breast Cancer. Breast cancer and breastfeeding: cancer risk: evidence from a meta-analysis.
collaborative reanalysis of individual data from Breastfeed Med. 2015 Apr;10(3):175-82
47 epidemiological studies in 30 countries,
18. Pettapiece-Phillips R1, Narod SA. The role of body
including 50?302 women with breast cancer
size and physical activity on the risk of breast
and 96,973 women without the disease. Lancet
cancer in BRCA mutation carriers. Cancer Causes
2002;360:187‑95-.
Control. 2015 Mar;26(3):333-44.
8. Rinaldi S, Peeters PHM, Bezemer ID, et al.
19. Romieu I1, Scoccianti C1, Chajès V1,et al. Alcohol
Relationship of alcohol intake and sex steroid
intake and breast cancer in the European prospective
concentrations in blood in pre- and post-menopausal
investigation into cancer and nutrition. Int J Cancer.
women: the European Prospective Investigation
2015 Oct 15;137(8):1921-30.
into Cancer and Nutrition. Cancer Cause Control
2006;17:1033-43 20. Negalign Getahun Dinegde 1, Li Xuying.
Awareness of Breast Cancer among Female Care
9. Mittra et al. A cluster randomized, controlled trial
Givers in Tertiary Cancer Hospital, China. Asian
of breast and cervix cancer screening in Mumbai,
Pac J Cancer Prev, 18 (7), 1977-1983
India: methodology and interim results after three
rounds of screening. Int. J. Cancer: 126, 976–984 21. Eritrea Amanuel Kidane Andegiorgish11, Eyob
(2010) Azeria Kidane12, Merhawi Teklezgi Gebrezgi3.
Knowledge, attitude, and practice of breast Cancer
10. Panieri E1. Breast cancer screening in developing
among nurses in hospitals in Asmara,. BMC
countries. Best Pract Res Clin Obstet Gynaecol.
Nursing (2018) 17:33
2012 Apr;26(2):283-90
22. Santhanakrishnan et al.: KAP regarding breast
11. Anderson BO, Shyyan R, Eniu A, Smith RA,
cancer among nursing staff. International Journal of
Yip CH, Bese NS, et al. Breast cancer in limited-
Medical Science and Public Health | 2016 | Vol 5 |
resource countries: an overview of the breast
Issue
health global initiative 2005 guidelines. Breast J.
2006;12(Suppl 1):S3–S15
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 375

Credibility of Health Care Advertising-An Empirical

Understanding of its Multi-Dimensional Structure and
Scale Validation with Special Reference to Children’s
Health Food Drinks

Indu Manish Kumar

Asst. Professor, Department of Commerce and Management, Amrita School of Arts and Sciences,
Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Abstract
Advertising techniques need to be transformed based on the observations of the perceptions of consumers
since they can be the directional force to any advertising aimed at those groups. The study fruitfully provides
an empirical understanding about the multiple components of advertising credibility of consumer healthcare
products. One of the major tasks undertaken in this research was to develop a scale which is statistically
reliable and valid to measure advertising credibility in the current marketing environment of Kerala with
special reference to children’s health drinks.

Keywords: Advertising credibility, corporate credibility, endorser credibility, message content credibility,
consumer health care, health food drinks.

Introduction area approached advertising credibility with limited

dimensions and items. Therefore, this paper attempts to
The tough competition in the market and large
develop a valid scale to measure Advertising Credibility.
volume of advertisements make the consumers confused
Children’s Health Food Drinks segment is opted to study
regarding purchase decision making. There is a tendency
the dimensions and structure of perceived advertising
in the minds of consumers to distrust advertising and to
credibility.
doubt about the genuineness of producers and products.
Sometimes they feel exploited by the advertisers. Credibility of Advertising: Credibility has been
This often results in the failure of advertisements identified as one of the most important characteristics of
and loss of money. The opportunity for consumers to a persuasive message which frequently affect the result
raise voice and file complaints against non-credible/ of persuasive messages1,2. Advertising credibility can be
misleading advertisements again increases the risk of defined as “the extent to which the consumer perceives
facing legal actions. According to Rodgers and Moore1, claims made about the brand in the ad, to be truthful
advertisements that lack credibility, are often ignored and believable”3,4. Rodgers and Moore1 argue that
or avoided by consumers. Hence knowledge about the the advertisements those lack credibility are generally
perceived credibility of advertisements and consumer ignored or avoided by consumers. According to Lafferty
psychology may help the advertisers and marketers to and Goldsmith5, irrespective of media type, advertising
avoid mistakes and adopt the right advertisement tactics. credibility is a crucial inspiration for creation of attitude
In fact, from a careful review of past-related works the and subsequent behaviors.
researcher could observe that still gaps existed in areas
of existing knowledge related to advertising credibility Dimensions of Advertising Credibility: Perceived
in terms of variables, dimensions, scales,sample, credibility of an advertisement is influenced by
context etc. The previous studies conducted in this numerous factors, especially by the firm’s credibility,
376 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
the credibility of the person who brings a message6 and the as the second stage a pilot study was conducted by
the credibility of the information content7. As per the collecting responses from 50 respondents from Kochi,
literature advertising credibility has three components: a South Indian City, and ensured the reliability of the
instruments used for data collection.
Advertiser/Corporate Credibility: Corporate
credibility is defined as “the extent to which consumers The children’s health food drinks (CHFD) industry
believe that a firm can design and deliver products and is selected for studying the credibility of advertising
services that satisfy customer needs and wants”8, and has communication. The CHFD brands selected for the
been found to have direct, positive impacts on attitude study are Horlicks, Bournivita, Complan and Boost. The
toward the ad, attitude toward the brand, and purchase sample for the study was taken from the six corporations
intention2,6,9. of Kerala state namely Kozhikode, Trichur, Kochi,
Kollam, Kannur and Thiruvananthapuram. The mothers
Endorser Credibility: An endorser is an of children between 5-15 years were surveyed. For the
individual,recognized by the public and uses this selection of the wards (divisions) under study and for
recognition on behalf of a consumer good, by the selection of the sample respondents from the wards,
appearing with it in an advertisement10. Endorser multistage random sampling is used. The 2011 census
credibility in this research indicates a term used to document and 2015 voters list of the corporation were
specify a communicator’s positive characteristics and taken as sampling frame. The research instruments
trustworthiness that affect the receiver’s acceptance included structured questionnaires, advertisement story
of a message6,11. Endorser credibility is further be board and recorded TV commercials. The mothers
classified intothree: -‘Expertise’,‘Trustworthiness’ and were informed to respond to the questions related to the
‘Attractiveness’6, 9,11. advertisements of their most preferred children’s health
Message Content Credibility: Quality of message drink brand. A total of 1252 responses were used for
or argument is another important determinant of ad data analysis.
credibility. In a study Austin and Dong12 tried to Measurement Tool Development: The results of
determine if the sender along with the message would focus interview and literature review gave insights in to
have anyimpact on the total credibility of the information. the dimensions that should be highlighted in the study.
They concluded that the perceived credibility of the After identifying the three relevant dimensions of ad
information is more influenced by the message than by credibility (corporate credibility, endorser credibility
the sender. and message-content credibility) through focus
Objectives of the Study: interview, the items from validated scales used in the
previous research were taken to construct the scale for
1. To understand the structure of perceived advertising advertising credibility. To measure corporate credibility
credibility 7 item scale is used based on the scale developed and
2. To develop and validate a multi-dimensional scale for validated by Newell and Goldsmith13. The endorser
measuring perceived advertising credibility credibility measurement (13 items) was based on the
scales of Ohanion, R.11 and Goldsmith, et al.6. The
Research Methodology message/ content credibility scale is developed based on
Exploratory and descriptive research design the measures of Kemp, Deena G.14, McKenzie and Lutz4
and survey approach have been used for the study. A and Wang15 and focus group study.
preliminary study was conducted to understand the Data Analysis and Discussion: The verification
dimension structure of advertising credibility which and cleaning of the collected data was done initially.
comprised a focus group interview and pilot study. Verification of Missing Values was done using
The sample for the focus group interview consisted of frequency test, Outliers using Z-scores, Normality and
50 mothers of children between 5-15 years old, and Randomness using Kolomogorov-Smirnov test with
who are the consumers of CHFD and who watch TV Lillefors significance correction. Skewness and kurtosis
commercials and 6 experts from advertising industry are used to ensure non-normality doesn’t exist to a
and 4 experts from marketing research. The in-depth problematic level. Durbin- Watson statistics was found
interviews with 50 respondents were conducted and 2.046 thus established independent observations and
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 377
“Runs” test was used to confirm randomness. Content CC4 The Company does not have much experience
validity is ensured through extensive literature review CC5 The Company is honest.
which helped also in the development of the constructs 16. CC6 I trust the Company.
In this research a pilot study is conducted to ensure that CC7 The Company makes truthful claims
the content validity concept is not violated. Criterion-
MC1 The information about the Product is Truthful
related validity is ensured by using a common scale
MC2 The health care communication is believable
(five-point Likert scale) for measurement throughout the
MC3 The overall presentation of the matter is convincing
questionnaire.
The communicated message is clear and
MC4
understandable
Exploratory Factor Analysis: The next step in the
scale validation procedure is to discover the dimension MC5 The ad is informative
structure of perceived advertising credibility using MC6 The content and presentation are ethical
the EFA. After considering the pilot study results, MC7 The communication by the characters seemed unbiased
eliminated 3 items and finally 27 scale items have been EC1 The persons appeared in the ad seems Trustworthy
used to measure advertising credibility. Exploratory EC2 The persons appeared in the ad seems Dependable
factor analysis (Maximum Likelihood) was done using EC3 The persons appeared in the ad seems to be Honest
varimax rotation and the items with loading above 0.5 EC4 The persons appeared in the ad seems Reliable
are taken while items with low loading were dropped. EC5 The persons appeared in the ad seems Sincere
To assess the internal consistency a reliability test was EC6 The persons appeared in the ad are knowledgeable
conducted. Following Nunnally’s suggestion17 it is EC7 The persons appeared in the ad are Experienced
ensured that for all the constructs the Cronbach alpha EC8 The persons appeared in the ad seems Qualified
coefficients were greater than 0.70. EC9 The persons in the ad are Skilled
EC10 The persons in the ad seems Classy
The KMO Measure was 0.940 and the Bartlett test
EC11 The persons in the ad seems Elegant
was significant with p< 0.001. The Chi-square value
EC12 The persons in the ad looks Attractive
of 14267.39 with 351 degrees of freedom affirmed the
quality of data for further analysis and served as basis EC13 The persons in the ad are Beautiful
for factorization. The EFA provided four components After EFA the factor structure evolved with four
with an ‘Eigen value’ greater than 1, which together dimensions. The 27 items used in the scale were classified
explained over 54.013 percent of the variance. The into 4 dimensions such as Corporate credibility, Message-
items used to measure Advertising credibility is shown content credibility, Endorser credibility- Trustworthiness
in Table 1. and Endorser credibility- Attractiveness which is given
Table 1: Measures of Advertising Credibility in Table 2. The single dimension endorser credibility is
divided into two subgroups here –‘trustworthiness of
Item endorser’ and ‘attractiveness of endorser’. The themes
Items used in the advertising credibility scale
Code behind the items were the basis for naming the factors.
CC1 The Company has great amount of experience. The factors extracted in each case are given in tables
CC2 The Company is skilled in what they do. below with Cronbach alpha coefficients.
CC3 The Company has great expertise.

Table 2: Factors extracted after EFA

Cronbach’s
Sl. No. Factor name Items No. of Items
alpha
1 Corporate Credibility CC1, CC2, CC3, CC4, CC5, CC6, CC7 7 0.849
2 Message Content Credibility MC1, MC2, MC3, MC4, MC5, MC6, MC7 7 0.837
3 Endorser Credibility-Trust worthiness EC1, EC2, EC3, EC4, EC5, EC6, EC7 7 0.85
4 Endorser Credibility- Attractiveness EC8, EC9, EC10, EC11, EC12, EC13 6 0.841
378 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
objective of conducting confirmatory factor analysis is to
check the model fit ie., whether the predefined model is
fit with the observed data. Confirmatory factor analysis
tested the construct validity of Advertising credibility
using Warp PLS 5.0 software as it is the most advanced
research tool. The results for the measurement model of
Advertising credibility showed an acceptable fit.

The various fit criteria are reported below:

Average path coefficient/APC=0.308, P < 0.001 and
Average R-squared /ARS=1.000, P<0.001 which was
found significant. Average adjusted R-squared/AARS =
1.000, P<0.001. AVIF = 1.876 which is acceptable if <=5
and ideally <= 3.3. TenenhausGoF/GoF = 0.744, which
should be >= 0.1, >= 0.25, >= 0.36 for small, medium
Figure 1: CFA Model - Advertising Credibility and large effects respectively. Sympson’s paradox ratio
SPR=1.000 which is acceptable if >= 0.7, ideally = 1.
Confirmatory Factor Analysis Using Warp PLS R-squared contribution ratio (RSCR)=1.000 which can
5.0: The CFA was done to confirm the factor structure be accepted if >= 0.9, ideally = 1. The other fit criteria
model of Advertising credibility construct. The main are given in Tables 4 and Table 5.

Table 3: Various Quality criteria for CFA Model

Composite Reliability Cronbach’s Alpha Average Variances

Advertising Credibility Dimensions
Coefficients Coefficients Extracted

Corporate Credibility (R)7i 0.886 0.849 0.527

Message Content Credibility (R)7i 0.877 0.837 0.506
Endorser Credibility-Trust worthiness (R)7i 0.886 0.85 0.527
Endorser Credibility- Attractiveness (R)6i 0.883 0.841 0.558

Table 4: Correlation among L.Vs. with square roots. of AVEs

Correlations among L.Vs. with sq. rts. of AVEs

CorpCre MsgCCre EnCred1 EnCred2 AdCred
CorpCre 0.726 0.648 0.539 0.435 0.719
MsgCCre 0.648 0.711 0.671 0.459 0.705
EnCred1 0.539 0.671 0.726 0.434 0.718
EnCred2 0.435 0.459 0.434 0.747 0.696
AdCred 0.719 0.705 0.718 0.696 0.807
Note: Square roots of AVEsare shown on the diagonals.

Results of CFA 0.336, 0.318, 0.267 for corporate credibility, message-

content credibility, endorser credibility-trustworthiness,
The combined loadings and cross loadings ofevery
endorser credibility-attractiveness, respectively.
indicator is significant as p-value is less than 0.05. P
values less than 0.05 are desirable for reflective indicators. The reliability of reflective constructs has been
The indicator weights for latent variables are 0.314, established as all composite reliability coefficient and
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 379
Cronbach alpha values were above 0.7. For formative committee on human experimentation (institutional and
constructs, reliability is not a crucial consideration. It is national) and with the Helsinki Declaration of 1975, as
noticed that all average variance extracted values were ˃ revised in 2000 (5).
0.5, p- values of the loadings were ˂0.05. The loadings
were equal to or ˃0.5 and cross loading were ˂0.5. Source of Funding: Self
Thus, the convergent validity of reflective indicators is Conflict of Interest: Nil
established. The convergent validity of the formative
construct. Advertising credibility is also affirmed by References
observing that the corresponding AVE was ˃ 0.5 and VIF
found ˂0.5 for all formative indicators and weights were 1. Rodgers S. L, Moore J. J. An Examination of
significant at p-value less than 0.05. Since the square Advertising Credibility and Skepticism in Five
root of the average variance extracted was higher than Different Media Using the Persuasion Knowledge
any of the correlations involving that latent variable, the Model. Proceedings of the conference of the
discriminant validity also was confirmed. American Academy of Advertising. 2005; 10-18:
ISBN:0931030307
Conclusion 2. Choi S. M., Rifon N. J. Antecedents and
Consequences of Web Advertising Credibility:
Measuring and building credibility in advertising
A Study of Consumer Response to Banner Ads.
communication lessens consumer’s doubt about the
Journal of Interactive Advertising. 2002;3(1).
intension of marketers and enhances the advertising
effects which will positively contribute to an increase 3. Cottea J., Coulterb R. A., Moore M. Enhancing
in sales. This again will save the companies from the or disrupting guilt: the role of ad credibility and
possible legal actions invited by the non-credible perceived manipulative intent. Journal of Business
advertisements. The empirical investigation into the Research.2005; 58: 361– 368.
dimensionality of ad credibility after confirmatory 4. Mac Kenzie S. B., Lutz R. J. An Empirical
factor analysis, revealed four ad credibility dimensions Examination of the Structural Antecedents of
containing 27 ad credibility attributes. Attitude Toward the Ad in an Advertising Pretesting
Context. Journal of Marketing. 1989; 53 (2):48-65.
The factor construction developed after EFA had
5. Lafferty B. A., Goldsmith R. E. Corporate
items with adequate loadings and less conflicting cross
Credibility’s Role in Consumers’ Attitudes and
loadings. All the 27 items could be classified into 4
Purchase Intentions When a High versus a Low
dimensions such as Corporate credibility, Message-
Credibility Endorser Is Used in the Ad. Journal of
content credibility, Endorser credibility- Trustworthiness
Business Research. 1999;44: 109-116.
and Endorser credibility- Attractiveness. Almost all the
dimensions identified as significant contributors to ad 6. Goldsmith R. E., Lafferty B. A. & Newell S.
credibility. The CFA model of Advertising Credibility J. The Impact of Corporate Credibility and
came out as good model with adequate fit and satisfied Celebrity Credibility on Consumer Reaction to
other quality parameters. This research contributes valid Advertisements and Brands. Journal of Advertising.
output to equip corporates and their ad agencies to assess 2000; 29(3): 43-54.
the perceived credibility of their advertisement and to 7. Gardete P. Cheap-Talk Advertising and
study its linkage with other brand related and purchase Misrepresentation in Vertically Differentiated
related variables. Based on such studies they can frame Markets. Marketing Science. 2013; 32: 609-621.
suitable advertising and marketing strategies. Since 8. Keller K.L. Branding Perspectives on Social
health is a sensitive issue, consumers are less willing Marketing”, in NA - Advances in Consumer
to take risk and involvement in information search for Research. 1998; 25, eds. Joseph W. Alba & J.
healthcare products is more. This also highlights the Wesley Hutchinson, Provo, UT : Association for
need for a credible communication from society’s point Consumer Research: 299-302.
of view.
9. Abdul Majid, M.A. The Impact of Source
Ethical Clearance: The procedures followed were in Credibility on Yemeni Male Consumers’ Attitudes
accordance with the ethical standards of the responsible Toward Print Advertisement, Brand attitudes and
Purchase Intention of Head Cover Product: The
380 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
moderating role of Brand Familiarity, PhD Thesis, 14. Kemp, D. G. Source credibility and public
University Sains Malaysia. 2009. information campaigns: The effect of audience
10. Byrne A. Whitehead M. & Breen S. The naked truth evaluations of organizational sponsors on message
of celebrity endorsement. British Food Journal. acceptance. Graduate Theses and Dissertations.
2003; 105(4/5): 288-296. 2007; http://scholarcommons.usf.edu/etd/2241.
11. Ohanian R. Construction and Validation of a 15. Wang, A. Advertising Engagement: A Driver of
Scale to Measure Celebrity Endorsers’ Perceived Message Involvement on Message Effects, Journal
Expertise, Trustworthiness, and Attractiveness. of advertising Research. 2006.
Journal of Advertising. 1990;19(3): 39-52. 16. Reji Kumar, G. Study on linkage between customer
12. Austin, E.W., Q. Dong. Source V. Content Effects expectation, service quality perception customer
on Judgments of News Believability. Journalism satisfaction and related behavioral intentions in
Quarterly. 1994; 71(4): 973–8. banking context, Anna University, Chennai. 2011.
13. Newell, S.J., Goldsmith, R. E. The development of 17. Nunnally, J. C. Psychometric Theory (2nd ed.).
a scale to measure perceived corporate credibility. 1978. New York, NY: McGraw-Hill.
Journal of Business Research. 2001; 52: 235-247.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 381

Association of Epicardial Adipose Tissue Thickness with

Resting and Post-Exercise Cardiac Output in Overweight and
Obese Individuals

Sridevi1, Kalyana Chakravarthy Bairapareddy2, Bhamini Krishna Rao3,

Arun G. Maiya4, Gopala Krishna Alaparthi5, Krishnananda Nayak6
1Department of Physiotherapy, Manipal Academy of Higher Education, Manipal, 2Assistant Professor, Department
of Physiotherapy,, College of Health Sciences, University of Sharjah, United Arab Emirates, 3Professor,
Department of Physiotherapy, Manipal Academy of Higher Education, Manipal, 4Professor and Dean, Department
of Physiotherapy, Manipal Academy of Higher Education, Manipal, 5Assistant Professor, Department of
Physiotherapy, College of Health Sciences, University of Sharjah, United Arab Emirates, 6Associate Professor,
Department of Cardiovascular Technology, Manipal Academy of Higher Education, Manipal

Abstract
Background: Epicardial adipose tissue is known to have adverse effect on local coronary health, cardiac
structure and function. Echocardiography has shown to be a reliable method to measure the adipose thickness.

Aim: To study the association between epicardial adipose tissue thickness with resting and post-exercise
test cardiac output.

Method: A cross-sectional study of 26 overweight and obese subjects in the age group of 20 to 50 was
included. Epicardial adipose tissue thickness was measured using M-mode echocardiogram. Resting and
post exercise cardiac output, ejection fraction and heart rate recovery were measured during sub-maximal
exercise on treadmill.

Results: There was no significant correlation of epicardial adipose tissue thickness with resting and post-
exercise cardiac output, ejection fraction and heart rate recovery.

Conclusion: Cardiac output, Ejection fractionat rest and post - exercise, also Heart rate recovery were not
affected by epicardial adipose tissue thickness of less than 4 mm.

Keywords: Epicardial adipose tissue, cardiac output, sub-maximal exercise test, body mass index,
overweight and obesity, echocardiography.

Introduction degenerative diseases and cancers.1 There is an increase

in morbidity and mortality resulting from obesity due
Overweight and obesity are considered as major
to lifestyle changes in Indians.2 Cardiovascular and
risk factors for cardiovascular diseases, diabetes,
metabolic diseases are found to be more prevalent
in obese individuals with increased visceral adipose
tissue.3 Epicardial adipose tissue (EAT) is the fat located
Corresponding Author: between the myocardium and visceral pericardium4.
Dr. Kalyana Chakravarthy Bairapareddy EAT is found to have influenceon local coronary artery
MPT, Ph.D., Assistant Professor, Department of health5,6. It is the true visceral fat depot of the heart.
Physiotherapy, College of Health Sciences, University Increased amount of EAT is associated with abnormal
of Sharjah, United Arab Emirates cardiac morphology as it adds to the weight of the
e-mail: [email protected] ventricles which may further restrict the contraction of
382 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
heart and pumping ability7,8. EAT has been shown to Procedure was explained to the subjects and following
be very closely related to intra-abdominal adiposity, a data were documented: Age(years), height (cm), weight
marker of entire body visceral adiposity, according to (kg), BMI (kg/m2), body fat percentage and the baseline
various magnetic resonance imaging studies. It is well characteristics like EAT thickness(mm), Heart rate
known that visceral adiposity rather than subcutaneous (bpm), Stroke volume (ml/beat), Ejection fraction(%)
adiposity is more responsible for health risks associated were measured in the left lateral decubitus position.
with fat deposition in humans.9,10
A single cardiovascular technician measured EAT
Even though the gold standard method to measure thickness, SV using 2-D, B-mode echocardiography,
EAT thickness is MRI, echocardiography has shown to with a Trans-thoracic, parasternal view [long – axis
be a reliable method to measure the adipose thickness. measurement of EAT thickness and apical 4- chambered
Epicardial fat thickness is measured on a free wall of method for stroke volume (which was calculated using
the right ventricle from both parasternal long–and short- the formula: end diastolic volume {EDV} – end systolic
axis views. The largest amount of epicardial fat is usually volume {ESV})]. And the EF was measured using
seen at this right ventricular free wall site. Epicardial M-mode parasternal long-axis view. Subjects were
adipose tissue is usually seen as an echo- free or if it is then allowed to walk on the treadmill for 2 minutes to
massive, hyper-echoic space.11,12 Stroke volume can also familiarize the instrument. Then test was conducted on
be measured using echocardiography. Excess VAT has the treadmill according to stages of Balke protocol (as
a detrimental effect on sub-maximal aerobic capacity.13 per mentioned in the appendices). Test was terminated
Fick’s principle states that VO2 peak will occur when when the subjects complained of fatigue or reached 75–
the maximal arterio-venous oxygen difference and the 85% of Maximum heart rate (HRmax).The termination
cardiac output (CO) reach their maximum during an criteria for the study include fatigue,onset of angina or
exercise test.14 Thus, VO2 peak is directly related to the angina-like symptoms,significant decrease in SBP of
maximal arterio-venous oxygen difference and CO. CO 20mm Hg or more,light-headedness, confusion, ataxia,
has been recognized as the most important measurement pallor, cyanosis, nausea, or signs of severe Peripheral
in the assessment of cardiac pump function and overall circulatory insufficiency,excessive increase in BP
hemodynamic function.15 The influence of increased systolic >260mm Hg, diastolic >115mm Hg,0 also when
amount of epicardial adipose tissue thickness on the subject requested to stop test for whatever reason and
cardiac function is unknown. The aim of the study is to the equipment failure. Immediately after cessation of the
determine the association between epicardial adipose test, subjects were made to lie on the left lateral position
tissue thickness and resting and post-exercise cardiac as before to measure SV and EF, within the first minute
output. and simultaneously HRR was measured at 0, 1st, 3rd, 5th
minute. The data was analyzed using SPSS version 19.
Method and Materials Pearson’s correlation was used to correlate EAT with
A cross-sectional study of 26 subjects with BMI and body fat percentage, EAT with resting and
convenience was conducted at Cardiology department, post exercise cardiac output and ejection fraction, EAT
Kasturba Hospital, Manipal. The participants of age with heart rate recovery. Heart rate recovery pattern was
between 20 to 50 years with BMI ≥ 24.9kg/m2, both male analyzed using repeated measures ANOVA
and female sedentary individuals (who exercise less than
Results
3 Times/week) were included. The participants with any
known respiratory and musculoskeletal conditions, those There was a significant difference in the resting
on regular medications were excluded from the study and post-exercise cardiac output. There was a moderate
correlation between epicardial adipose tissue thickness
Approval from the University Ethical Committee and body mass index, but no significant correlation was
was obtained, following which a verbal advertisement found between EAT and total body fat percentage. There
was given among all staff and students of the constituent was a significant rise in heart rate during the first minute
colleges of University. Participants went for a complete of recovery, but it did not return to baseline by the 5th
cardiac evaluation to rule out any undiagnosed cardiac minute of recovery. However, there was no significant
conditions and then subjects were recruited as per the correlation found between epicardial adipose tissue
inclusion and exclusion criteria. A written informed thickness and heart rate recovery.
consent was obtained from all the eligible subjects.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 383

Figure A: Procedure of echocardiographic Figure D: Measurement of SV using and apical

measurement of EAT thickness, SV, EF (resting and 4-chambered method (SV=EDV- ESV)
post-exercise) in the left lateral decubitus position.
Table 1: Demographic characteristic of subjects
from age group 20-50 years

Mean ± SD (n = 26)
Age (Year) 27.46±8.78
BMI (kg/m2) 30.16±4.41
Body fat Percentage 38.35±5.6
EAT Thickness (mm)* 2.58±0.447

°BMI – Body Mass Index *EAT- Epicardial Adipose Tissue

Table 2: Comparison of resting and post-exercise

cardiac output and ejection fraction

Post-exercise
Resting (L/min)
(L/min) p value
Mean ±SD
Mean ±SD
Figure B: 2-D, B-mode transthoracic Parasternal
Cardiac output 3.30±0.8 6.8±1.8 <0.05
view, long axis measurement of EAT thickness.
Ejection fraction 66.5±3.6 74.5±2.9 <0.05

Table 3: Correlation of BMI and body fat

percentage with epicardial adipose tissue thickness

r p value
BMI & EAT 0.424 0.015
Total body fat % and EAT 0.183 0.186

Discussion
This study was conducted to determine the influence
of EAT thickness on cardiac function. Increased amount
of EAT is known to have a potential active role in the
development of cardiovascular and metabolic disorders.16
But whether excess amount of EAT thickness influences
Figure C: B-mode echocardiographic, parasternal
the cardiac function is not known.
view, long axis measurement of EAT showing
thickness of 3.9 mm (marked area).
384 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
In the present study, we investigated the influence size and also because of EAT thickness was not more
of EAT thickness on CO, EF and HRR. We found that than 4mm. Further studies are required to focus on larger
all the participants in the present study were under sample size with wider age group distribution. Future
the categories of overweight and obese (Class 1 & 2) research should include all categories of overweight and
Indian subjects. The EAT values obtained in the present obesity. There was no significant correlation between
study were relatively low (1.9mm - 3.9mm) [n = 26] in epicardial adipose tissue thickness and resting and
comparison with African American (n = 50) & Non – post-exercise cardiac output. Cardiac output, Ejection
Hispanic white (n=106) population (6.7- 8.9mm).17, 18 fractionat rest and post - exercise, also Heart rate
We found a moderate correlation between overweight as recovery were not affected by epicardial adipose tissue
well as class 1 and class 2 obesity with EAT thickness. thickness of less than 4mm.
We could not study the subjects in class 3 obese category.
Source of Funding: Self. There is no external source
In our study, a linear increase in the resting and of funding who supported this study
post-exercise cardiac output and ejection fraction was
found. It is known that the aerobic capacity is directly Conflict of Interest: The authors hereby declare
proportional to cardiac output and arterio-venous oxygen that there is no conflict of interest with regards to the
difference.19 It has been shown that higher cardiac output content in the mansucript.
in response to exercise testing in overweight people
compared with normal –weight people may be explained
References
by higher stroke volume. It is also shown that large 1. Pi-Sunyer FX. Health implications of obesity. The
differences in VO2 peak values in general population American journal of clinical nutrition. 1991 Jun
are due primarily to large differences in maximal stroke 1;53(6):1595S-603S.
volume.20, 21 2. Gopalan C. Rising Incidence of Obesity, Coronary
Heart Disease and Diabetes in the Indian Urban
EAT can substantially modulate the cardiac
Middle Class. World Review of Nutrition and
morphology and function.22 Ejection fraction and stroke
Fitness. 2001;90:127-43.
volume are good indicators of cardiac function. In this
study we found no significant correlation between EAT 3. Matsuzawa Y, Nakamura T, Shimomura I, Kotani
thickness less than 4mm and resting and post-exercise K. Visceral fat accumulation and cardiovascular
cardiac output and ejection fraction. We did not find disease. Obesity research. 1995 Dec;3(S5):645S‑7S.
literature on association of EAT thickness with cardiac 4. Talman AH, Psaltis PJ, Cameron JD, Meredith
output and ejection fraction. IT, Seneviratne SK, Wong DT. Epicardial adipose
tissue: far more than a fat depot. Cardiovascular
Heart rate recovery is a predictor of future diagnosis and therapy. 2014 Dec;4(6):416.
cardiovascular events and indicates the autonomic
5. Mahabadi AA, Massaro JM, Rosito GA, Levy
function of the body.23 We found no significant
D, Murabito JM, Wolf PA, O’Donnell CJ, Fox
correlation between EAT thickness and HRR. HRR in
CS, Hoffmann U. Association of pericardial fat,
the first minute was dropped by more than 20 beats per
intrathoracic fat, and visceral abdominal fat with
minutes (mean HRR was 28 bpm), indicating normal
cardiovascular disease burden: the Framingham
autonomic function. However, baseline values were not
Heart Study. European heart journal. 2009 Jan
achieved within the fifth minute. In the study conducted
9;30(7):850-6.
by Kim et al, there was a blunted heart rate response in the
1- and 2- minute of recovery. And the cardiorespiratory 6. Payne GA, Kohr MC, Tune JD. Epicardial
fitness which was assessed as VO2 peak was also reduced perivascular adipose tissue as a therapeutic target
in obese men.24 This study suggests that EAT thickness in obesity‐related coronary artery disease. British
of less than 4mm does not affect the cardiac function and journal of pharmacology. 2012 Feb;165(3):659-69.
aerobic capacity was not affected by EAT thickness in 7. Petta S, Argano C, Colomba D, Cammà C, Di
overweight, as well as class 1 & 2 obese subjects. Marco V, Cabibi D, Tuttolomondo A, Marchesini
G, Pinto A, Licata G, Craxì A. Epicardial fat,
The exact relationship of EAT thickness with cardiac cardiac geometry and cardiac function in patients
output could not be established because of small sample with non-alcoholic fatty liver disease: association
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 385
with the severity of liver disease. Journal of 17. Yerramasu A, Dey D, Venuraju S, Anand DV,
hepatology. 2015 Apr 1;62(4):928-33. Atwal S, Corder R, Berman DS, Lahiri A. Increased
8. Iacobellis G, Ribaudo MC, Leto G, Zappaterreno volume of epicardial fat is an independent risk
A, Vecci E, Di Mario U, Leonetti F. Influence of factor for accelerated progression of sub-clinical
excess fat on cardiac morphology and function: coronary atherosclerosis. Atherosclerosis. 2012 Jan
study in uncomplicated obesity. Obesity research. 1;220(1):223-30.
2002 Aug;10(8):767-73. 18. Pierdomenico SD, Pierdomenico AM, Cuccurullo
9. Flüchter S, Haghi D, Dinter D, Heberlein W, F, Iacobellis G. Meta-analysis of the relation
Kühl HP, Neff W, Sueselbeck T, Borggrefe M, of echocardiographic epicardial adipose tissue
Papavassiliu T. Volumetric assessment of epicardial thickness and the metabolic syndrome. The
adipose tissue with cardiovascular magnetic American journal of cardiology. 2013 Jan
resonance imaging. Obesity. 2007 Apr;15(4):870- 1;111(1):73-8.
8.10. Nelson AJ, Worthley MI, Psaltis PJ, 19. Stringer WW, Hansen JE, Wasserman K. Cardiac
Carbone A, Dundon BK, Duncan RF, Piantadosi output estimated noninvasively from oxygen uptake
C, Lau DH, Sanders P, Wittert GA, Worthley SG. during exercise. Journal of Applied Physiology.
Validation of cardiovascular magnetic resonance 1997 Mar 1;82(3):908-12.
assessment of pericardial adipose tissue volume. 20. Ogawa T, Spina RJ, Martin 3rd WH, Kohrt
Journal of Cardiovascular Magnetic Resonance. WM, Schechtman KB, Holloszy JO, Ehsani AA.
2009 Dec;11(1):15. Effects of aging, sex, and physical training on
11. Iacobellis G, Willens HJ. Echocardiographic cardiovascular responses to exercise. Circulation.
epicardial fat: a review of research and clinical 1992 Aug;86(2):494-503.
applications. Journal of the American Society of 21. Vella CA, Paul DR, Bader J. Cardiac response to
Echocardiography. 2009 Dec 1;22(12):1311-9. exercise in normal‐weight and obese, Hispanic men
12. Iacobellis G, Willens HJ, Barbaro G, Sharma AM. and women: implications for exercise prescription.
Threshold values of high‐risk echocardiographic Acta physiologica. 2012 May;205(1):113-23.
epicardial fat thickness. Obesity. 2008 22. Petta S, Argano C, Colomba D, Cammà C, Di
Apr;16(4):887-92. Marco V, Cabibi D, Tuttolomondo A, Marchesini
13. Dubin J, Wallerson DC, Cody RJ, Devereux G, Pinto A, Licata G, Craxì A. Epicardial fat,
RB. Comparative accuracy of Doppler cardiac geometry and cardiac function in patients
echocardiographic method for clinical stroke with non-alcoholic fatty liver disease: association
volume determination. American heart journal. with the severity of liver disease. Journal of
1990 Jul 1;120(1):116-23. hepatology. 2015 Apr 1;62(4):928-33.
14. Wagner PD. An integrated view of the determinants 23. Cole CR, Blackstone EH, Pashkow FJ, Snader CE,
of maximum oxygen uptake. InOxygen transfer Lauer MS. Heart-rate recovery immediately after
from atmosphere to tissues 1988 (pp. 245-256). exercise as a predictor of mortality. New England
Springer, Boston, MA. journal of medicine. 1999 Oct 28;341(18):1351-7.
15. de Divitiis OR, Fazio SE, Petitto M, Maddalena 24. Kim MK, Tanaka K, Kim MJ, Matsuo T, Tomita
G, Contaldo F, Mancini M. Obesity and cardiac T, Ohkubo H, Maeda S, Ajisaka R. Epicardial fat
function. Circulation. 1981 Sep;64(3):477-82. tissue: relationship with cardiorespiratory fitness in
16. Iacobellis G, Sharma AM. Epicardial adipose tissue men. Medicine and science in sports and exercise.
as new cardio-metabolic risk marker and potential 2010 Mar;42(3):463-9.
therapeutic target in the metabolic syndrome.
Current pharmaceutical design. 2007 Jul 1;
13(21):2180-4.
386 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

The Effectiveness of Health Belief Model as an Educational

Intervention in Improvement of Oral Hygiene:
A Systematic Review

Nesa Aurlene1, Sunayana Manipal2, Rajmohan3, Prabu D.4

1Post
Graduate Student (Masters in Dental Surgery), 2Masters in Dental Surgery, Reader, 3Masters in Dental
Surgery, Senior Lecturer, 4Masters in Dental Surgery, Head of the Department and Professor, Department of Public
Health Dentistry, SRM Dental College and Hospital, Ramapuram, Chennai, India

Abstract
Background: A lot of health education and promotion theories have been put forward for behaviour
counselling of patients in a dental operatory. Among these, the Health Belief Model is one of the oldest
theories that stats that a person’s beliefs and attitudes determine the likelihood of a behaviour change.

Aims and Objectives: A systematic review was conducted to assess the effectiveness of a Health Belief
Model based educational intervention in improving the oral hygiene status.

Method: An electronic database search was conducted in the months of September 2018 to November 2018
using the keywords of Health Belief Model (HBM), gingivitis, periodontitis and dental caries. Research
papers and original articles using a randomized controlled trial design with assessment of oral health status
through any standard indices such as DMFT, Plaque Index (PI), Periodontal pocket depth were included
in the review. A total of 41 abstracts appeared, after initial screening, duplicates removal, final screening
based on the inclusion criteria for the review and full-text availability of articles, a total of five articles were
included in the review.

Results: All the five trials using the Health Belief Model as an educational intervention reported an
improvement in the oral hygiene status of study subjects in the intervention group which was significantly
different to those in the control group.

Conclusion: The Health Belief Model can be regarded as a useful educational tool to change behaviours and
help in the development of behaviours that are conducive for the maintenance of good oral health. Further
research is warranted to supplement the evidence that already exists to provide a clearer evidence of the
usefulness of Health Belief Model in health education and health promotion.

Keywords: HBM, dental caries, oral health, gingivitis, periodontitis.

Introduction
The Health Belief Model developed by Irwin
Corresponding Author: Rosenstock in 1966 is one the oldest health promotion
Dr. Nesa Aurlene theories that explained the association between health
Post Graduate, Masters in Dental Surgery, Department beliefs and behaviour.[1] It was conceptualized based
of Public Health Dentistry, SRM Dental College and on the reasons people gave for why they accepted or
Hospital, Ramapuram, Chennai-600089, India declined an X-ray examination to detect the presence of
e-mail: [email protected] tuberculosis. This theory holds that a person’s behaviour
Phone Number: +91 9600472196 is based on six constructs of the health belief model
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 387
which are perceived susceptibility, perceived severity, In-vivo studies
perceived benefits, perceived barriers, self-efficacy and
cues to action. Randomized controlled trials

A person’s subjective belief of whether he is Articles done on the effectiveness of HBM as an

susceptible to a condition or health threat, the severity of educational intervention in improvement of oral hygiene
the threat, the benefits that would be accrued by adopting a Articles with full-text access
recommended behaviour change, the barriers that would
likely be encountered in adopting the behaviour change, Exclusion Criteria:
the degree to which people believe that personal actions
will have an effect on a health outcome, and triggers to Review articles
effect a health behaviour such as mass media campaigns, Articles without open access
advice from physicians etc., act in combination to bring
about a behaviour change in individuals.[2]In a nutshell, Studies done on HBM’s effectiveness in changing
people engage in a cost benefit analysis and then decide general health behaviours.
to adopt or not adopt a new behaviour.
Results
Thus far, cross-sectional studies have shown a good
correlation between oral hygiene behaviours and health The literature search yielded 41 abstracts, out of
belief model.[3] Likewise, various constructs of the which 15 were related to the research question. Of these
health belief model have also been found to be a good articles, a total of six articles with full text access were
predictor of dental health behaviours in studies.[4] included in the final review. Figure 1 represents the
flow diagram of the research papers that were searched,
This review was conducted to assess the effectiveness identified, screened, assessed for eligibility and included
of health belief model as an educational intervention in or excluded in the review based on the inclusion and
the improvement of oral hygiene. exclusion criteria for the review.

Method Table 1 shows the characterization of bias in all the

five studies included in the review. Most authors had
Objectives: To assess the effectiveness of health not presented sufficient information in their article for a
belief model as an educational intervention in oral proper bias assessment. The characterisation of bias was
hygiene improvement made according to PRISMA (Preferred Reporting Items
Inclusion Criteria: for Systematic Reviews and Meta-Analysis) guidelines
for randomized controlled trials.
Original articles

Table 1: BIAS Analysis of the Included Studies

Random Blinding of Blinding of

Allocation Incomplete Selective Other
Studies Sequence Participants and Outcome
Concealment Outcome Data Reporting Biases
Generation Personnel Assessment
Wickremasinghe et al (2017)[5] ? ? ? ? - ? ?
Shahnazi et al (2014)[6] ? ? ? ? - ? ?
)[7]
Solhi M et al (2010 ? ? ? ? + ? ?
Shahnazi et al (2016)[8] ? ? ? ? - ? ?
Rivandi SH et al (2017)[9] ? ? ? ? + ? ?

+ High risk, - Low risk, ? unclear risk of bias

388 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Discussion which state that behaviour modification is not only

based on internal factors but also external factors with
The cornerstone of the Health Belief Model (HBM)
“important others” playing a major role in influencing
is that health perceptions affect health behaviours.
behaviours.[14-16] Primary care-givers’ knowledge and
Most studies conducted on the HBM, ascertain only
attitudes have been determined to be a predictor of oral
the improvement in patient perceptions and oral health
health of children in many studies.[17,18]. The weakness
behaviours after an educational intervention, rather than
of this study was that sufficient information was not
reporting on whether an educational intervention led
presented by the authors to ascertain the risk of bias
to any changes in the oral health status.[10-13] Hence,
in the study. Also, no attempt was made to evaluate
articles for this review were exclusively chosen only if
whether a HBM based intervention affected the oral
they had reported on the oral health status using intra-
health status of the mothers participating in the study.
oral examination as one of the components of the study.
The response rate was found to be 100% at the end of the
After electronic database search, screening and study period with no losses to follow up. This resulted
retraction a total of five articles with full- text accessibility in an ascertainment of low risk of bias due to incomplete
was included in this review. The first study was conducted data in this study.
by Wickremasinghe et al (2017) on 15-year-old children
The third study included in this review was a study
in Kellage district, Sri Lanka. The study sample was
conducted by Solhi M et al (2010) on 291 twelve-year-
randomized into three groups with 208 members in
old school children. The main outcome of this study was
each group, two groups served as control and one group
a reduction in mean DMFT and OHI in the HBM based
served as the intervention group. The primary outcomes
intervention group at the end of six months in comparison
of plaque scores and bleeding on probing were found to
to the control group which showed no improvement in
be significantly different when comparisons were made
DMFT or OHI.[7] There were considerable limitations in
pre and post educational intervention in the intervention
this study, one of which was substantial losses to follow
group.[5]The strength of this study is that it used a
up which led to the classification of high risk of bias due
didactic educational intervention in the control groups
to incomplete data. Also, the methodology presented
rather than no intervention. Hence, a comparison could
by the authors was not sufficient to ascertain the risk of
be made between a traditional educational intervention
other biases in this study.
and HBM based intervention. On such comparison,
the HBM based educational intervention was found to The fourth study included in this review was a
perform better. study conducted by Shahnazi et al (2016) on eighty-
eight women in their first trimester of pregnancy. It was
The weaknesses of this study are that sufficient
postulated that pregnant women were a vulnerable group
information was not presented by the authors to ascertain
prone to developing oral diseases due to a number of
the risk of bias in the study. Further, as this was a study
reasons including but not limited to hormonal changes
with a follow-up period of six months there were some
and nutritional deficiencies.[19,20]The primary outcome of
losses to follow up which resulted in a low-risk of bias
this study was that the DMFT status of pregnant mothers
due to incomplete data in the bias analysis.
in the HBM intervention group remained unchanged
The second study included in this review was at the four months follow up period whereas there was
conducted by Shahnazi et al on 56 mothers of 3-6-year- an increase in DMFT status of pregnant mothers in the
old children. The primary outcome of interest in this study control group.[8]The weakness of this study was that the
was the improvement of oral health status of children mean DMFT was assessed at the four months follow up
following HBM based education of the mothers. In this period for mothers in intervention and control group but
study, the dental plaque scores of children as measured no other covariates that could have confounded the study
by Navy Plaque Index was found to be significantly results were assessed. This study had a 100% response
different in the intervention and control groups after a rate at the end of the study period and hence it could
one-month interval.[6] be ascertained that bias due to attrition could not have
occurred in the present study. There was not sufficient
The strength of this study is that, it incorporates information provided by the authors to ascertain other
the elements of other behavioural theories such as the kinds of biases in the study.
Precede-Proceed model and Theory of reasoned action,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 389
The last study included in this review was a study References
done by Rivandi SH et al (2017) on 196 30-60-year-old
1. Strecher VJ, Rosenstock IM. The health belief
outpatients attending a dental clinic in Tehran, Iran. The
model. Cambridge handbook of psychology, health
patients were randomized equally into a HBM based
and medicine.1997:113-7.
educational intervention group and control group. The
primary outcome observed in the study was a reduction 2. Champion VL. Instrument development for health
in microbial plaque scores and periodontal pocket depth belief model constructs. Advances in Nursing
at the one-month and three-month follow up in the HBM Science.1984.
intervention group which was statistically significant 3. Pine CM, McGoldrick PM, Burnside G, Curnow
in comparison to the control group.[9] There was a MM, Chesters RK, Nicholson J, Huntington E.
considerable loss to follow up at the third month interval An intervention programme to establish regular
in this study which led to the ascertainment of a high toothbrushing: understanding parents’ beliefs and
risk of bias due to incomplete data. The authors did not motivating children. International dental journal.
present sufficient information to ascertain risk of other 2000;50(6):312-23.
biases in the study. 4. Rahmati-Najarkolaei F, Rahnama P, Fesharaki MG,
Yahaghi H, Yaghoubi M. Determinants of Dental
In this review, it was found that all the five studies
Health Behaviors of Iranian Students Based on the
unanimously reported an improvement in oral health
Health Belief Model (HBM). Shiraz E-Medical
status following a HBM based educational intervention
Journal. 2016;17(7-8).
in comparison to control groups which received alternate
or no intervention. The limitation of this review is that 5. Wickremasinghe WMPNR, Ekanayake L.
all the five articles assessed did not provide enough Effectiveness of a health education intervention
information to judge the risk of most biases. Even so, this based on the Health Belief Model to improve oral
review can act as sufficient evidence as all the randomized health behaviours among adolescents. Asian Pacific
trials included in this review showed an improvement Journal of Health Sciences. 2017;4(1):48–55.
in oral health, as shown by an improvement in standard 6. Shahnazi H, Sharifirad G, Hajimiri K, Hassanzadeh
indices measuring dentition status or periodontal status A. Effect of mother’s education based on Health
in the study subjects included in these trials. Further Belief Model (HBM) on 3-6 years old children’s
research with HBM based educational intervention is dental plaque index. Bulletin of Environment,
warranted to understand whether health education based Pharmacology and Life Sciences. 2014;3(9):183–8.
on a theoretical model is more effective than traditional 7. Solhi M, Zadeh DS, Seraj B, Zadeh SF. The
or routine method of health education. Application of the Health Belief Model in Oral
Health Education . Iranian Journal of Public Health.
Conclusion 2010;39(4):114–9.
A systematic review was conducted to assess the 8. Shahnazi H, Hosseintalaei M, Ghashghaei FE,
effectiveness of a theory-based approach of health Charkazi A, Yahyavi Y. Effect of Educational
education using the Health Belief Model in improvement Intervention on Perceived Susceptibility Self-
of oral health status. However, bias ascertainment could Efficacy and DMFT of Pregnant Women. Iranian
not be done properly with the information presented Red Crescent Medical Journal. 2016;18(5):e24960.
by the authors and hence this review can be taken as 9. Rivandi SH, Garmaroudi G, Sadeghi R, Abbasipour
moderate evidence for the effectiveness of HBM based F, Yaseri M. The Effect of Educational Intervention
health education. Based on Health Belief Model on the Improvement
of Periodontitis and Gingivitis in Adults. Journal of
Ethical Clearance: The ethical clearance for this
Oral Health and Dental Science. 2018;2(3):1–11.
study was obtained from the Institutional Review Board
of SRM Dental College and Hospital. 10. Jeihooni A, Jamshidi H, Kashfi S, Avand A, Khiyali
Z. The effect of health education program based
Conflicts of Interest: Nil on health belief model on oral health behaviors in
pregnant women of Fasa city, Fars province, south of
Financial Support: Nil
Iran. Journal of International Society of Preventive
and Community Dentistry. 2017;7(6):336–43.
390 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
11. Ghorbani B, Shahnazi H, Hassanzadeh A. dwelling older people. Journal of Physical
Improving Student’s Self-Efficacy and Perceived Education and Medicine. 2010;11(1):27–35.
Susceptibility Toward Oral and Dental Health: 16. Sato K, Oda M. Analysis of the factors that affect
A Randomized Controlled Trial. Oman Medical dental health behaviour and attendance at scheduled
Journal. 2018Oct;33(5):423–8. dental check-ups using the PRECEDE-PROCEED
12. Kasmaei P, Shokravi FA, Hidarnia A, Hajizadeh Model. Acta Med Okayama. 2011;65(2):71–80.
E, Atrkar-Roushan Z, Shirazi KK, et al. Brushing 17. Bozorgmehr E, Hajizamani A, Mohammadi TM.
behavior among young adolescents: does perceived Oral Health Behavior of Parents as a Predictor
severity matter. BMC Public Health. 2014; of Oral Health Status of Their Children. ISRN
14(1):1‑6. Dentistry. 2013;2013(741783):1–5.
13. Kasmaei P, Shokravi FA, Hajizadeh E, Atrkar- 18. Poutanen R, Lahti S, Tolvanen M, Hausen H.
Roushan Z. Role of Oral Hygiene Beliefs in Regular Parental influence on childrens oral health-related
Brushing among the 9-10 Years Old Female behavior. Acta Odontologica Scandinavica.
Students.Health Education and Health Promotion. 2006;64(5):286–92.
2013;1(3):45–58.
19. Reddy KMP, Hunasgi S, Koneru A, Amrutha
14. Buunk-Werkhoven YA, Dijkstra A, Schans R, Manvikar V. Comparison of oral health status
CPVD. Determinants of oral hygiene behavior: among pregnant and non-pregnant women residing
a study based on the theory of planned behavior. in Raichur district. Journal of Advanced Clinical &
Community Dentistry and Oral Epidemiology. Research Insights. 2017;4(5):158–61.
2010;39(3):250–9.
20. Patil S. Oral changes in pregnant and nonpregnant
15. Fukita M, Momose Y, Fukada J, Morimoto S, women: A case-control study. Journal of Orofacial
Yokoya Y. Oral health behavior among community- Sciences. 2013;5(2):118–22.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 391

Do Stress and Resilience among

Undergraduate Nursing Students Exist?

Priscilla Roselyn Sam1, Premila Lee2

1Professor, 2Professor, College of Nursing, Christian Medical College & Hospital, Vellore

Abstract
Nursing students face developmental challenges as all other college students do and in addition experience
unique stress due to exposure to clinical area that intensifies stress. These stressors can either contribute
negatively and cause psychological harm or make them resilient. The aim of this study was to assess
perceived stress and resilience levels of nursing students. There were 700 undergraduate nursing students
studying in the college of whom 620 participants who gave their consent and fulfilled the sampling criteria
were taken for the study. Perceived stress and the resilience scales were self administered to collect data
from the study participants. The data obtained was analysed using both descriptive and inferential statistics.
Study of perceived stress showed that 45.7% of them had severe stress. Study on resilience showed that 55%
of them had low resilience. The study revealed a significant weak negative correlation (r = -0.236, p = <
0.001) between perceived stress and resilience. These findings suggest that resilience measures be adapted
and made an intrinsic part of the educational program. This would give the students the needed strength and
endurance to face the profession with confidence.

Keywords: Perceived stress, resilience, education, profession, undergraduate nursing students.

Introduction stressors are due to procedures that they perform on

patients that can harm them, realities of life like death
Stress is a strain when you are faced with a demand
and dying etc. The chaotic nature of health care itself
that is either challenging or threatening. All individuals
coupled with these can have a cumulative effect on the
at all phases of life are exposed to stress and face varied
psychological wellbeing of students.2,3,4. Unwarranted
challenges. But the most challenging period in one’s life
stress can be detrimental and can interfere even with
has been identified to be the adolescent and early adult
academic performances and therefore investigating
period. According to research evidence students are
nursing students specifically in this set up can provide
stressed because of the crucial decisions that they are
contextual understanding of stress among them.
called to make on career and various other stressors that
arise from academics, finances, lack of time management On the other hand it is believed and acknowledged
skills, unfamiliar environment, amount of work, student that there are those who also enjoy their work and find
and teacher interaction etc.1 it satisfying despite stress and is said to have an element
called resilience5,6,7. Psychologists explain this resilience
Nursing students too are called to face these
to be the ability to keep bouncing back each time one is
stressors and in addition clinical stressors. These clinical
faced with stress. Study of resilience revealed that it is not
an inherent quality but is developed over time when faced
with challenges. Knowing resilience to be an essential
quality that can buffer stress, help must be offered to
Corresponding Author: develop positive emotions and coping strategies among
Priscilla Roselyn Sam nursing trainees which are very vital for professional
Professor, College of Nursing, CMC, Vellore growth.8 This would certainly boost students general
email: [email protected] health and wellbeing, as it has the ability to nullify the
392 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
effects of stress and promote adaptation. This would also (0=Never, 1=Almost never, 2=Sometimes, 3=Fairly
help in the future sustain ability of nurses in healthcare. often, 4=Very often). There are 4 items on the scale
that are worded positively. The remaining ten items are
Further stress and resilience of nursing students worded negatively and reverse scoring was done for
were thought to have a relationship with each other them. Interpretation of the scores of the perceived stress
which showed that individuals who are highly resilient scale was done by calculating the median. Those above
are less stressed than those who are not so resilient. This the median was considered as high level of stress and
suggests that the impact of stressors is based on how it median below it as low level of stress.10
is perceived .Therefore the present study will help assess
stress and resilience.9 Resilience Scale: Resilience scale is a standardised
scale that was used to measure resilience. It is a 25 item
Objectives: response scale that measures the degree of individual
• To assess perceived stress and resilience in resilience which is considered a positive personality. All
undergraduate nursing students responses are scored on a seven point rating scale that
ranges from one(disagree) to seven (agree). All responses
• To determine relationship between stress and
are worded positively. Possible scores ranges from 25
resilience in undergraduate nursing students
to 175. According to the author of the instrument those
• To associate stress and resilience of undergraduate who scored 130 or lower were considered to have low
nursing students with selected demographic resilience and those with 160 and above were grouped
variables to have high resilience. Those who scored between the
range of 130 to 160 were considered to have medium
Method resilience. 9
Design and Sampling: The study was conducted
Data Collection Procedure: The investigator met
in a college of nursing that was attached for clinical
the participants class wise. The purpose of the study was
experience to a multi-speciality tertiary care centre
informed to the participants and a written consent was
in South India. A quantitative approach with a cross
obtained from them. Those who fulfilled the sampling
sectional design was used to assess stress and resilience
criteria were given self administered scales to assess
among undergraduate nursing students. The population
both perceived stress and resilience. The time taken to
consisted of 700 undergraduate nursing students
complete these questionnaires was about 15- 20 minutes.
studying in this college. Those who belonged to the
Ethical clearance was obtained from the institution
baccalaureate program were 400 and diploma program
research committee. The participants were assured that
were 300. About 620 undergraduate nursing students
the information given would be kept strictly confidential
who consented to participate and fulfilled the sampling
and used only for the study purpose.
criteria were selected for the study.

Instruments: The instruments used for the study Results and Discussion
included demographic proforma, perceived stress and The study of the demographics revealed that
resilience scale. majority of the study participants were in the age group
of 20 – 22 years (65%). These findings are found to be
Demographic Proforma: It consisted of age,
consistent with the findings of the study done by on age
gender, marital status, religion, type of family, type of
(66.7 %) that was done on nursing students in Ghana.
community, medium of instruction at school, board of
Gender distribution of females were high as 88% as
education completed, facademic school final exam and,
nursing predominantly consists of female population.
current year of study, socio-economic status and co-
About 92% were single and 74% were Christians who
morbidities if present.
hailed from nuclear families (84%). About half of them
Perceived Stress Scale: Perceived stress scale (57%) were from urban community. Approximately
(PSS) was used to measure stress. Participants were 74% had English as the medium of instruction and about
asked to circle how often they felt or thought a certain 62% of them were educated in state board. The study
way. The scale has 14 items with a 5 point rating scale also showed that 88% were from middle class families.11
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 393
The current study reveals that those who had high
stress amounted to 45.7% as given in figure one. These
findings are congruent with similar studies done among
nursing students who showed high levels of stress.12,13
This is true as they face both academic and clinical
challenges during their study.

Figure 1: Perceived stress of the nursing students

Figure 2: Resilience in nursing students

The present study of the undergraduate nursing significant association between stress and resilience
students showed that only 1.5% of the nursing students scores and the selected variables. These findings are
had high resilience as presented in figure two. This consistent with similar studies done on stress and
contradicts the study done by others who reported stressors in nursing students. It shows that immaterial of
that 50% of the students had moderate to high levels the students background based on various demographics
of resiliency. This is true as cultural differences exist they are more or less similar when it comes to enduring
among nursing students in the Indian context, where stress and developing resilience.17, 18
they are generally more timid and lack the needed coping
strategies to encounter stress faced by them.14 Conclusion
Further analysis demonstrates that there is a This study informs that stress is high and the
significant negative relationship that exists between fundamental element to counteract this stress called
stress and resilience (r = -0.236, P = < 0.001). This resilience is low. Although some amount of stress is
suggests that as stress goes higher resilience becomes necessary to perform daily tasks, when present in high
lower and vice versa and thereby influence each other. amounts raises a concern. Knowing resilience being the
This is congruent with a similar study reported in the key indicator for counteracting stress and protects the
literature.15,16 From this it is evident that resilience wellbeing of the students, there exists a huge need for
mediates perceived stress so that when students are it to be developed. Help can be offered to students to
all faced with the basic level of stress, the individuals develop their own tool kit of strategies to cope. They
protective factors determine whether the individual should be taught to have positive self talk about the
perceives the situation as stressful or not. On the other value they bring, making healthy lifestyle choices,
hand perhaps the individuals perception of stress having adequate rest, intake of nutritious food, exercise
mediates their resilience when the individual does not and play. Educators have a great responsibility to make
perceive situation as stressful and makes them resilient. them more resilient to face stress. They ought to make
them more competent academically and clinically such
Current findings also indicate that there is no that they face the future with confidence.
394 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Conflict of Interest: None 7. Mealer M. The presence of resilience is associated
with a healthier psychological profile in intensive
Source of Fund: Self care unit (ICU) nurses: Results of a national survey.
Ethical Consideration: The study was conducted International Journal of Nursing studies. 2007; 49,
after approval by the college of nursing research 292 – 299.
committee. Permission of the dean was obtained before 8. Bergemann CS, Bisconti L, Wallace KA. Role of
proceeding with the study. A written consent was psychological resilience and positive emotions in
obtained from all the participants, after informing them stress process. 2006
about the following: 9. Wagnild G, Young H. Development & psychometric
evaluation of the resilience scale. Journal of nursing
• Purpose of the study
measurement 1993; 165 – 178.
• Voluntary participation of the students 10. Cohen S, Kamarck, Mermelstein. A global measure
• Benefits of perceived stress, Journal of health Society and
behaviors 1983; 24; 385-396 .
• Maintenance of confidentiality.
11. Lauresse S, Yvonne, A.. Stress management and
References resilience in nursing students. European journal
of Research and reflection in educational sciences
1. Agolla JE, Ongori H. An assessment of academic
2015; Volume: 3; No. 2
stress among undergraduate students: The case of
university of Botswana. Educational research and 12. Bam B, Oppong GA. Ibitoye MB. Stress and
review 2012; 4 (2); 63 – 70. coping mechanism of nursing students during
clinical practice in Ghana. Journal of Science and
2. Shirey MR. Stress and coping in nurse managers:
Technology 2014; volume 34; No:2;55-59
two decades of research. Nursing Economics 2006;
24 (4); 193-211. 13. Viji P, Amrutha S, Dina K, Thomas, Pritty MK,
Sumaida B, VijayapuraM, (2013); 19 -23.
3. Shah S, Hasan S, Malik C. Sources and severity of
stress among medical undergraduates in a Pakistani 14. Ayman M, Hamdan M, Saleh N, Azzeghaiby,
medical school, Medical Education (2010); 10 IbrahimN, Alzoghaib T, AlB, Omayah S, Nassar,
Abeer, M, Shaheen. Correlates of Resilience among
4. Misra R, Castillo L. Academic stress among
University Students. American Journal of Nursing
college students: Comparison of american and
Research, 2014;2 (4), 74-79.
international students. International Journal of
stress management. 2004; 11(2); 132 – 148 15. Petrie. The relationship between perceived stress
and resilience among adolescents with cystic
5. Stalker CA, Mandell D, Frensch KM, Harvey
fibrosis. 2010.
C, Wright M. Child welfare workers who are
exhausted yet satisfied with their jobs: how do they 16. Frigborg O, Hjemdal, O, Rosennings JH,
do it ? Child and family Social work. 2007; 12 (2); Martinussen M, Aslaksen PM & Flatten MA.
182 – 191. Resilience as a moderator of pain and stress. Journal
of psychosomatic research, 2006; 61 (2); 213 – 219.
6. Collins S. Statutory social workers: stress, job
satisfaction, coping, social support and individual 17. Tully A. Stress, sources of stress & ways of coping
differences. British Journal of Social Work. 2008; among psychiatry students. 2004; 11: 43-47
38 (6); 1173–93.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 1

Marriage Trajectories among Patient with Metal Health

Problem

Chittaranjan Subudhi1, Ramakrishna Biswal2, Padmanaban Srinivasan3

1AssistantProfessor, Department of Social Work, Central University of Tamil Nadu, India, 2Assistant Professor,
Department of Humanities and Social Sciences, National Institute of Technology Rourkela, India,
3Associate Professor, Department of Education, Central University of Tamil Nadu, India

Abstract
Objective: To explore effect of mental illness on marriage and marital life among the tribal Patient with
Mental Illness (PMI).

Method: To achieve the objective of the study, qualitative method with multiple case study has been adopted.

Population and Sampling Technique: Population is a tribal Person with Mental Illness (PMI) and Purposive
Sampling Technique is used.

Findings: The analysis has been categories into two broad areas, that is, effects of mental illness among
married patient and unmarried patient with mental illness. Results indicate that, there is an adverse effect of
mental illness on marriage and marital life among the patient with mental illness.

Conclusion: Marriage and mental health problems are closely related and multi-faced one. The evidence
shows that, there is an adverse effect of mental illness on marriage and marital life among the tribal patient
with mental illness.

Keywords: Marriage, Mental Illness, Marriage Trajectories, Marital Life, Tribal

Introduction in achieving the personality maturation through psycho-

social status.
Everybody will have aspirations in their life.
Marriage is one among them. In general, Marriage is a If any one of the spouse becomes mentally ill, there
union between a man and a woman for the rest of the life. comes the problem in the union. If the problem is more,
They are united not only physically, but psychologically, then the gap between them will be more. Sometimes it
and socially too. The united souls now form a family. may result in break of the union also. There is an adverse
Marriage is considered as a sacred religious obligation effect of mental illness on the marriage and marital life
between heterosexuals that admits individual into a among the patient with mental health problems3-5. Even
family life1. It gives more balanced to individual’s there is positive association between mental illness
lives through establishing an enduring and continuing and subsequent divorce also4. Different legislatures on
bond between husband and wife. It helps in solving and marriage also have certain constraints on the marriage
reducing emotional, psychological, economical and other of person having mental health problems. In Hindu
problems2. So marriage is not only gratifying the sexual Marriage and Special Marriage Acts, marriage became
needs of the individuals but also helps the individuals voidable in the presence of severe mental illness6.
Because the impact of illness will decrease the social
Corresponding Author: abilities from successful marital life. Marital discord is
Chittaranjan Subudhi one of the consequences among people having chronic
Assistant Professor, Department of Social Work, mental health problems7. Behere, Rao and Verma (2011)
Central University of Tamil Nadu, India, have mentioned that, mental illness and problems in
Email: [email protected] marriage are closely associated. Even patient with
 2 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

mental illness is considered as a burden to the spouse8. sampling’ with inclusion and exclusion criteria.
Inclusion Criteria: Following are included: Gender
When compared to men, if the woman in a family is of the sample is both male and female; the age group
educated, then the family will blossom. The same is in is from 18 and above who is diagnosed with any form
the case of illness. When compared to men, if the women of mental disorder as per International Classification of
in a family fell in ill, then the family will be affected Disease (ICD) 10; Currently admission in the hospital
more. Among the spouses, if the women are affected, (In-door patients). Exclusion Criteria: Following are
then the trouble is more. The condition for married excluded: Outdoor patients (OPD); Refused to give the
women having mental illness is very worst as they are information; Mental retarded persons.
sent back to their natal homes, divorced, or in the form
of abandoned9-10. In Indian society, the expectation of a The key subject of the study is tribal person with
married woman is different from natal house to in-laws mental illness. Since the subject is affected with mental
house10. In Indian marriage system, the severity notion illness, their cognitive ability may be reduced and the
of suffering is more when women married a mentally ill information provided by the patient may be incomplete.
man than men married a mentally ill women10. Studies In order to get the in-depth information, it is required to
show that, constant neurotic behaviour of the patient collect the information from the family members or care
creates a marital tension to the spouse and increase the givers also.
alienation among them11-12.
Data Collection procedure: Data sources for the
Mental illness also reduces the probability of study include the interviews with the tribal patient with
getting married. Pre-existing mental illness reduce the mental illness. Data collection for this study consisted
chance of marriage along with in delaying the marriage of face to face structured interviews with fifty patients
process also4, 9. Low marital rates have been reported and their family members / care givers. The researcher
among the patient with mental health problems from conducted interviews between June 2015 and May 2016.
the several studies9. In case of schizophrenia, patients The mean duration of personal interview is 56.74 minutes
are more likely to be staying alone or unmarried7.This with range of 22 minutes to 150 minutes. A specially
piece of research tries and find how mental is related to designed interview schedule was used to collect the
prosperity of marriage and the married life. information. The interview process has conducted with
one case in several times as per the availability of the
Objective of the Study: The present research respondent, the family members / care givers, time and
explores the impact of mental illness on marriage and their mood.
marital life among the tribal patient with mental illness.
Ethical Consideration and confidentiality:
Materials and Method The proposed study has been approved by the Ethical
Study Design: The study is based on qualitative Committee Review Board (ECRB) of Ispat General
design with multiple case study method. Qualitative Hospital (IGH), Rourkela, India. All the information
methods are more suitable for understanding the including personal identifications shared by the
phenomenon of mental illness, as it focuses on the respondents have been kept confidential; only the average
experience of the subjects. information has been used for the research purpose.

Study Area: The purposed study has been carried Data Analysis and Interpretation
out in the institutional setup. The researcher has selected Socio-demographic details of the responded:
the Department of Psychiatry, Ispat General Hospital The representation of male and female proportion is 28
(IGH), Rourkela, Odisha. IGH is a multi-speciality (56%) and 22 (44%) respectively. The age of the patients
hospital located in the sector 19 of Rourkela city. The with mental illness ranged from 18-72 with the mean
hospital was setup and administered Rourkela steel age of the sampling 36.34. Majority of the sample (56%)
plant. belongs to the age group of 21-40. 64% respondents
Study Population and Sampling: The present with mental illness are married while 36% respondents
study has fifty cases of tribal people with mental illness. are unmarried. The unmarried age ranges from 18 to 40.
The sampling procedure had followed the ‘purposive
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 3

Impact of Illness on marriage and marital life of leaving alcohol and it has its subsequent negative effects
the patient with mental illness to the family and the children. In that case wife is staying
separately for the better future of the children with a
The impact of mental illness on marriage and peaceful and dignified life.
marital life among the patient with mental illness has
been categories into two broad areas i.e. effects of Impact of Illness on Marriage among Unmarried
mental illness after marriage and before marriage. As Patient: Data representing on impact of illness on
a result, the respondents are divided into two broad marriage among unmarried patient shows that, 8%
categories: married (64%) and unmarried (36%). The not attended marriage age, another 8% responded not
married category again divided into three types, namely: to marry, yet another 8% reported that they wait till
normal, disturbances, and divorce or separated. Likewise recovery of the illness, and worry about the marriage
unmarried category has divided into four types: not attend represents for 16% sampled population.
the marriage age, not to marry, wait till the recovery of
the illness, and worry about the marriage. Not to marry: Three important reasons found
by the researchers for ‘not to marry’. The family members
Impact of illness on Marital Life: Data representing of the PMI don’t want to spoil another (partner) life.
on impact of illness on marital life shows that, out of Sometimes, it is believed by the patient and the family
64% married PMI, 42% represents a normal marital members that, the patient may suffer after marriage, if
life without any marital discord, 12% respondents have the partner may not able to cope with the patient. In
family discord and rest 8 % are divorced or staying some cases, though family members are interested for
separate. marriage but the patient don’t want to go for marriage
because s/he doesn’t want loose the freedom of another
Normal: In most of the married patient those have human being.
reached their adult hood or/and late adult hood stage,
they don’t have marital discord. They are trying to cope Worry about the marriage: For most of the male
up with the situation and manage the illness along with cases where age is not reaching the marriage age or
their family members also. And in the rest of the case, nearly about to marriage age, the family members are
where the partner is cooperative they are also maintain ready to wait till recovery of the illness. But in the
the balanced marital life and try to control the illness. case of female attending the marriage age, it is creating
In case of married female, where the husband and other headache to the family members.
in-laws members are cooperative, in that case family
life going smooth and normal. Family support is the Discussion
main reason to maintain normal life for the patient with Evidence from the data shows, there is high impact
mental illness. of mental illness on marriage and marital life among the
Disturbances: The researchers found below PMI. This finding is supported by the findings of the
mentioned reasons for the marital discord among existing study13.The present research also shows that, in
PMI. In case where the partner is not supporting or adulthood and in late adult hood, the marital life is normal.
not understanding the situation about the patient, the Research conducted by Miller et al.14 shows that, mental
disturbances have started. The interference of the in- disorders are positively associated with the marital
laws members or not getting support from them is disputes but for later age populations it is negatively
also creating marital discord among the female patient associated. Another research which supports the same is
and husband. If the male person is consumes alcohol by Oltmanns and Balsis (2011) which states that Well-
during the medication is the main reason for the family being in long-term marriages seems to be influenced by
disturbances. The researchers also found some other factors that are somewhat different from those factors
reasons like lack of proper sexual relationship, dubious that have been identified in younger couples15. Mental
attitude towards the partner, create the disturbances. illness is a risk factor for both marriage and marital life.
These are the causes are the symptoms or side effects of Nambi (2005)9 has mentioned that, alcohol addict is one
the illness or psychiatric medicines. of the prominent cause of family disturbance among
the substance user’s patients. So, high rate of divorces
Divorce/separated: The main reason for the and family disturbances are virtually inevitable among
divorce or separated is, where the patient (male) is not families with alcohol addicts due to high incidence of
 4 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

domestic violence16. 2011; 124(6), 474-486.

5. Thara, R., & Srinivasan, T. N. Outcome of marriage
16% of the samples are worried about their change
in schizophrenia. Social psychiatry and psychiatric
of getting married. This report is supported by the two
epidemiology. 1997; 32(7), 416-420.
findings. a. Pre-existing mental illness having worsen
condition for marriage and reduce the chance of marriage 6. Sharma, I., Reddy, K. R., & Kamath, R. M.
(Behere et al., 2011; Nambi, 2005).b. Premarital mental Marriage, mental illness and law. Indian journal of
health problems are associated with lower likelihood of psychiatry. 2015; 57(Suppl 2), S339.
ever marrying (Breslau et al., 2011). 7. Rao, T. S. S., Nambi, S., & Chandrashekhar, H.
Marriage, mental health and Indian legislation.
Limitations: The study has focused only limited Indian journal of psychiatry. 2009 51, 113-128.
sample size due to time constraint.
8. Behere, P. B., Rao, S. T., & Verma, K. (2011).
Conclusion Effect of marriage on pre-existing psychoses.
Indian journal of psychiatry. 2011; 53(4), 287.
The authors conclude that, marriage and mental
9. Nambi, S. Marriage, mental health and the Indian
health problems are closely related and multi-faced one.
legislation. Indian journal of psychiatry. 2005;
The evidence shows that, there is an adverse effect of
47(1), 3.
mental illness on marriage and marital life among the
tribal patient with mental illness. Mental health problems 10. Srivastava, A. Marriage as a perceived panacea
are working as conflagration in marriage and marital life to mental illness in India: Reality check. Indian
in the Indian marriage system. So, further extensive and journal of psychiatry. 2013; 55(Suppl 2), S239.
large sample empirical studies are to be undertaken to 11. Ovenstone, I. M. The development of neurosis in
understand the severity of the problem. the wives of neurotic men: Part II: Marital role
functions and marital tension. The British journal
Conflict of Interest: No of psychiatry. 1973a; 122(571), 711-717.
Source of Funding: The first author is enrolled in 12. Ovenstone, I. M. The Development of Neurosis in
PhD programme at the National Institute of Technology the Wives of Neurotic Men Part I. Symptomatology
Rourkela, Odisha, India and Personality. The British journal of psychiatry.
1973b; 122(566), 35-45.
Ethical Clearance: Yes, Ethical Committee 13. Barrett, A. E. Marital trajectories and mental
Review Board (ECRB) of Ispat General Hospital (IGH), health. Journal of health and social behavior. 2000;
Rourkela, Odisha 451-464.

References 14. Miller, R. B., Nunes, N. A., Bean, R. A., Day, R.

D., Falceto, O. G., Hollist, C. S., & Fernandes, C.
1. Abraham, M. F. Contemporary Sociology: An L. Marital problems and marital satisfaction among
introduction to concepts and theories. Oxford Brazilian couples. The American Journal of Family
University Press; 2015 Therapy, 2014; 42(2), 153-166.
2. Dasgupta, S. and Saha, P. An introduction to 15. Oltmanns, T. F., & Balsis, S. Personality disorders
sociology. Pearson Publication; 2012 in later life: Questions about the measurement,
3. Agarwal, A. K. Pattern of marital disharmonies. course, and impact of disorders. Annual review of
Indian journal of psychiatry. 1971; 13:185-193. clinical psychology. 2011; 7, 321-349.
4. Breslau, J., Miller, E., Jin, R., Sampson, N. A., 16. Batra, L., & Gautam, S. Psychiatric morbidity and
Alonso, J., Andrade, L. H., ...& Fukao, A. A personality profile in divorce seeking couples.
multinational study of mental disorders, marriage, Indian journal of psychiatry, 1995; 37(4), 179.
and divorce. Acta Psychiatrica Scandinavica.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 5

Revalence of Goiter and its Association with Consumption

of Iodized Salt among School Children, in a Rural Area,
Tamilnadu

D.Jayashri1, B.Charumathi1, Timsi Jain2, Gomathy Parasuraman3, Ruma Dutta3

1
Post Graduate, 2Professor and Head, 3Associate Professor, Department of Community Medicine, Saveetha
Medical College Hospital, Thandalam, Kanchipuram District

Abstract
Background: Iodine Deficiency Disorders is a significant public health problem all over the world.Iodine
is essential element for thyroid function, necessary for normal growth, development and functioning of
brain and body. Objectives:To estimate the prevalence of goiter among school children and to assess
the prevalence of useof iodized salt. Material and Methods: A Cross sectional study conducted among
Children between 6-12 years of ageinMappedu area.A pre-tested questionnaire, Rapid test kit to find iodine
content of salt and clinical examination to assess goitre was done for the study subjects.The sample size
calculated was120.Dataanalysis:Proportions and chi-square was used for analysis. Results: 65% were
using iodized salt and remaining 35% were using non-iodised salt.The prevalence of goiter was found to be
17(14.2%).Conclusion:One-third of children and their family were not consuming adequately iodized salt.
The consumption of iodized salt is still less in the community and Iodine Deficiency Disorders continue to
be a public health problem.

Key words: IDD, Goiter, Iodized Salt, Rapid test kit.

Introduction Iodine deficiency disorders are estimated to result in

loss of 2.5 million disability adjusted life years (DALYs)
Iodine Deficiency Disorders is known to be a
(0.2% of total globally).3In India it is estimated that more
significant public health problem all over the world.
than 71 million individuals suffer from Iodine Deficiency
Iodine is essential element for thyroid function, necessary
Disorder, while another 200 million people stay in iodine
for normal growth, development and functioning of brain
deficient areas.4The Iodine Deficiency Disorder control
and body.Iodine deficiency is known to cause endemic
goal in India was to reduce the prevalence of IDD below
goitre..1
10% in the entire country by 2012.5
Salt iodization programs is being implemented in
In Tamil Nadu, the IDD control cell was established
many countries of the world for more than five decades
with Central Government assistance and is functioning
,currently only two-thirds of the global population (71%)
since 1st July 1994.Goiter surveys and resurveys of all
is estimated to be covered by iodized salt, while the rest
the districts are being carried out periodically since 1991.
(31%) of the world population have insufficient iodine
According to National Family Health Survey (NFHS)-4
intakes, with the most affected WHO regions being
in Tamil Nadu proportions of households using iodized
South-East Asia and Europe.2
salt is 82.8%.TotalGoitre rate is reported as 13.5% in
Tamil Nadu.6

Corresponding Author: Although the importance of iodized salt and its usage
Dr. D. Jayashri, has increased in the community,Iodine deficiency poses
Post Graduate, Department Of Community Medicine, a threat to health, wellbeing and economic productivity
Saveetha Medical College. Email id: jayashri49@ of the community.Progress toward the elimination of
gmail.com, Ph no:9943080711 Iodine Deficiency Disorder can only be demonstrated if
 6 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

it is measured. the salt sample,if the colourchanged from white to blue/

purple, indicated the presence of iodine to threshold of
Monitoring iodine levels of salt and iodine status of 15ppm.
population are the two important components of Iodine
Deficiency Disorder program monitoring, hence the • For alkaline salt samples or salt with high
study has been conducted. moisture content, one drop of recheck solution followed
by starch solution was used to test the presence of iodine
Objectives in salt.
1.To estimate the prevalence of goiter among school Clinical Examination:
children in rural area.
Enlargement of thyroid gland was assessed and
2.To assess the prevalence of use of iodized salt presence of goiter was graded as per WHO guidelines. 6,11
among them .
• Grade 0: Thyroid gland was neither palpable
Methodology nor visible/ no goiter.
A cross sectional study was conducted in Primary • Grade 1: A mass in the neck that is consistent
School,Mappedu between May 2018 – July 2018. with an enlarged thyroid that is palpable but not visible
Children between 6-12 years of age were selected by when the neck is in normal position. The mass moves
using Simple Random Sampling method. The sample upwards with deglutition/goitre palpable not visible.
size of 120 was calculated by using 76.2% of households
residing in rural area were using iodized salt.7Using a • Grade2: A swelling in the neck that is visible
pre-tested questionnaire,details regarding edible salt when the neck is in normal position and consistent with
used within the family was obtained. Children were enlarged thyroid when the neck is palpated/goiter visible
asked to bring 1-2 teaspoon of salt which is used for and palpable.
cooking purpose at their home in a sealed plastic bag
Operational Definition For Iodised Salt:
and Iodine content in salt wasestimated using Rapid Test
Kit. Iodised salt is defined as one which contains iodine
content of ≥ 15ppm at the household level as determined
Children were clinically examined for the presence
by Rapid Test Kit.12,13,14
of enlargement of thyroid gland.Children who were
not present in the school at the time of data collection
Results
and those who are not willing to participate were
excluded from the study. Data was entered in MS Excel. 120 children participated in the study, they belonged
Proportions and chi-square were used for data analysis. to 6-12 years age group mean age was found to be 9.14
years. Majority of them (50.8%) were using powdered
Salt Sample Collection & Testing: form of salt. 80% of the study population were storing
One teaspoon of salt was obtained from each salt away from the fire.More than 90% of respondents
household for testing purposes.Rapid test kit was used have kept the salt in closed container.Majority of the
to estimate the iodine content of salt. 8,9,10 households have bought packed type of salt 88.3% while
11.7% were found to purchase unpacked type of salt.
• One to two drops of the test solution was put on (Table-1)

Table 1: Background Characteristics of Study Subjects (N=120)

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 7

Background Characteristics of the study subjects (N = 120)

S.no Characteristics (N) (%)

1 AGE

6 years 18 15.0

7 years 15 12.5

8 years 14 11.7

9 years 16 13.3

10 years 18 15.0

11 years 20 16.7

12 years 19 15.8

2 FORM OF SALT

Powdered 61 50.8

Crystalline 59 49.2

3 PLACE OF KEEPING THE SALT

Kept near fire 24 20.0

Kept away from fire 96 80.0

4 TYPE OF SALT BOUGHT

Packed 106 88.3

Unpacked 14 11.7

5 STORAGE OF SALT

Open container 8 6.7

Closed container 112 93.3

All the 120 children brought the salt samples from their houses. On testing the salt samples with Rapid Iodine
testing kit 65% of the samples colour was changed to blue which indicate the presence of iodine≥15ppm.(Table-2).

Table 2- Distribution of iodized salt among study participants.

Iodine Content of Salt N (%)

Non-Iodized 42 35.0

Iodized 78 65.0

Total 120 100.0

 8 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Among the salt samples which the participants told children, 15(12.5%) of the children were found to have
they buy packed salt 70.8% were found to be iodised. grade 1 and 2 children (1.7%) were found to have Grade
While only 21.5% of unpacked salt was iodised. This 2 Goiter.(Table-5).
difference was found to be statistically significant.
(Table-3) TABLE 5- DISTRIBUTION OF
GOITREAMONG THE PARTICIPANTS
Table 3- Association between iodine contentof
salt and types of salt.
GRADING
N (%)
OF GOITER
Non- TOTAL
Type of Iodized
Iodized
salt (%)
(%) G0 103 85.8

Packed 75(70.8) 31(29.2) 106 G1 15 12.5

G2 2 1.7
Unpacked 3(21.5) 11(78.5) 14
Among 17 children who were clinically diagnosed to
have goiter, 16 (94.2%) were not consuming iodised salt
while only 25.2% children without any signs of clinical
Total 78(100) 42(100) 120
goiter were not consuming iodised salt. The difference
was found to statistically highly significant.(Table-6)
*Chi square:13.225,P value: 0.000 *P<0.05 is
considered as significant. TABLE 6- ASSOCIATION BETWEEN
IODIZED SALT AND GOITER AMONG STUDY
In the present study 61 salt samples were in PARTICIPANTS.
powdered form and remaining 59 were crystalline.
70.5% of powdered salt was found to be iodised while Goitre Goitre
59.3% of the crystalline salt was iodised.This difference Iodine Total
Present Absent
Content
was not found to be statistically significant.(Table-4) (%) (%)

TABLE 4- ASSOCIATION BETWEEN IODINE

CONTENTOF SALT AND FORM OF SALT. Non-Iodized 16(94.2%) 26(25.2%) 42

TOTAL
Form of salt Iodized(%) Non-Iodized (%)
Iodized 1(5.8%) 77(74.8%) 78

Powdered 43(70.5) 18(29.5) 61

Total 17(100%) 103(100%) 120
Crystalline 35(59.3) 24(40.7) 59
*Chi square:30.42,P value : 0.000 *P<0.05 is considered
Total 78(100) 42(100) 120 as significant OR= 47.

Chi square: 1.644,P value :0.199. *P<0.05 is considered Discussion

as significant
This study was carried out to assess the utilization
Clinical examination was done among school of iodized salt in the rural community and prevalence
children, the presence of enlargement of thyroid was of Clinical goiter.In the present study only 65% of the
checked and grading was done as per WHO guidelines. participants were consuming iodized salt which was less
Goitre was diagnosed in 17 children. The prevalence than reported by NFHS 4 in rural Tamil Nadu 76.2%.7
of goiter was found to be 17(14.2%). Among those 17
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 9

In our study 49.2% of the participants were using Conflict of Interest:nil

crystalline form of salt and 11.7% were getting unpacked
salt. Source of Funding:nil

The prevalence of goiter was found to be 14.2% in Ethical Clearance: Ethical approval was obtained
our study which was found to be similar to the results from the Institutional Review Board (IRB) and
of national level survey data conducted by ICMR Institutional Ethics committee. Written informed consent
where the goiter prevalence was 14.1% (5-14 years age was obtained from the parents of the study participants
group).15Chandrakant et al reported 13.5% of school and information sheet regarding the study was given to
children showed enlargement of thyroid gland.6 Zargar all the participants.
et al reported a higher prevalence of goiter30.2 % in
children less than 6 years old and 50.6 % in children
References
greater than 12 years old in Kashmir.15 1. J. Larry Jameson, Leslie J. De Groot. IDD. In: J.
Larry Jameson, Leslie J. De Groot, eds. De Groot
In the present study all except 1 child who were and Jameson Endocrinology. 4 ed. Philadelphia:
diagnosed to have clinical Goiter were not consuming Saunders; 2008: 1529.
iodised salt. Odd’s Ratio was found to be 47, this shows
2. UNICEF. The State of the World’s Children.
all those who were not consuming iodised salt were at
Adolescence: An Age of Opportunity. New York:
47 times greater risk of getting Goiter. Goiter is just
United Nations Children’s Fund; 2011. Available
one of the clinical manifestation of Iodine Deficiency
from URL:https://www.unicef.org/adolescence/
Disorders,IDDs can also manifest as mental retardation,
files/SOWC_2011_Main_Report_EN_02092011.
still birth, abortion, deafness, mutism, squint and
pdf. Accessed on 26March 2019.
neuromotor defects.16
3. World health Organization. The world health
More number of packed and powdered salt samples report: Reducing risks,promoting healthy life.
were found to be iodized in comparison to unpacked Geneva:World health organization,2002 Available
and crystalline salt. Indian government has issued the from URL: https://www.who.int/whr/2002/en/.
notification on banning the sale of non-iodised salt for Accessed on 26 March 2019.
direct human consumption in the country in May 2006 4. Revised policy guidelines on National Iodine
under the Prevention of Food Adulteration Act 1954.17 deficiency disorders control programme: IDD
In the present study one third of the families are found and nutrition cell; Ministry of Health and
to consuming non-iodised salt. Therefore Government Family welfare,Oct-2006.Available from URL:
should take necessary actions to check the sale of http://pbhealth.gov.in/Revised%20Policy%20
unpacked salt and non-iodised crystalline salt in the Guidelines%20Govt.%20of%20India.pdf.
market. Accessed on 02 March 2019.

Conclusion 5. National Rural Health Mission IDD & Nutrition

Cell. Revised Policy Guidelines On National
One-third of children and their family were not Iodine Deficiency Disorders Control Programme.
consuming adequately iodized salt. National Iodine New Delhi: Directorate General of Health
Deficiency DisordersControl Programmewas startedfifty Services Ministry of Health & Family Welfare,
years back, but the consumption of iodized salt is still less Government of India; 2006. Available from: http://
and Iodine Deficiency Disorders continue to be a public www.whoindia.org/LinkFiles/Nutrition_Revised_
health problem. Hence health education regarding Iodine Policy_Guidelines_On_NIDDCP.pdf, Accessed on
deficiency disorders and adequate utilization of iodized 02 March 2019.
salt is the need of the hour. Strict actionsshould be taken
6. Chandrakant S, Pandav, P Krishnamurthy, R
on the sale of non-iodised salt to have significant impact
Sankar, KapilYadav,C.Palanivel. A Review of
on the health and well-being of the country.
Tracking Progress towards Elimination of Iodine
Limitation: The Urinary iodine excretion level was Deficiency Disorders in Tamilnadu, India. Indian
not estimated in this study. Journal of Public Health. 2010;54(3):120-125
7. NationalFamilyHealthsurvey-4(2015-
 10 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

2016),TamilnaduFactsheet. Available from Bhanot;2017,p.646-704.

URL:www.rchiips.org/nfhs/factsheet_nfhs-4. 13. United Nations Children’s Fund. Sustainable
shtml, Accessed on 10March 2019 Elimination of Iodine Deficiency, Progress since
8. Rupali Roy, Manish Chaturvedi, DeepikaAgrawal, the 1990 World Summit for Children; May,
HaroonAli,”Household use of iodized salt in rural 2008. Available from: URL:http://www.unicef.
area”,Journal of Family Medicine and Primary org/iran/Sustainable_Elimination_of_iodine_
Care,2016;5(1):77–81 Deficiency_053008%281%29.pdf. Accessed on 26
9. WHO/NHD.Assessment of iodine deficiency March 2019.
disorders and moitoring their elimination:Aguide 14. Chandrakant S, Pandav, P Krishnamurthy, R
for programmemanagers.3rded.2007,Available Sankar, KapilYadav,C.Palanivel. A Review of
from URL:https://apps.who.int/iris/bitstream/ Tracking Progress towards Elimination of Iodine
handle/10665/43781/9789241595827_ Deficiency Disorders in Tamilnadu, India. Indian
eng. pdf;jsessionid= 19A02512D332B Journal of Public Health 2010;54(3):120-125.
971398645CCC4FEFB5D? sequence=1, Accessed 15. Zargar AH, Shah JA, Laway BA, Mir MM.
on 26 March 2019. Prevalence of Goiter among school children in
10. Government of India. Policy guidelines on Kashmir valley.Indian Pediatrics 1997;64(2):225-
National Iodine Deficiency Disorders Control 30.
Programme, IDD and Nutrition cell, DGHS, 16. Suryakantha.Nutrition and Health.Textbook of
MOH and FW,GOVT.OF India:2006. Available Community Medicine with Recent Advances,3rd
from URL:http://pbhealth.gov.in/Revised%20 Edition: Jaypee Brothers; 2018,p.153-212.
Policy%20 Guidelines%20Govt.% 20of %20 India.
17. Revised Policy Guidelines On National Iodine
pdf.Accessed on 26 March 2019.
Deficiency Disorders Control Programme,
11. Sunderlal, Adarsh, Pankaj.Applied
revised edition –October 2006.Available from
NutritonProgrammes and Interventions.
URL:http:// pbhealth.gov.in/ Revised% 20
Textbook of Community Medicine and
Policy%20 Guidelines%20Govt.%20 of% 20
Preventive and Social Medicine,5thedition:CBS
Publications;2017,p.189-247.
India. pdf. Accessed on 26 March 2019.

12. K Park.Nutrition and Health.

Park’sTextbook of Preventive and
th
Social Medicine,24 Edition:Banarsidas
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 11

Health Care Facilities in Child Care Institutions in Delhi

Hrishika1, Rakesh Rai2

1PhD Scholar, 2Assistant Professor, Amity Institute of Social Sciences, Amity University, Noida,
Uttar-Pradesh, India

Abstract
United Nation’s Convention on the Rights of the Child (abbreviated as UNCRC) has defined a child is a
person who has not attained 18 years of age. The recent statistics shows child population in India is to be
472 million which constitutes 39% of the country’s total population [1]. India’s population of orphaned and
destitute children is projected to be 20 million [2]. Children who needs care and protection and who are
conflict with law [3] are placed in institutional care both in long term and short term care depending on the
identified need of the child. Children who are in institutional care require basic care, health services and
rehabilitation and integration programme which addresses their needs and challenges they face. As per
the standardized norms under Juvenile Justice (Care and Protection) Act 2015; the institutions offers the
basic requirement to children; which includes food, safe shelter, appropriate clothing, medical facility and
other suitable aids. The present research study is an attempt to understand the significance of the facilities
provided to children with special reference to health care facilities in Child Care Institutions in Delhi.

Keywords: Child Care Institutions, Children in Need of Care and Protection, Health, Health- facilities,
Medical-care, Medical-services

Introduction parents for their needs, growth and development. It is

believed that family holds the primary responsibility of
India is the second most crowded nation in the world
the child. Family caters all kind of physical, emotional,
and when it comes to child population it is projected that
psychological and financial needs of the child. A family
472 million are children (age of 0-18 years). It means
is usually the most important and protective environment
children represent 39% of the country’s total population
of the children (Richard Carter, 2005). The UNCRC and
(National Institute of Urban Affairs (NIUA), 2016).
the Juvenile Justice (Care and Protection of Children)
It’s been 71 years since India achieved independence
Act 2000 [3] constitutes that family unit holds primary
and as an independent nation the constant and regular
responsibility to provide them basic care and protection
efforts have been made to ensure the rights of its citizens
and in absence of familial support this responsibility is
including children but child protection have been an
of State is obliged to protect children who are deprived
undefined and unaddressed issue of the country. There
of family love and support [9]. A large number of children
is a large population of children who suffer neglect,
who are in need of care and protection and are conflict
abuse, unequal access to resources, discrimination,
with law are placed in institutional care both in long term
poverty and homelessness [6]. A number of researches
and short term care depending on the identified need of
have been taken up over a period of time to describe
the child [4]. India’s population of orphaned and destitute
the deprived condition of children living in difficult
children is projected to be 20 million [3]. When a child
circumstances in India. It is factual and so evident that
faces any difficult circumstances in family or outside
children are dependent on adults primarily on their
the family in such case the second responsibility is of
the state or government to provide them opportunity to
Corresponding Author: grow with their full potential. Juvenile Justice (Care and
Dr. Thilak Shetty Protection) Act 2015 (abbreviated as J.J Act) has made
Email ID- thilak.shettyb@manipal .edu Contact No- special provisions and emphasis of rehabilitation and
+91-9980436867, Address: Department No. 7, Manipal assimilation of children in society [5].
College of Dental Sciences, Lighthouse Hill road,
Mangalore 575001
 12 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Children in Need of Care and Protection for CNCP it includes children homes, adoption agencies
(abbreviated as CNCP): and open shelters. All types of Child Care Institutions
are adhere to mandatory registration under the act
rior to defining CNCP we need to understand who and to follow the standardized norms as mentioned in
is a child in legal terms? Article 1 of Convention on the the act [8]. If Child Care Institutions fails to meet the
Rights of the Child (abbreviated as CRC) in its definition standard norms it leads to cancelation of the registration
states a child is under the age of 18 years but also specifies and punishment. Children who are in institutional care
in different laws applicable to them or when attained needs proper rehabilitation and integration programme
majority whichever is earlier [7]. The CNCP cases of which addresses their needs and challenges they face [11].
children are defined Under the JJ Act which says: a Child Care Institutions are setup based on the objectives
child who is found in any conditions working, abused, to fulfill needs of children in institutional care. These
orphaned, abandoned, victims of sexual exploitation, at institutions provide safe environment to children, ensure
families at risk, differently abled, HIV AIDS affected, their complete rehabilitation, promote their physical
on streets, beggars, affected by disasters, physically and and mental health which aims to support overall growth
mentally abused, drug abusers or found in any difficult and development of all children including physical,
circumstances comes under the purview of CNCP cases. emotional, psychological, social and intellectual.
The Act further states that in order to deal with the cases
of CNCP the competent authority is formed which is Facilities provided in Child Care
known as Child Welfare Committee (abbreviated as Institutions:
CWC). Child welfare committee (CWC) is a bench of
members consists of a chairperson and four members i. Basic and essential care facility:
who are expertise in the area of child rights are designate
to exercise their rights in cases of CNCP. Each CNCP Basic and essential care facilities provided in
case has to produce before Child Welfare Comittee. The Child Care Institutions are endorsed to provide
committee shall takes decision in the best interest of basic requirements to all the children including safe
the child. The committee has power to restore children accommodation, age and gender appropriate clothes,
to their biological parents or guardian or any extended healthy and sufficient food, adult supervision and
family members. Child Welfare Committee also attention [10].
declares the child legally free for adoption if restoration ii. Health care facility:
and reunion is not possible in the biological family of
the child. In the cases where no family alternatives are All Child Care Institutions are mandate to take
found the custody of the child shall be given to the fit care of physical health of the children and to give them
person or institution or children home as per the action proper medical care. The heath care services given to
required to deal with cases. children includes: facilitate immunization as per their
age, monitoring of physical growth and maintenance of
Significance of Child Care Institutions (CCIs): the records, routine check ups and arranging visits of the
Child Care Institutions are widely considered as the doctors, taking children to doctors as and when needed,
best sources to provide care and protection to children giving children medicinces on time, taking care of their
who are in need difficult situations especially those diet and ensuring proper medical care.
who require long period care. According to the JJ Act iii. Educational facility:
“child care institution” means children home including
governmental or non-governmental or any particular Child Care Institutions provide formal education to
home or place of safety or specialized adoption agency all the children. Every child has right to be admitted to
and a fit facility meant for children for providing school as per his/ her age. Also bridge and tuition classes
care and protection. Children homes look after all the are provided to ensure that no child would lack behind in
developmental needs of the children and provide them education because of their past events.
physical, emotional, mental and educational support for
iv. Counseling facility for psychological needs:
their holistic development. For children in conflict with
law Child Care Institutions means observation homes, Child Care Institutions provide regular counseling
place of safety or fit facility and special homes whereas sessions to children by a trained professional psychologist
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 13

to cater to the need of psychological and mental well number of 10 interviews would be conducted from
being which aim to meet the developmental needs of Government running children homes and 10 will be
every child in institutional care. taken from NGO running home of both girls and boys.
A total number of 5 stakeholders working under heath
v. Recreational facility: care unit of the children homes were also interviewed to
Every child must get right to participate in activities understand the functioning of health care services.
which help in enhancing social and emotional skills
hence Child Care Institutions facilitate age appropriate
Findings
recreational activities which includes dance, yoga, Thematic Analysis:
music, picnics, outings, sightseeing, monuments visits,
educational visits, participation in cultural events, Health of the children: Children living in Child
festival celebrations, national and international days Care Institutions have traumatic past experiences due to
celebration, birthdays celebration all this helps in which they are found with illness like fits, skin diseases,
cultivating the child’s interest and aptitudes as well as lower immunity, low weight, malnourishment and other
provide children opportunity to explore and experience diseases at the time of the admission in children homes
[12]
new world. . Children are found to be frequently ill and have
complains of frequent fever, stomach pain, headache,
Objectives etc, due to lower immunity system and malnourishment.

The objectives of present study are- Heath care facilities in Child Care Institutions: Each
child care institutions have medical staff including a full
• To understand the significance and facilities time nurse and a visiting physician. When children are
provided to children in Child Care Institutions in Delhi. admitted in child care institutions their health needs are
• To examine the health care facilities provided taken care by the medical staffs and all the basic and
to children living in Child Care Institutions in Delhi. necessary facilities are given to them. There are regular
and part time doctors and staff nurses who monitor
Methodology regular check-up of the children. The health care team
or staff members are responsible to provide following
The present research study is an effort to analyze services to all the children:
the status of health and health care services provided
to children who are residing in Child Care Institutions • Facilitating immunization as per the age
in Delhi. Integrated research approach using both of the child,
quantitative and qualitative method is been adopted in
the present study to develop deeper perceptive of present • Monitoring of physical growth including
status of children brought up in children homes. The weight, height, head and chest circumference,
data is collected by means of self made semi structured
interview schedule. The collected data was analyzed • Maintenance of the health records and
through thematic analysis and also transferred to the individual files,
computer in software called Statistical Package for
Social Science (SPSS). • Routine check ups,
The universe of the study would be children homes • Arranging visits of the doctors in case of
situated in Delhi. In Delhi two types of children homes- refer to special doctors,
NGO run home and Government run home where
children stay in long term care would be selected for the • Taking children to hospitals as and when
purpose of data collection. The sample includes a total needed,
number of 20 children living in institutional care- 10
male and 10 female; from the age bar of 10 - 18 years. • Giving children medicines on time,
The sample would be collected from 4 children homes
that is 2 Government homes (1 boys and 1 girls home) • Taking care of the eatery habit and diet of
and 2 NGO home (1 Girls and 1 Boys home). A total each child,
 14 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

• Ensuring delivery of medical services to Children who were included in the research were
all the children. from two types of home government run and NGO run.
Two sampled t test was used in order to find out if the
Quantittive Analysis: type of home has any relation with regard to the health
of the children.
Health and Type of Children Home:

Don’t Know Good Not Good Grand Total

Row Labels
Count %age Count %age Count %age Count %age

Govt. Home 3 30.00% 4 40.00% 3 30.00% 10 50.00%

NGO Home 1 8.33% 8 83.33% 1 8.33% 10 50.00%

Grand Total 4 18.18% 12 63.64% 4 18.18% 20 100.00%

Test used - Two Sample t-test

t = 0.22086 df = 4 p-value = 0.418

95 percent confidence interval: (-5.768231,Inf)

From the analysis it was found that there is no link between the health status and the type of home the children
reside. The children in government home are equally healthy as in children living in NGO run homes. And the same
health facilities are offered to children in both the homes.

Conclusion support and care. It is known as fit facility for children.

The main aim of Child Care Institutions is to protect Child Care Institutions are authorized to provide physical
children from difficult hazardous and harmful situations. health care, safe and secured accommodation and
It is considered as best means to give children necessary educational facilities. The research study was undertaken
and required care especially to children who do not to understand the services and facilities available to
have families and require long tenure accommodation, children in institutional care which includes their safety,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 15

health and educational facilities. Children homes follow Confict of Interest: Nil
the instructions as prescribed under JJ Act to provide
facilities to all children living in institutional care. The References
results of the study indicates that children living in Child [1.] Status of Children in Urban India, Baseline Study.
Care Institutions have traumatic past experiences due to 2016.
which they are found with illness like fits, skin diseases,
[2.] Report on2nd biennial conference on Improving
lower immunity, low weight, malnourishment and others
standard of care for alternative child and Youth
at the time of the admission in children homes but when
care: Systems, Policies and Practises. 2016.
they are admitted in children homes their health needs
are taken care by the medical staffs and all the basic [3.] The Juvenile Justice (Care and Protection of
and necessary facilities is been given to them. There children) Amendment Act 2000
are regular and part time doctors and staff nurses who [4.] United Nation’s Declaration of the Rights of the
monitor regular check-up of the children. When they fall Child. Geneva. 1989.
sick they are taken to the hospitals by the elders of the [5.] Nilima, M. Children Protection and Juvenile
children. The data suggest that children in government Justice System for Children in Need of Care and
home are equally healthy as in children living in NGO Protection. 2018.
run homes. And the same health facilities are offered to
[6.] Savita, B. Children in India and their Rights.
children in both the homes.
National Human Rights Commission. 2006.
Ethical Clearance: As part of the primary data, [7.] Bajpai, A. Child Rights in India: Law, Policy and
the data was collected under the PhD programme of Practice”. India. 2012.
Amity University by the PhD scholar from children [8.] Verma, A. K. Neglected child- Changing
living in child care institutions and stakeholders. The Perspective. 1993.
consent of the primary respondents was taken at the time
[9.] Development, M. o. (n.d.). India: Building a
of interviews and their identities remain confidential.
Protective Environment for Children. India:
Hence, data does not contain any identifiers and no
Government of India.
ethical issues were involved in this research study.
Therefore, no ethical clearance was taken. [10.] Bhalla, T. M. Case Study on Compliance of
Juvenile Justice (Care and Protection of Children)
Source of Funding: Rules 2007 by Juvenile Institutions in Kolkata”.
2014.
The data was collected under the PhD programme
[11.] UNICEF, T. U. Children in Institutions: The
hence this research study is self financed by the PhD
Beginning of the end?. 2003.
scholar.
[12.] Gupta, K. M. Mental Health Challenges and Best
Practices in Children Homes in India. 2005.
 16 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

E-waste: The Serious Health Hazard

Trailokya Deka
Assistant Professor, Deptt. of Economics, B. P. Chaliha College, Nagarbera, Kamrup (Assam)

Abstract
Science and technology have led to production of many electronics and electric tools and equipments
starting from 18th century. Especially twenty first century is characterized by change in traditional habits
and customs and adoption of modern technologies in all around the works and activities of the world.
Electronic gadgets are meant to make our life happy and smooth functioning. These electronic gadgets
have penetrated every aspects of our life. Frequent change of television sets; computers and mobile phones
become the general habit of majority individuals in the world. We like to keep ourselves updated with the
current scientific advancements. In all such a situation we never think about appropriate recycling of old
electronic equipments. We frequently throw out the old electric items and usually become interested to
purchase updated new items. Electronic wastes (e-waste) are increasing all around the life and works of
human being. Each unit of e-waste may create every types of hazardous situation especially the health
related. Electrical equipments contain toxic substances and their disposal and recycling becomes a question
of health nightmare. Paper discussed definition, types and all about the health hazards of e-waste. Paper also
explained little about the recycling of e-wastes in India.

Keywords: E-waste, Hazards, Human Health, Recycling, Technology, etc.

Introduction varies region to region but urban areas suffers more than
Advances in science and technology have led to the rural areas.
production of many electronics and electric tools and
Defining E-waste
equipments starting from 18th century. More specifically
21st century is characterized by change of traditional Electronic waste or e-waste refers to all forms of
habits and customs and adoption of modern technology electronics and electrical equipments and it’s different
along with luxurious tools or equipments. All electronic small and big parts that have been redundant by it’s
gadgets are meant to make our lives happy and smooth owner as waste without the intent of re-use1. E-waste
functioning. These electric gadgets have penetrated encompasses various forms of electrical and electronic
every aspect of our lives. Frequent change of television equipments that may be old, might have reached the end
sets; computers and mobile phones become the general of life and most importantly cease to be of any value
habit of every individual. Some times to make ourselves to the present owner. E-waste is also synonymously
updated with the current scientific advancements we called WEEE, the short form of Waste Electrical and
also become bound to change our electronic items. In all Electronic Equipment and has been identified as one of
such situation we never think about reuse or appropriate the fastest growing waste streams in the world. E-waste
recycling of old electronic items. We frequently throw may or may not create visible mountains like municipal
out the old electric items and purchase regularly the waste but definitely a very complex, non biodegradable
updated new items. In that way electronic wastes and toxic form of modern waste. With scientific and
(e-wastes) are increasing day by day in every walk of technological advancements total quantity of e-waste
works and human life. Each unit of e-waste may create and at the same time problems generated by e-waste has
every types of hazardous situation especially the health been increasing day by day.
related. Electronics and electrical equipments contain
toxic substances and their disposal and recycling become Types of E-waste:
a question of health nightmare. Though the problem Electronics and electrical goods are broadly
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 17

classified into major heads- ‘White goods’ comprise of Asia, China generates the highest e-waste quantity both
household appliances like refrigerator, washing machine, in Asia and the world (7.2 Mt.). Japan generated 2.1 Mt,
dishwashers, air conditioner etc., ‘Brown goods’ that and India 2 Mt. The top four Asian economies that have
include television, cameras etc. and ‘Grey goods’ the highest e-waste generation in relative quantities are-
include computers, scanners, printer, mobile phones Cyprus (19.1 KG per inhabitant), Hong Kong, China (19
etc2. Including all the above mentioned categories, total KG per inhabitant), Brunei and Singapore (around 18
E-waste emphatically covers the following important KG per inhabitant) (Balde, CP et al, 2017). Amount of
tools and equipments- E-waste is expected to grow to 52.2 Mt. in 2021 with an
annual growth rate of 3% to 4%.
• Temperature Exchange Equipments: It
include different types of cooling and freezing items like Quantity of current (2016) E-waste generation for
refrigerators, freezers, air conditions, heat pumps etc. a few countries of the world is given in the following
table. As it is shown in the table, quantity of E-waste
• Screens and Monitors: It include different generation ranges between 0.8 to 28.5 KG per inhabitant.
types of televisions, monitors, laptops, notebooks and
tablets. Table: Country wise domestic E-waste generated
in 2016
• Large Equipments: It includes washing
machines, dryers, dish washing machines, electric Sl. E-waste generated (in KG per
stoves, large printing machines, copying equipments etc. Country
No. inhabitant)

• Small Equipments: It includes vacuum 1 Australia 23.6

cleaners, microwaves, ventilations, toasters, electric
2 Bangladesh 0.9
kettles, radio, calculators, video camera, electric toys,
small medical devices, etc. 3 Bhutan 2.5

4 China 5.2
• IT and Telecommunication Equipments:
It includes all types of mobile phones, GPS, routers, 5 France 21.3
telephones and personal computers.
6 Germany 22.8
• Different Lamps: It include high intensity 7 India 1.5
discharge lamps, LED lamps, fluorescent lamps etc.
8 Italy 18.9
All the above mentioned electric and electronic items
9 Japan 16.9
or equipments have different life period and respective
economic values. After the end of lifetime owners 10 Malaysia 8.8
generally throw out the equipments and respectively add 11 Myanmar 1.0
to total quantity of E-waste.
12 Nepal 0.8
E-waste Statistics:
13 Norway 28.5
Global quantity of E-waste generation in 2016 was 14 Pakistan 1.6
around 44.7 Mt. or 6.1 KG per inhabitant. The global
quantity of e-waste in 2016 is mainly comprised of 15 Singapore 17.9
small equipment (16.8 Mt.), large equipment (9.1 Mt.), 16 Sri Lanka 4.5
temperature exchange equipment (7.6 Mt.), and screens
17 Thailand 7.4
(6.6 Mt.) respectively. Lamps and small IT represent a
smaller share of the global quantity of e-waste generated 18 USA 19.4
in 2016, 0.7 Mt. and 3.9 Mt. respectively. According to
one estimate, about 20 to 50 million tonnes of E-waste are 19 Vietnam 1.5
being generated annually worldwide. Significantly, most
of the E-waste in 2016 was generated in Asian continent Source: The Global E-waste Monitor, 2017, Balde, C.P.
which is around 18.2 Mt. or 4.2 KG per inhabitant. In et.al.
 18 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

If we see the level of E-waste generated in developed Besides, wastes from medical operations are
and developing countries of the world then the difference directly dumped on nearby soil and water bodies. These
is quite large. The richest country in the world in 2016 activities are carried out without wearing any protective
generated an average of 19.6 KG per inhabitant whereas measures like masks, gloves etc. In many urban regions
the poorest generated only 0.6 KG per inhabitant. people are using cable wastes as fuel to cook food. In
fact, people are being exposed to toxins 24 hours a day
In India, total 65 cities generated more than 60 as they live, cook and sleep in the same place where
percent of the total E-waste in the country. Among the waste is being recycled. Thus, in absence of suitable
top ten cities that generate E-waste in India, Mumbai process and protective measures, recycling E-waste
ranks first, followed by Delhi, Bangalore, Chennai, results toxic emissions to the air, water, soil and poses a
Kolkata, Ahmadabad, Hyderabad, Pune, Surat and serious environmental and health hazard.
Nagpur respectively. Department of IT wants to provide
internet connectivity in all villages in India and wants Some of the available academic literature
to increase the internet penetration to 90 subscribers per also explained the same serious types of issues
1000 people by 2019. Further, the replacement rate of
developed from e-waste. As it is explained by Yu,
PCs in new age service sectors like BPOs, IT advertising
etc. are on the rise. India by 2020, targeted to achieve
Welford and Hills (2006), overall human health
a PC penetration of 80 per 1000 from the existing 14 risks from e-waste include breathing difficulties,
per 1000 people. At present India have approximately respiratory irritation, coughing, choking,
15 million computers, target being 85 million computers pneumonitis, tremors, neuropsychiatric problems,
by 2020. Unfortunately, if all these goals are attained convulsions, coma and even death. According
that will directly lead to manifold increase in E-waste to Raghupathy, K., Chaturvedi, Arora, Henzler
in India (https://rajyasabha.nic.in...E-Waste in India;
(2010), e-waste workers are also exposed to other
2011).
hazards leading to physical injuries and chronic
E-waste Health Hazards ailments such as asthma, skin diseases, eye
irritations and stomach disease. Similarly Yang,
E-waste now makes up around 05 percent of all
municipals’ solid wastes worldwide, more or less the Jin, Xu & Lu (2011) explained that particulate
same amount as general plastic waste, but much more matter collected from e-waste recycling areas
hazardous. With the fast and rapid technological change can lead to inflammatory response, oxidative
and lesser lifespan of all electric and electronic products, stress and DNA damage. Thus the health related
the problem of E-waste seems to be further compounded hazardous issues of e-waste are serious to discuss
in future days to come. E-waste has different potential in every works of human life. It is urgently needed
environment and health impacts if not recycled or cycled
to tackle the problem generated from the waste
inappropriately.
electronics and electric tools and equipments.
Electronic products are the multifaceted mixture
of several hundreds of tiny components. Most of E-waste Recycle:
the components in electronic devices contain Lead, Currently, out of total e-waste recycled in the
Mercury, PVCs, Brominated Flame Retardants (BFRs), country mere 05 percent is recycled by the handful of
Chromium, Beryllium and, Phthalates. Many of these tiny formal recyclers and the rest is recycled by the informal
components and substances contain deadly chemicals. recyclers. The E-waste recycled by the formal recyclers
These chemicals are the sprain on human health and the is done following environmentally sound practices which
environment. Long term exposure to these substances ensure that the damage to environment is minimized.
can damage the nervous system, kidney and bones, Formal recyclers also adopt processes so that the work
and the reproductive and endocrine systems of human force is not exposed to toxic and hazardous substances
health. Some of the problems are even Carcinogenic. released while recycling the waste. Most of the processes
Heavy amounts of BFRs are used to manufacture several used by the informal recyclers are manual, using simple
millions of mobile phones in the world. BFRs have been tools like hammer, screw driver, scissor etc. and by the
linked to neurotoxicity3. use of rudimentary techniques like burning of wires in
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 19

open and using acid baths for the extraction of precious responsible for its content.
metals.
References
The situation in India is alarming because of
adoption of unethical practices. India has also become 1. Balde, CP, Forti V, Stegmann P, et al. The Global
the dumping ground of all kinds of waste from the E-waste Monitor. United Nations University
developed countries. E-waste finds it’s way into India (UNU), International Telecommunication Union
in the name of second hand use or scrap metals. E-waste (ITU) and International Solid Waste Association
is being recycled in all most all the metros in India. (ISWA), Bonn, Geneva. 2017.
Problem of E-waste recycling gets further complicated 2. Sitaramaiah Y, Kusuma Kumari M. Impact of
due to the adoption of unethical practices by corporate electronic waste leading to environmental pollution.
and IT companies. According to one estimate, only a few JCHPS special issue. 2014; ISSN 0974 2115.
quantity of available e-waste in India is being recycled 3. Rajya Sabha Secretariat. E-waste in India. New
through the authorized recycling facility. This shows Delhi: Rajya Sabha. 2011. Available from: https://
that some corporate are selling the waste to informal rajyasabha.nic.in › rsnew › publication_electronic
recyclers to make some quick money without realizing › E-Waste_in_india.
that they are putting people and the environment at great 4. Chaudhary, N. Electronic wastes in India: A study
risk. of panel issues. ILI Law Review. The Indian Law
Institute, New Delhi. 2018; winter issue, Vol.II.
Conclusion
5. Yu J, Welford R, Hills P. Industry responses to
Handling of E-waste is dangerous due to chemicals EU WEEE and ROHS Directives: Perspectives
present in the products and the way to tackle the problem from China. Corporate Social Responsibility and
is to design clean products that free from chemicals Environmental Management. 2006; Vol.13 (5).
with longer life span. They should be easy and safe to
6. Raghupathy L, Krger C, Chaturvedi A, et al.
recycle and not expose workers and the environment
E-waste recycling in India: Bridging the gap
to hazardous chemicals. Manufacturers of electronic
between the informal and formal sector. 2010.
products must stop using hazardous chemicals and
Available from: http://www.iswa.org/fileadmin/
substitute them with safer alternatives.
galleries/General%.
Unfortunately, the trend of going green and clean 7. Yang F, Jin S, Xu Y, et al. Comparisons of IL-8,
manufacturing products free from chemicals is slowly ROS and p53 responses in human lung epithelial
catching up in the world as well as the country India. cells exposed to two extracts of PM2.5 collected
In April 2008, Ministry of Environment and Forest, from an e-waste recycling area. Environmental
Government of India has issued ‘Guide lines for Research Letters, China. 2011; Vol.6 (2).
environmentally sound management of E-waste’. It 8. Alan Watson, Kevin Brigden, Melissa Shinn, et
focuses on the need to facilitate the recovery or reuse al. Toxic Transformers: a review of the hazards of
of useful electric materials. It incorporates reduction of brominated and chlorinated substances in electrical
e-waste quantity in every walk of life. If appropriately and electronic equipment. Technical Note.
implemented, government initiative will reduce the Greenpeace Research Laboratories, England. 2010.
wastes destined for final disposal and subsequently
9. Devin N. Perkins, Marie-Noel Brune Drisse,
ensure environmentally sound management of all
Tapiwa Nxele, et al. E-Waste: A Global Hazard.
materials in India.
Icahn School of Medicine, Mount Sinai, New York.
2014.
Declaration
10. Keshav Parajuly, Ruediger Kuehr, Abhishek Kumar
Preparation of this article is not based on any Awasthi, et al. Future E-waste scenarios: The
external source of funding. It is an original work and Sustainable Cycles (SCYCLE) Programme. Report.
has not been sent to any other journal for publication. United Nations University (UNU), Germany. 2019.
Conflict of interest is nil. Moreover, we have a tradition
11. Lundgren, Karin. The global impact of e-waste:
to submit a copy of paper to Institutional Research
addressing the challenge. International Labour
Committee. Fully checked and author is individually
Office Publications. Geneva. 2012.
 20 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

12. Anusree PS, Balasubramanian P. Awareness and Environmental Medicine. 2008; Vol.12 (2).
disposal practices of e-waste with reference to 14. https://www.ncbi.nlm.nih.gov › pmc › articles ›
household users in Kochi City. International PMC6236536
Journal of Recent Technology and Engineering.
15. www.greenpeace.to › publications › Toxic-
2019; ISSN 2277-3878, Vol.8.
Transformers-2010
13. Pinto, V. NE-waste hazard: The impending
challenge. Indian Journal of Occupational and
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 21

A Survey of Oral Medicine Curriculum and Practice in India

Priyanka.S.R1, M.Arvind2
1Post Graduate Student, 2Professor & Head, Department of Oral Medicine and Radiology, Saveetha Dental
College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, India

Abstract
Background: Oral Medicine specialists provide clinical care to patients with a wide variety of chronic
diseases affecting the oral and maxillofacial region, oral manifestations of systemic diseases and behavioral
disorders and provide general dental care to patients with medically compromised states. It is important to
conduct studies that address the strengths and shortcomings of our specialty and the current system of its
education and practice in order to yield highly skilled professionals and truly serve the oral health care needs
of the public.

Aim & Method: This study aims to describe the current status of Oral Medicine curriculum and practice
in India. A survey was designed to assess the current status of oral medicine education and clinical practice.
The survey was sent to Oral Medicine Specialists across India to assess their opinion and analyze the benefits
and shortcomings of the present system.

Results: 52 respondents completed the survey from various states across India. More than 87% of
respondents considered management of oral mucosal diseases, salivary dysfunction, oral manifestations
of dermatological diseases, HIV, oral manifestations of systemic disease and facial pain as part of Oral
Medicine. Only 27% of respondents reported participating in multidisciplinary clinics for treatment of
patients, and 85% of respondents agreed to the need for presence of multidisciplinary clinics. 85% of
respondents agreed to the suggestion of developing a curriculum for training in Special Care Dentistry for
Oral Medicine postgraduates in India.

Conclusion: Limitations to this survey study include a small sample size. Future efforts at defining the
scope of oral medicine practice in India and improvements in training and education can help model future
graduates and inspire undergraduates to choose Oral Medicine as a career.

Keywords: Oral Medicine, Survey, Clinical Practice, Oral Medicine curriculum

Introduction of Oral Medicine defines it as the discipline of dentistry

concerned with the oral health care of medically
Oral Medicine is a specialty largely credited to
compromised patients and the diagnosis and nonsurgical
Dr.Lester Burket, considered as the Father of Oral
treatment/management of medically related disorders or
Medicine [1]. It has been a recognized specialty in many
conditions affecting the oral and maxillofacial region [2].
but not all countries and has been a way to integrate
Medicine and Dentistry, via oral health and its effects on Oral Medicine experts typically provide non-
systemic health and vice versa. The American Academy surgical treatment to various oral mucosal diseases,
soft and hard tissue lesions, salivary gland disorders,
Corresponding Author: viral, bacterial and fungal infections of the oral cavity,
Dr. Priyanka.S.R temporomandibular joint disorders, orofacial pain
Post Graduate Student syndromes, chemosensory disorders, oral complications
Department of Oral Medicine and Radiology of cancer chemo/radiotherapy and also care for patients
Saveetha Dental College, 162, Poonamallee High Road, with oral manifestations of systemic illnesses[1]. Oral
Velappanchavadi, Chennai – 600077 Medicine as a specialty is driven by the type of training
 22 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

offered, and the scope of clinical practice. Very few

articles have been published that have investigated the
standard of training in postgraduates and the scope of
clinical practice globally [3, 4]. In two global survey
studies, results have been quite parallel, most of the
respondents recognizing postgraduate Oral Medicine
training as a distinct field, and that the scope of practice
and training competence in diagnosing and managing oral
conditions that have been previously listed [3, 4]. Stoopler Figure 2 Distribution of professional responsibilities among
practitioners
et al have reported that India had the largest number of
oral medicine specialists compared to other countries, Less than 25% of the time was spent on research
maybe because the Oral Medicine specialist initially among practitioners.
screens patients in dental hospitals [4]. The objectives
94.3% of participants had a formal training for three
of this survey is to describe the status of Oral Medicine
years followed by an examination for certification. 24%
training and clinical practice among experts in India, to
of participants hold a PhD. 5.7% of participants had a
discuss the benefits of the current system, to address any
fellowship or equivalent by a board examination and
possible shortcomings and to make recommendations to
certification. Majority of respondents reported that no
remodel future training and practice.
funding was obtained and training was predominantly
self-funded.
Materials and Method
The survey was designed using existing information Most commonly, practitioners reported to be a part
from previous studies, with a closed response of Oral Medicine department in Hospital/ Dental College
pattern. Standardized emails linked to online survey settings with maximum time spent on teaching duties.
questionnaires (using Google Forms) were used. The The most common settings for Oral Medicine practice
email invitation to participate in the survey was sent were dental hospitals and dental schools, followed by
to Oral Medicine specialists across India. A total of 52 private practice. Practice in medical schools was the
respondents fully completed the survey. Data obtained least common.
were analyzed using simple descriptive statistics.
When asked about the definition of Oral Medicine,
more than 87% respondents considered management
Results
of oral mucosal diseases, salivary dysfunction, oral
The average age of Oral Medicine practitioners in manifestations of dermatological diseases, HIV, oral
India among the respondents was 33.8 years, with an manifestations of systemic disease and facial pain as
average experience of 7.8 years. The distribution of part of their duties. Fewer respondents considered
respondents based on location has been illustrated in management of patients with physical and mental
Figure 1. The average number of colleagues practicing disabilities and general dentistry for medically complex
with the respondents in a hospital setting was 7.6. patients in the definition of Oral Medicine. Oral medicine
Respondents reported a mean of working 27 h per week plays an important role in detection, treatment and
including clinical practice, teaching and administrative monitoring of oral potentially malignant disorders, oral
duties with a maximum of 40 hours per week manifestations of systemic diseases and oral treatment
of medically compromised states. The latter two are
important as they are the link between medicine and
dentistry that can be a useful service for both the patient
and the medical practitioner. Oral manifestations can
sometimes be the starting point of diagnosis of a systemic
illness or may be a sign of progression of the disease
state which highlights the importance of collaboration
between doctors and oral medicine practitioners [5].
Figure 1 Percentage of respondents by state.
A prospective survey conducted by the Diplomates
of the American Board of Oral Medicine showed an
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 23

increase in patients with medically compromising states, Only 27% of respondents reported participating in
with more than 80% of cases requiring a comprehensive multidisciplinary clinics for treatment of patients, and
evaluation of the medical condition and dental treatment 85% of respondents agreed to the need for presence of
for patients with severe systemic disease. Majority multidisciplinary clinics. The use of multidisciplinary
of referrals were from general dentists and medical clinics is especially important when treating oncology
practitioners [6]. This highlights the changing scenario patients, patients with severe systemic illnesses.
in oral medicine treatment needs among the public.
A survey conducted among medical practitioners in 24% of respondents reported less than 25% of
Chennai about the awareness of Oral Medicine as a patients are seen on follow up, 45% of respondents had
specialty in dentistry. Only 71% of respondents were more than 50% of patients with follow up visits.
aware of the specialty of Oral Medicine and the scope
of the specialty. 29% were not aware of it and many oral
manifestations and orofacial disorders were not always
referred to the right dental practitioner [7]. The aging
population will lead to an increase in oral complications
in medically compromised patients and practitioners
will spend most of the times caring for the elderly and
severely ill patients. So, the integration of medicine and Figure 4 Use of Multidisciplinary clinics
dentistry becomes even more important and training
Figure 5 represents the types of oral and maxillofacial
oral medicine graduates in managing oral health needs
diseases and conditions seen in oral medicine practices
of medically compromised, physically challenged
in India as reported by the respondents. Previous
and behaviorally compromised patients is imperative
[8]. Figure 3 shows the types of oral and maxillofacial studies from other countries have reported the scope of
practice, sources of referral, lesion occurrence and types
diseases that constitute the definition of oral medicine
of patients reporting to Oral Medicine Practices [10, 11].
according to the survey respondents.
Reports such as these are required to be done periodically
and methodically to better understand the scope of oral
medicine practice in India and to improve the curricula
of postgraduate students for them to be better equipped
with knowledge and skills needed to handle patients [10].

Figure 3 Definition of Oral Medicine

95% of survey respondents agreed that there is a
need for better communication and integration between
dental and medical practitioners. Collaboration between
Figure 5 Percentage of patients with different orofacial
the dental and medical profession can highly benefit the diseases.
patient, especially, patients undergoing cancer therapy,
85% of respondents agreed to the suggestion of
patients in intensive care units and patients in long term
developing a curriculum for training in Special Care
care facilities where dental care can be provided by a
Dentistry for Oral Medicine postgraduates in India.
trained professional rather than non-dental personnel as
Various studies have reported the medical problems in
poor oral health can contribute to increased morbidity
these patients and the rate of occurrence demonstrates
and decreases quality of life [9]. This reinforces the need
the importance of general medicine knowledge and
for educating the oral medicine graduates to serve as a
training in handling such patients [12-14]. Inclusion of
partner to physicians thereby enhancing the level of care
Special Care Dentistry in the Oral Medicine curriculum
provided to patients [9].
does pose challenges in obtaining national consensus.
Studies to identify types of patients, services available
 24 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

and core skills required to qualify dentists are required systemic disease [18, 19]. Oral Medicine graduates should
for the introduction of Special Care Dentistry in the be competent enough to understand the interactions
curriculum [15]. between, oral health, nutrition, general health, drug
interactions, oral effects of systemic diseases, and also
90% of respondents were open to the introduction be familiar with provision of dental care to severely
of the internet and Smartphone applications in ill and physically/mentally challenged patients in a
communication among clinicians and between patients hospital setup. Training in Special Care Dentistry can
and clinicians. Although studies have confirmed safety provide the specialists the ability to handle challenges
and benefits of Smartphone use in healthcare, adequate associated with treating physically/medically/mentally
training and awareness of possibilities and limitations is compromised patients including the management
imperative. This can be an adjunct in doctor-doctor and of medical emergencies, management of anxiety,
doctor-patient communication and help in referral and management of frail/elderly patients, patients with severe
documentation [16, 17]. systemic disease, patients in long term care facilities,
treatment under general anaesthesia and sedation, and
Discussion provision of dental treatment in different setups like
This preliminary study was an attempt to investigate hospitals, intensive care units, nursing homes, special
the current status Oral Medicine education and clinical schools and general practice [15, 20].
practice across India. Our objective was to assess the
practitioner and practice characteristics, investigate Older trends of procedure driven/mechanical
the types of patients treated, and the opinion of oral dentistry are gradually being replaced by a more
medicine specialists in on recommending changes preventive/regenerative approach. Oral medicine is the
and improvement in training and curriculum. Our best choice to handle the noninvasive and preventive
findings suggest that oral medicine specialists in India aspects of future oral healthcare and for the integration into
treat a wide variety of patients including oral mucosal the medical field [21, 22]. Future studies are recommended
lesions, mucocutaneous diseases, salivary gland to obtain a more detailed report of the status of oral
disorders, temporomandibular joint disorders, and oral medicine in India. Efforts at defining the scope of oral
manifestations of systemic diseases. Fewer respondents medicine practice in India and improvements in training
reported participation in multidisciplinary clinics, the and education can help modeling future graduates and
presence of a Special Care Dentistry curriculum in inspire more students to choose oral medicine as a career.
the Oral Medicine postgraduate training. But almost Conflict of Interests: The authors declare no
all respondents considered provision of dental care conflict of interests.
for medically compromised patients, physically and
mentally disabled patients to be a part of Oral Medicine Source of Funding: Self-Funding
Practice [4]. The diversity in practice characteristics can
be attributed to regional variations in opinions among Ethical Clearance: Not Required
specialists, different systems of training and clinical
References
practice.
1. Sollecito TP, Rogers H, Prescott-Clements L,
There is increasing evidence that oral health has Felix DH, Kerr AR, Wray D, Shirlaw P, Brennan MT,
a significant effect on overall systemic health and that Greenberg MS, Stoopler ET. Oral medicine: defining
there are inadequacies in the interrelationships between an emerging specialty in the United States. Journal of
dental and non-dental health care providers. It is time dental education. 2013 Apr 1;77(4):392-4.
for dental education to establish integration of dental
and medical training and practice in order to increase 2. American Academy of Oral Medicine. Oral
oral health knowledge among medical professionals medicine definition. At: www.aaom.com/about-aaom/.
and to increase the knowledge of oral-systemic health
interface and a working knowledge of General Medicine 3. Rogers H, Sollecito TP, Felix DH, Yepes JF,
among dental professionals. Oral Medicine Specialists Williams M, D’Ambrosio JA, Hodgson TA, Prescott‐
may be considered the best choice for this integration Clements L, Wray D, Kerr AR. An international survey
because of its close connection with general health and in postgraduate training in Oral Medicine. Oral diseases.
2011 Apr 1;17(s1):95-8.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 25

4. Stoopler ET, Shirlaw P, Arvind M, Lo Russo L, implications. Journal of dental education. 2007 Apr
Bez C, De Rossi S, Garfunkel AA, Gibson J, Liu 1;71(4):487-91.
H, Liu Q, Thongprasom K. An international survey 14. G.Muthu Laakshmi. Awareness of Oral Cancer
of oral medicine practice: Proceedings from the 5th among a Hospital based Out-Patient Population
World Workshop in Oral Medicine. Oral diseases. – A Questionnaire based study. Journal of
2011 Apr 1;17(s1):99-104. Pharmaceutical Sciences and Research. 2016, Vol
5. Zakrzewska JM, Downer C, Lopes V. The oral 8(7), 687-691.
medicine clinic—what is its role?. Journal of the 15. Dougall A, Pani SC, Thompson S, Faulks D,
Royal Society of Medicine. 1994 Jul 1;87(7):390-2. Romer M, Nunn J. Developing an undergraduate
6. Miller CS, Hall EH, Falace DA, Jacobson JJ, curriculum in Special Care Dentistry–by consensus.
Lederman DA, Segelman AE. Need and demand European journal of dental education. 2013 Feb
for oral medicine services in 1996. Oral Surg Oral 1;17(1):46-56.
Med Oral Pathol Oral Radiol Endod 1997;84:630- 16. Petruzzi M, De Benedittis M. WhatsApp: a
4. telemedicine platform for facilitating remote oral
7. Subramanian VS. Awareness of Oral Medicine medicine consultation and improving clinical
Specialty among Medical practitioners in and examinations. Oral surgery, oral medicine,
around the locality of Chennai: A Survey. oral pathology and oral radiology. 2016 Mar
Research Journal of Pharmacy and Technology. 31;121(3):248-54.
2016;9(8):1073-6. 17. Bradley M, Black P, Noble S, Thompson R, Lamey
8. Miller CS, Epstein JB, Hall EH, Sirois D. Changing PJ. Application of teledentistry in oral medicine
oral care needs in the United States: the continuing in a community dental service, N. Ireland. British
need for oral medicine. Oral Surgery, Oral dental journal. 2010 Oct 23;209(8):399-404.
Medicine, Oral Pathology, Oral Radiology, and 18. Tanaka K, Honda T, Kitamura K. Dentistry in
Endodontology. 2001 Jan 31;91(1):34-44. Japan should become a specialty of medicine with
9. Migliorati CA, Madrid C. The interface between dentists educated as oral physicians. Journal of
oral and systemic health: the need for more dental education. 2008 Sep 1;72(9):1077-83.
collaboration. Clinical Microbiology and Infection. 19. Hein C, Schönwetter DJ, Iacopino AM. Inclusion of
2007 Oct 1;13(s4):11-6. oral-systemic health in predoctoral/undergraduate
10. Suarez P. Oral conditions of 1,049 patients referred curricula of pharmacy, nursing, and medical schools
to a university‐based oral medicine and orofacial around the world: a preliminary study. Journal of
pain center. Special Care in Dentistry. 2007 Sep Dental Education. 2011 Sep 1;75(9):1187-99.
1;27(5):191-5. 20. Sanz M, Treasure E, Dijk WV, Feldman C,
11. Farah CS, Simanovic B, Savage NW. Scope of Groeneveld H, Kellett M, Pazdera J, Rouse L,
practice, referral patterns and lesion occurrence of Sae‐Lim V, Seth‐Smith A, Yen E. Profile of the
an oral medicine service in Australia. Oral diseases. dentist in the oral healthcare team in countries with
2008 May 1;14(4):367-75. developed economies. European Journal of Dental
12. Al-Bayaty HF, Murti PR, Naidu RS, Matthews Education. 2008 Feb 1;12(s1):101-10.
R, Simeon D. Medical problems among dental 21. Spielman AI. The future of oral medicine.
patients at the school of dentistry, the university of 22. Kragelund C, Reibel J, Hadler‐Olsen ES, Hietanen
the West Indies. Journal of dental education. 2009 J, Johannessen AC, Kenrad B, Nylander K, Puranen
Dec 1;73(12):1408-14. M, Rozell B, Salo T, Syrjänen S. Scandinavian
13. Sardella A, Demarosi F, Lodi G, Canegallo L, Fellowship for Oral Pathology and Oral Medicine:
Rimondini L, Carrassi A. Accuracy of referrals to statement on oral pathology and oral medicine in
a specialist oral medicine unit by general medical the European Dental Curriculum. Journal of Oral
and dental practitioners and the educational Pathology & Medicine. 2010 Nov 1;39(10):800.
 26 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A Retrospective Study on Side of Nerve Involvement and

Distribution of Pain in Patients with Trigeminal Neuralgia

Priyanka.S.R, M.Arvind1, Priyanka.S.R2

1Post Graduate Student, 2Professor & Head, Department of Oral Medicine and Radiology,
Saveetha Dental College and Hospital, Chennai, India

Abstract
BACKGROUND: Trigeminal neuralgia is chronic, debilitating and painful condition involving the trigeminal
nerve and has a major impact on patients’ quality of life. It is characterized by brief attacks of excruciating
pain in the area of distribution of one or more branches of the trigeminal nerve. It has an annual incidence of
about 4.5 to 12.6 per 100,000 population and has a female predilection. According to studies, it commonly
occurs in the older age group and a hallmark of idiopathic trigeminal neuralgia is that it occurs twice as often
on the right side of the face. There are various hypotheses proposed to explain this side predilection.

AIM: To evaluate and analyze the side of occurrence, distribution of pain in patients diagnosed with
trigeminal neuralgia among patients visiting Saveetha Dental College.

MATERIALS AND METHOD: The retrospective clinical data of 42 patients who reported with a complaint
of orofacial pain and diagnosed with trigeminal neuralgia in the department of Oral Medicine and Radiology,
Saveetha Dental College from Jan 2016 to Dec 2017 were obtained. The data regarding age of onset, gender,
side of nerve involvement, and distribution of pain was retrieved and analyzed.

RESULTS: Trigeminal neuralgia was mostly diagnosed in the 5th and 6thdecades of life with a mean age of
55.3 years. Male patients were affected more than female patients but the difference was not comparable. It
affected the right side more frequently and the maxillary branch was the most commonly involved.

CONCLUSION: This study investigated the clinical characteristics of 42 patients diagnosed with trigeminal
neuralgia. Further multicentre studies need to be done to investigate the clinical characteristics and imaging
studies need to be done along with anatomical studies to investigate causes for nerve entrapment as an
etiological agent for trigeminal neuralgia.

Keywords: Trigeminal neuralgia, site predilection, trigeminal nerve, orofacial pain, neuropathic pain

Introduction name “trigeminal nerve” meaning “three twins” was

derived from the name “nerf trijumeau” given by a
The trigeminal nerve is the principal nerve that
Danish anatomist Jacques-Benigne Winslow [1]. The
provides general sensory supply to the face, scalp
mesencephalic nucleus, main sensory nucleus, spinal
and mouth. First described by Galen in 200 A.D as 2
nucleus and the motor nucleus give rise to sensory and
pairs of separate nerves due to its large peripheral
motor fibres. The nerve from the pons has a relay in
branches, Fallopius (1500’s) later said that the three
the Meckel’s cave wherein the Gasserian ganglion lies.
branches merged as one within the cranial cavity. The
Three divisions of the trigeminal nerve arise from the
gasserian ganglion and exit the cranial cavity through the
Corresponding Author: superior orbital fissure, foramen Rotundum and Ovale.
Dr. Priyanka.S.R The 3 divisions are the ophthalmic (V1) and Maxillary
Department of Oral Medicine and Radiology (V2) and the Mandibular division (V3). The nerve may
Saveetha Dental College, 162, Poonamallee High Road, be involved in a number of pathologies. A thorough
Chennai – 600077 understanding of its anatomy is of vital importance in
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 27

diagnosis and treatment of disease [2]. possible compressing vessels on the nerve root [9].

Trigeminal neuralgia (TN) is a rare condition One clinical hallmark of classical TN is that the right
causing excruciating, intermittent, short lasting, usually side is more commonly affected than the left but there
unilateral facial pain, also called as tic doloreux meaning are no reasons for the blood vessels causing vascular
“painful spasm”. The prevalence tends to be higher in compression to be more tortuous in the right side. One
females than in males and most commonly reported hypothesis which said that higher incidence on the right
above the age of 40 with a peak at 50-60 years. The right side is caused by improper brushing on this side by right
side has been reported to occur more frequently than the handed people leading to a higher incidence of caries
left [3, 4]. Sharp, stabbing or shooting, electric shock-like was discarded because the frequency of left sided TN
pain occurs in the area of distribution of one or more in left handed people is not different from right handed
branches of the nerve. Pain is provoked by light touch to individuals [12]. Anatomical and radiological studies
areas of the face termed as trigger zones. Trigger factors have reported that foramina rotundum and ovale are
include washing the face, brushing teeth, shaving, and asymmetrical and that the left side is wider and larger
others [5].TN can be classified as Classical TN (idiopathic than the right [13] [14]. Vascular compression produces
or primary TN) and Symptomatic TN (secondary TN). demyelination, an inflammatory reaction and an increase
Patients with multiple sclerosis are also susceptible and in perivascular lymphocytes, lipid laden macrophages
frequently have bilateral facial pain [6]. While classical and collagen content of the neuronal extracellular matrix
TN occurs without an apparent cause, symptomatic distal to the site of compression [15] [16]. Neto et al [17]
TN can usually be attributed to a recognizable disorder say that these changes can cause entrapment of the nerve
or pathology in intrinsic or extrinsic locations such on the right side more commonly than the left because
as trauma, infections such as herpes zoster, multiple of the difference in size of the foramina which could
sclerosis, space occupying lesions including cysts and explain the higher incidence of TN on the right side.
tumours[7, 8]. For example, cases of TN related to multiple sclerosis
is also more common in the right side, and in bilateral
Several mechanisms attempt to explain the neuralgia, the right side had more severe symptoms than
pathogenesis of classical TN. The leading theory is the the left [18]. No differences in size of foramina have
demyelination of sensory nerve fibres due to compression been established in women and men [17]. Although
by blood vessels at the nerve root. The offending vessel earlier reports show a strong female predilection, recent
is the superior cerebellar artery or the anterior inferior reports suggest that only 60 % of the TN patients are
cerebellar artery. Histological studies have revealed focal female. No known racial or ethnic risk been reported
demyelination in the vicinity of the vascular compression. [19]. The objective of this study is to investigate the
The demyelinated axons allow spontaneous generation clinical characteristics of patients diagnosed with TN.
of ectopic nerve impulses and ephaptic transmission to
adjacent fibres[9]. The “Ignition hypothesis” (Devor et Materials and Method
al) is the most accepted hypothesis stating that TN arises
from abnormalities of the afferent neurons in the root This descriptive study was carried out in the
or ganglion. Injury from neurovascular conflict causes department of Oral Medicine and Radiology. Clinical
axons hyperexcitability, resulting in paroxysmal painful data was retrieved retrospectively from the electronic
sensory discharge. Neighbouring neurons are recruited, clinical record database of patients diagnosed with TN
leading to a rapid buildup of electrical activity (ephaptic from January 2016 to December 2017. 42 patients who
cross talk) and pain amplification as the demyelinated were diagnosed with TN based on clinical features and
neurons lie in close contact. Devor described the stop response to treatment with carbamazapine were included.
mechanism as due to post-discharge hyperpolarisation All patients were examined using orthopantomography
which makes the nerve refractory to further excitation. to rule out any pathology or other odontogenic causes.
This is seen as asymptomatic periods between attacks Clinical data regarding age, gender, side and distribution
of pain [10]. The disease is characterized by recurrences of pain over areas supplied by the trigeminal nerve were
and remissions with 50% of patients reporting periods of collected and analyzed for applying descriptive statistics.
spontaneous remission lasting weeks, months or years
[11]. Patients with new onset TN typically undergo an
Results
MRI to rule out recognizable causes and to visualize The age of patients varied from 31 to 85 years with
 28 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

a mean age of 55.3 years at presentation. Table 1 shows Table 2 Side of involvement among male and
the distribution of patients based on age of onset. female patients

Table 1 Age distribution among patients

Side of Male Female Total Percen-
Involvement (n=23) (n=19) (n=42) tage (%)
Age in Male Female Total
Percentage (%)
years (n=23) (n=19) (n=42)
Right 12 14 26 61.9%
31-40 1 3 4 9.5%

Left 11 3 14 33.3%
41-50 4 3 7 16.6%

51-60 5 8 13 30.9% Table 3 shows the involvement of various divisions

of the trigeminal nerve in the sample. The right
61-70 12 4 16 38%
maxillary division was the most commonly involved
nerve seen in 26.1% of patients. This was followed by
71-80 0 1 1 2.3%
equal involvement of left maxillary and right mandibular
>80 1 0 1 2.3% division of the trigeminal nerve seen in 19% of cases each.
A combination of right maxillary and right mandibular
Out of 42, 23 (54.7%) patients were male and 19 division of the trigeminal nerve was involved in 11.9%
(45.2%) were female. Most of male patients were in of patients. The involvement of the ophthalmic division
their 6th decade of life and most of the female patients was the least common. Only 1 patient was diagnosed
were in their 5th decade of life. Most common age group with TN of the left ophthalmic division. 1 patient had
for occurrence of TN was 51-60 years (30.9%). Table involvement of right ophthalmic and maxillary nerves.
2 shows the side involved in male and female patients. In female patients, the most common area involved is
61.9% of patients had right sided TN and 33.3% had left the area distributed by the right mandibular division and
sided neuralgia. The difference in side involved is more in male patients, the most commonly involved nerve was
apparent in female patients – 14 (73.6%) patients had the right maxillary nerve.
right sided neuralgia and only 3 (15.7%) patients had left Table 3 Pain distribution among divisions of
sided neuralgia. No cases of bilateral TN were found. trigeminal nerve

Division of Trigeminal nerve involved Male (n=23) Female (n=19) Total (n=42) Percentage (%)

Right ophthalmic (V1) 0 0 0 0

Left ophthalmic (V1) 1 0 1 2.3%

Right maxillary (V2) 7 4 11 26.1%

Left maxillary (V2) 5 3 8 19%

Right mandibular (V3) 3 5 8 19%

Left mandibular (V3) 3 1 4 9.5%

Combinations

Right maxillary and mandibular (V2,V3) 1 4 5 11.9%

Left maxillary and mandibular (V2,V3) 2 2 4 9.5%

Right ophthalmic and maxillary (V1,V2) 1 0 1 2.3%

Total 23 19 42 100%
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 29

Discussion could also reveal an asymmetry in foramina in the right

and left side in different populations. Imaging and
Neuralgic pain imposes substantial amount of anatomical studies should be done to detect and quantify
burden to affected patients. Patients experience any such discrepancies which could explain the side and
excruciating pain that lasts seconds to minutes gender predilection in the Indian population.
followed by a painless refractory period in between
attacks. Even during the refractory period, patients are Conclusion
overwhelmed with fear that the pain could occur at any This study investigated the clinical characteristics
instant. This causes significant impairment in function of 42 patients diagnosed with TN. It was more common
and daily life [20]. Clinical criteria for diagnosis based in the right side and more common in male patients.
on pain characteristics are given by the International The major limitation to the present study is the small
Headache Society. Neurological examinations, MRI sample size which could have caused discrepancies in
scanning, Sensory testing, electrophysiological studies the results compared to previous studies and the results
may be used as specific investigations to rule out organic cannot be generalized to a larger population. Further
causes for symptomatic TN [8]. Early epidemiological multicentre studies need to be done to investigate the
studies have reported the right trigeminal nerve to be clinical characteristics and imaging studies need to be
more involved than the left. There is very little research done along with anatomical studies to investigate causes
to explain this phenomenon. Neto et al have stated the for nerve entrapment as an etiological agent for TN.
following reasons to support their hypothesis that nerve
entrapment following vascular compression of nerve Conflict of Interests: The authors declare no
root is responsible for more incidence of right sided conflict of interests.
TN [17]. The difference in size of foramen ovale and
Source of Funding: Self-Funding
rotundum is one reason. But, while the difference in size
of foramen ovale is found in 75% of cases, difference in Ethical Clearance: Not Required
size of foramen rotundum is seen only in 8% of cases
[13, 14]. Another finding that supports this hypothesis is
References
related to Bell’s palsy. In Bell’s palsy, the facial nerve
1. Renton T, Egbuniwe O. Pain Part 2a: trigeminal
also shows oedema and both right and left sides are
anatomy related to pain. Dental update. 2015 Apr
involved with equal frequency. This could because there
2;42(3):238-44.
is very little asymmetry in the stylomastoid foramen and
internal acoustic meatus for the right and left side [13, 2. Bathla G, Hegde AN. The trigeminal nerve:
21]. In other syndromes involving the cranial nerves such an illustrated review of its imaging anatomy
as glossopharyngeal neuralgia, hemifacial spasm, the and pathology. Clinical radiology. 2013 Feb
right and left sides are equally affected and the foramina 28;68(2):203-13.
of these nerves are only slightly asymmetrical [13, 22]. 3. Koopman JS, Dieleman JP, Huygen FJ, de Mos M,
Even TN occurring due to cysts and tumours in the Martin CG, Sturkenboom MC. Incidence of facial
posterior cranial fossa occur predominantly on the right pain in the general population. Pain 2009; 147:
side even though the cysts and tumours showed no side 122-7.
predilection [17]. 4. Obermann M, Katsarava Z. Update on trigeminal
neuralgia. Expert Rev Neurother 2009;9(3):323–9.
As substantial recurrence rates are reported after
decompression surgery, involvement of other factors 5. Zakrzewska JM, McMillan R. Trigeminal neuralgia:
is more likely. Nerve entrapment in the foramina may the diagnosis and management of this excruciating
be one such factor. So, more studies are required to test and poorly understood facial pain. Postgraduate
this hypothesis as it may improve treatment and patient medical journal. 2011 Jun 1;87(1028):410-6.
selection for surgery. In this investigation, as reported in 6. Hupp WS, Firriolo FJ. Cranial neuralgias. Dental
previous studies [23-26], right side was more commonly Clinics. 2013 Jul 1;57(3):481-95.
involved than the left side. But, in contrast, male patients 7. Zakrzewska JM, Patsalos PN. Long-term cohort
were affected more than female patients. This may be study comparing medical (oxcarbazepine) and
attributed to the small sample size. Anatomical studies surgical management of intractable trigeminal
 30 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

neuralgia. Pain 2002;95:259e66. 18. Siegfried J, Lindenberger J. Trigeminal neuralgia

8. Vasappa CK, Kapur S, Krovvidi H. Trigeminal in multiple sclerosis. Il Dolore 1979;1:183–6.
neuralgia. BJA Education. 2016 Apr 26;16(10):353- 19. Bennetto L, Patel NK, Fuller G. Trigeminal
6. neuralgia and its management. BMJ 2007; 334:
9. Prasad S and Galetta S (2007) The trigeminal nerve. 201-5.
In: Goetz C (ed.) Textbook of Clinical Neurology, 20. Tolle T Duke E, Sadosky A. Patient burden of
3rd edn, pp. 165–183. Philadelphia: Elsevier trigeminal neuralgia: results from a cross-sectional
10. Devor M, Amir R, Rappaport ZH. Pathophysiology survey of health state impairment and treatment
of trigeminal neuralgia: the ignition hypothesis. patterns in European countries. Pain Pract
The Clinical journal of pain. 2002 Jan 1;18(1):4-13. 2006;6:153-60.
11. Zakrzewska JM, Linskey ME. Trigeminal 21. Sanna M, Saleh E, Russo A, Taibah AK. In: Atlas
neuralgia. Bmj. 2014 Feb 17;348(9):g474. of temporal bone and lateral skull base surgery.
Stuttgart: Thieme Medical Publishers; 1995. p. 37–
12. Penman J. In: Vinken PJ, Bruyn GW, editors.
50.
Handbook ofclinical neurology: Trigeminal
neuralgia. New York: AmericanElsevier Publishing 22. Patel A, Kassam A, Horowitz M, Chang YF.
CO; 1964. p. 296–321. Microvascular decompression in the management
of glossopharyngeal neuralgia: analysis of 217
13. Berge JK, Bergmann RA. Variations in size and in
cases. Neurosurgery 2002;50:705–10.
symmetry of foramina of the human skull. ClinAnat
2001;14:406–13. 23. Rai A, Kumar A, Chandra A, Naikmasur V,
Abraham L. Clinical profile of patients with
14. Shapiro R, Robinson F. The foramina of the middle
trigeminal neuralgia visiting a dental hospital: A
fossa; a phylogenetic, anatomic and pathologic
prospective study. Indian Journal of Pain. 2017
study. Am J Radiol 1967;101:779–94.
May 1;31(2):94.
15. Hilton DA, Love S, GradIdge T, Coakham HB.
24. Yadav S, Mittal HC, Sachdeva A, Verma A,
Pathological findings associated with trigeminal
Dhupar V, Dhupar A. A retrospective study of
neuralgia caused by vascular compression.
72 cases diagnosed with idiopathic trigeminal
Neurosurg 1994;35:299–303.
neuralgia in indian populace. Journal of clinical and
16. Rappaport ZH, Govrin-Lippmann R, Devor M. An experimental dentistry. 2015 Feb;7(1):e40.
electronmicroscopic analysis of biopsy samples
25. Sathasivam HP, Ismail S, Ahmad AR, Basri NN,
of the trigeminal root taken during microvascular
Muhamad H, Tahir NF, Saw CL, Kipli NH, Lau SH.
decompressive surgery. StereotactFunctNeurosurg
Trigeminal neuralgia: a retrospective multicentre
1997;68:182–6.
study of 320 Asian patients. Oral surgery, oral
17. Santo Neto H, Camilli JA, Marques MJ. Trigeminal medicine, oral pathology and oral radiology. 2017
neuralgia is caused by maxillary and mandibular Jan 31;123(1):51-7.
nerve entrapment: greater incidence of right-sided
26. Shah SA, Murad N, Salaar A, Iqbal A. Trigeminal
facial symptoms is due to the foramen rotundum
neuralgia: analysis of pain distribution and nerve
and foramen ovale being narrower on the right side
involvement. Pakistan Oral Dent J. 2008;28(1):37-
of the cranium. Medical hypotheses. 2005 Dec
41.
31;65(6):1179-82.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 31

A Comparative Analysis of Self-Efficacy in Low Fidelity Vs

High Fidelity Simulation Post Advanced Cardiac Life Support
(ACLS) Sessions on Cardiac Arrest Algorithm amongst EMS
Students of Pune, India

Parag Rishipathak1, Anand Hinduja2, Navnita Sengupta3

1
Director, 2Adjunct Faculty, 3Medical Officer, Academics, Symbiosis Centre for Health Skills, Symbiosis
International (Deemed University), Pune, India

Abstract
Background: Self-efficacy is a personal characteristic believed to increase an individual’s abilities to be
successful in a task. Self-efficacy, as defined by Albert Bandura is a “belief” that one possesses the requisite
skills to do what is needed to reach a successful outcome.”

Cardiac arrest is one of the most common emergencies encountered by EMTs in real clinical world, hence
self-efficacy in such a situation is of paramount importance. Self-efficacy is composed of two key components
i.e. satisfaction and confidence in one’s own abilities.

Objective: The objective of the study is to compare self-efficacy reported by EMS students after

ACLS protocol on cardiac arrest algorithm using High fidelity vs low Fidelity simulation.

Methodology: Hundred PGDEMS students were chosen for the study by convenience sampling. The
students were divided into two groups of fifty each after matching for age, sex and previous course grades.

Both groups were taught ACLS protocol on Cardiac Arrest Algorithm by classroom teaching over a four
hour session conducted on two days.

The students were provided with a standardized and pretested “Student Satisfaction and Self- Confidence
Learning Questionnaire consisting of 13 items (5 items on Satisfaction and 8 items on Self Confidence in
learning). Each item was rated on a 5 point Likert Scale.

Discussion: The students in HFS group found the High Fidelity methodology to be more helpful and
effective. Also the students reported greater enjoyment during the simulation activity on the High Fidelity
manikin.

In terms of confidence, the HFS group reported statistically significant higher scores in 6 out of the 8 items
on the questionnaire.

Conclusion: The findings of the study favor the use of High Fidelity Simulation (HFS) as the preferred
methodology to teach cardiac arrest algorithm to EMS students.

Keywords: High Fidelity Simulation (HFS), Low Fidelity Simulation (LFS), Emergency Medical Services
(EMS)

Background “belief” that one possesses the requisite skills to do what

is needed to reach a successful outcome.”1
Self-efficacy is a personal characteristic believed
to increase an individual’s abilities to be successful in Self-efficacy is a very important trait required in
a task. Self-efficacy, as defined by Albert Bandura is a Emergency medicine as Emergency Medical Technician
 32 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

(EMT) has to respond to complex unpredictable paramount importance. Self-efficacy is composed of two
situations in an extremely short period of time.2 key components i.e satisfaction and confidence in one’s
own abilities.9
The Post Graduate Diploma in Emergency Medical
Services (PGDEMS) trains medical professionals in the Objective
basics of Emergency Medical Services (EMS).These
students are taught life saving skills which help them The objective of the study is to compare self-
provide medical aid even before the patient reaches efficacy reported by EMS students after ACLS protocol
the hospital. Currently EMS students are taught with on cardiac arrest algorithm using High fidelity vs low
the help of part-task trainers, a form of Low Fidelity Fidelity simulation.
Simulation (LFS) wherein students engage in problem
based learning with the help of case studies. In recent
Methodology
years High Fidelity Simulation (HFS) using hi-tech Hundred PGDEMS students were chosen for the
manikins and dynamic clinical scenarios are being study by convenience sampling. The students were
utilized to teach EMS students.3 divided into two groups of fifty each (Low Fidelity
simulation group and High Fidelity Simulation group)
A study by Massoth et.al4 (2019) concluded after matching for age, sex and previous course grades.
that simulation based training has evolved into an
indispensable tool in medical education. Simulation can Both groups were taught ACLS protocol on Cardiac
nurture self-efficacy with the necessary motivation to Arrest Algorithm by classroom teaching over a four hour
create behavioral shifts that might positively influence session conducted on two days.
the individual, team and patients. A study conducted
by Hoadley Theresa et.al5 (2009) showed a positive On the day of simulation session, students of both
correlation between enhanced practice and learning groups were further divided into batches of ten each.
using HFS but no significant correlation was found The Low Fidelity Simulation group was given a case
between the posttest and skills test scores obtained in the scenario of Cardiac arrest on a part task trainer (LFS)
students of the two groups. while the High Fidelity Simulation group was given a
simulated case scenario of cardiac arrest designed on
Another study conducted by Stellflug SM et.al6 High Fidelity Manikin. Each simulation session lasted
(2017) concluded that HFS in critical emergencies for fifteen minutes.
increases Health Care Providers (HCPs’) ability to recall
valuable knowledge that can positively impact patient’s The students then underwent a focused debriefing
outcomes. of five minutes after each simulation session. On
completion of debriefing, the students were provided
A study by Cynthia A Blum et.al7 (2010) indicated an with a standardized and pretested “Student Satisfaction
overall improvement in self-confidence and competence and Self- Confidence Learning Questionnaire consisting
among nursing students trained on simulation. Another of 13 items (5 items on Satisfaction and 8 items on Self
study by Morfoot et.al8 (2018) concluded that self- Confidence in learning). Each item was rated on a 5 point
efficacy, or the belief in one’s ability to succeed, is a Likert Scale. The questionnaire’s Cronbach’s alpha for
commonly cited outcome of simulation training and can Satisfaction is 0.94 and for self- confidence is 0.87
influence confidence, achievement and performance.
The data collected was tabulated and analyzed for
Cardiac arrest is one of the most common significance in difference of means using two-tailed t -
emergencies encountered by EMTs in real clinical test on Statistical Package for Social Sciences (SPSS)
world, hence self-efficacy in such a situation is of v23.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 33

Results

Figure 1.
The above Figure 1. depicts the comparative total mean scores obtained on the 5 items of satisfaction questionnaire
by the two groups of students with High Fidelity vs low Fidelity simulation. The High Fidelity group gave higher
satisfaction scores on all items except the one pertaining to the variety of learning materials and activities used during
simulation.

Figure 2.
The above Figure 2. depicts the comparative mean score obtained in the 8 items of self -confidence questionnaire
by the two groups of students. The High Fidelity Simulation (HFS) group exuded greater confidence in all parameters
except the one pertaining to the resourcefulness of the techniques in learning simulation.
 34 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table No 1: p value for 13 items of Student Satisfaction and Self Confidence in Learning
Questionnaire:

Satisfaction p Value

Teaching methods used in simulation helpful and effective 0.00004*

Promote learning the medical and surgical curriculum 0.59

Enjoyed the simulation 0.006*

Teaching materials used in simulation was helpful and

0.14
effective

Way the simulation taught was suitable 0.24

Confidence

Mastering the content of simulation activity 0.00002*

Simulation covered critical content necessary for the mastery

0.00002*
of medical and surgical curriculum

Developed skills and obtained required knowledge from

0.00002*
simulation to perform necessary task in clinical settings

helpful resource to teach the simulation 0.0001*

Responsibility as a student to learn what is needed to know

0.09
from simulation activity

To get help when didn’t understand the concepts covered in

0.002*
simulation

To use simulation activities to learn critical aspects of these

0.0001*
skills

Instructor responsibilities to tell what is needed to learn out

0.0008*
of simulation content

*indicates significance
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 35

Discussion: satisfaction thereby boosting the self-efficacy of

EMS students. Repeated sessions of HFS for various
The study aimed to compare the self-efficacy after
a cardiac arrest reported by EMS students after a cardia emergencies can further augment self-efficacy among
arrest algorithm on Low Fidelity Simulation (LFS) vs students. This can be explored in future research.
High Fidelity Simulation (HFS). In terms of satisfaction,
Ethical Clearance – IEC, SIU
2 items on the questionnaire showed statistical difference
between the two groups. Source of Funding - Nil

The students in HFS group found the High Fidelity Conflict of Interest - Nil
methodology to be more helpful and effective. Also
the students reported greater enjoyment during the References
simulation activity on the High Fidelity manikin. It is
1. Morfoot, C, Stanley, H, Ohlenburg, H, Hessler, M,
essential that students enjoy a learning activity in order
Zarbock. A Simulation-based education for neonatal
to increase the retention of knowledge and to motivate
skills training and its impact on self-efficacy in
the students to participate in further learning activities.
post-registration nurses. Infant. 2018;14(2): 77-81.
In terms of confidence, the HFS group reported 2. Lauria, M.J, Gallo, I.A, Rush, S, Brooks, J, Weingart,
statistically significant higher scores in 6 out of the 8 S.D. Psychological Skills to Improve Emergency
items on the questionnaire. The students agreed that Care Providers’ Performance Under Stress. Annals
coverage of critical content necessary for mastering the of Emergency Medicine. 2017;70(6): 884-890.
topic of cardiac arrest algorithm was achieved better with 3. Massoth, C, Röder, H, Ohlenburg, H, Hessler,
high Fidelity technique. The HFS group considered High M, Zarbock. A High fidelity is not superior
Fidelity as a better alternative for developing skills and to low-fidelity simulation but leads to
obtaining knowledge on the subject. The students also overconfidence in medical students. BMC Medical
felt more confident regarding the utility of simulation foundation. 2019;19(29): 1464-1467.
activities in learning, role of facilitation and instructor’s
4. Hoadley, T.A. A Comparison Study of the Effects
responsibilities in HFS.
of Low - and High-Fidelity Simulation, Nurs
Interestingly the LFS group reported greater Educ Perspect. Learning Advanced Cardiac Life
confidence in attributing simulation as a helpful resource Support. 2009;30(2): 91.5.
in learning. 5. Stellflug, S.M, Lowe, N.K. The Effect of High
Fidelity Simulators on Knowledge Retention
This finding indicates greater comfort zone shown and Skill Self-Efficacy in Pediatric Advanced
by students to LFS as they are routinely exposed to the Life Support Courses in a Rural State. Pediatr
technique during the course. HFS being a new technique Nurs. 2018;39(0): 21-26.
shall need more frequent exposure to be considered as a
6. Cynthia a Blum. High-Fidelity Nursing Simulation:
truly precise and helpful resource.
Impact on Student Self-Confidence and Clinical
Conclusion Competence. Int J Nurs Educ Scholarsh. 2010;7(18).
7. Nlnorg. Nlnorg. [Online]. Available from: http://
The findings of the study favor the use of High
www.nln.org/about/who’s-who-at-the-nln/
Fidelity Simulation (HFS) as the preferred methodology
management-team-bios/beverly-malone Accessed
to teach cardiac arrest algorithm to EMS students.
24 August 2019.
A single session positively impacted confidence and
 36 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Concept Map Prebriefing versus Traditional Prebriefing in

Ischemic Stroke Management amongst EMS Students of Pune,
India

Parag Rishipathak1, Shrimathy Vijayraghavan2, Anand Hinduja3

1
Director, 2Medical Officer, Academics, Pune, India, 3Adjunct Faculty, Symbiosis Centre for Health Skills,
Symbiosis International (Deemed University), Pune, India

Abstract
Introduction: Worldwide, stroke is the commonest cause of mortality after coronary artery disease. Majority
of the stroke cases present in Emergency Department (ED). Therefore, the clinical acumen of medical staff
in pre-hospital and ED in assessment of stroke is can significantly reduce the morbidity and mortality.
Prebriefing helps to build confidence before exposure to the clinical scenario. This can prove to be very
helpful in ischemic stroke assessment.

Objective: To study difference in competency performance amongst EMS students who participate in
concept Map Prebriefing versus Traditional Prebriefing in clinical simulation scenario on Ischemic Stroke
Management.

Methodology: Seventy-two PGDEMS students were chosen for the study by convenience sampling. The
students were divided into two groups, A and B of 36 each after matching for age, sex and previous course
grades. On the day of Simulation session, Group A was administered traditional prebriefing while Group
B underwent Concept Map Prebriefing on the topic of Ischemic Stroke. The prebriefing concluded with
narration of a case of Ischemic stroke. Each group was further subdivided into 6 smaller groups for ease
of conducting assessment. A structured debriefing for each subgroup lasting for 20 minutes followed the
Simulation session. The competency performance was scored using The LAPSS survey. The score obtained
by a group could range from 0 to 8.

Discussion: The students prebriefed by the concept map methodology scored better than their peers on
a number of parameters including key points in history taking. The above findings emphasize the role of
comprehensive concept map prebriefing in impacting the student performance as measured by the LAPSS
survey.

Conclusion: Traditional prebriefing orients the student to simulation environment but is found to be inferior
to concept map prebriefing in terms of improving competency performance assessment in ischemic stroke.

Keywords: rebriefing, Concept Map, Ischemic Stroke, high fidelity Simulation.

Introduction Ischemic and Hemorrhagic. Ischemic stroke is by far

the commonest, accounting for 85% of all strokes while
The World Health Organization (WHO) defines
hemorrhagic stroke accounts for the rest.
stroke as “rapidly developing clinical
Worldwide, stroke is the commonest cause of
Signs of focal (at times global) disturbance of
mortality after coronary artery disease. In addition,
cerebral function, lasting more than 24 hours or
it is the commonest cause of chronic adult disability.
leading to death with no apparent cause other than More than four-fifth of all strokes occur in developing
of vascular origin”1. It is classified into two major types: countries In contrast to industrialized Western countries
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 37

where there has been a steady decline in stroke over the contribution of prebriefing in building competencies.
past 30 years. India is currently facing the challenge of a An emerging alternative view to traditional prebriefing
high stroke incidence.3 8–12% of patients die within 30 is utilization of concept mapping. Concept Mapping
days of their first stroke and those that survive the first serves to connect the cognitive and reflective processes
attack are at increased risk of a recurrence4. Hence, early in a framework that is understandable to the learner. It
assessment and management of patient is of paramount enables them to use pre-existing knowledge and their
importance. assessment of a situation to develop clinical decision-
making skills.9
Majority of the stroke cases present in Emergency
Department (ED). Therefore, the clinical acumen of This can prove to be very helpful in ischemic stroke
medical staff in pre-hospital and ED in assessment assessment.
of stroke is can significantly reduce the morbidity
and mortality. Identifying signs and symptoms of a Objective
suspected stroke patient is a challenging task. Usage To study difference in competency performance
of standardized tools for assessment can definitively amongst EMS students who participate in concept Map
improve the diagnostic accuracy5. Prebriefing versus Traditional Prebriefing in clinical
Los Angeles Prehospital Stroke Screen (LAPSS) is simulation scenario on Ischemic Stroke Management.
an 8-item survey tool consisting of four items pertaining
to history taking, one item pertaining to blood glucose
Methodology
measurement and three items pertaining to examination Seventy-two PGDEMS students were chosen for
for detecting unilateral motor weakness. The LAPSS the study by convenience sampling. The students were
allows prehospital personnel to identify patients with divided into two groups, A and B of 36 each after
acute cerebral ischemia with a high degree of sensitivity matching for age, sex and previous course grades.
and specificity. The assessment of a suspected stroke
patient involves quick and accurate clinical judgement On the day of Simulation session, Group A was
. Prompt assessment can help prehospital personnel to administered traditional prebriefing while Group B
initiate neuroprotective drug administration in the field underwent Concept Map Prebriefing on the topic of
thereby providing treatment in the narrow therapeutic Ischemic Stroke.
window6. Group A was shown a powerpoint presentation
Varying degrees of simulation have been used on assessment and management of Ischaemic Stroke
to teach cases of ischemic cases of ischemic stroke of and Group B was taught the algorithm of assessment
EMS students. The purpose of simulation is to act as an and management of Ischemic Stroke by a concept map
adjunct to clinical hours, for specialty experiences ,for devised by Danielle Devine 10
competency assessment, for crisis resource management Both groups were given an orientation of the
or team training, and for inter-professional education7. simulation lab, manikin and supplies . The prebriefing
Simulation experiences involve three main concluded with narration of a case of Ischemic stroke.
dimensions: pre-briefing, unfolding the scenario and The prebriefing session lasted for 25-30 minutes for
debriefing. Prebriefing is the first step in a simulation both groups followed by actual simulation session for 10
based education experience. minutes. Prebriefing by both methods was conducted by
In simulation, traditional prebriefing activities assist the same trainer to avoid trainer bias.
learners by introducing scenario objectives, and typically Each group was further subdivided into 6 smaller
include communication of the patient presentation, groups for ease of conducting assessment. The Simulation
participant roles, tasks, time allotment, and an orientation session was followed by a structured debriefing for each
to equipment and to the general environment.8 rebriefing subgroup lasting for 20 minutes.
helps to build confidence before exposure to the
clinical scenario. There are numerous studies, which The entire simulation session was video recorded
have evaluated the impact of debriefing in competency with consent of the students and were later reviewed
assessment, but very few studies have focused on the by two educators to avoid bias. The competency
 38 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

performance was scored using The LAPSS survey. The score obtained by a group could range from 0 to 8.

The data was tabulated and compared for difference in means.

Result
Table 1. Traditional Prebriefing Group: The below tables show the scores obtained by each group on the
items of LAPSS survey.

Subgroup Subgroup Subgroup Subgroup Subgroup Subgroup

CRITERIA
1 2 3 4 5 6

Age over 45 years Y Y Y Y Y N

No prior History of Seizure

N N Y Y N N
Disorder

New onset of Neurologic

N N Y N N Y
Symptoms in last 24 hours

Patient was ambulatory at

Y Y N N N N
baseline

Blood Glucose between 60 and

Y Y Y Y Y Y
100

Facial Grimace Y Y Y N Y N
Grip Y Y Y N Y N
Arm Weakness Y Y Y Y Y N
Y Score out of 8 6 6 7 4 5 2

KEY: Y indicates ‘assessment done’ as per LAPSS survey

N indicates ‘assessment not done’ as per LAPSS survey

Table 2. Concept Map Prebriefing Group

Subgroup Subgroup Subgroup Subgroup Subgroup Subgroup

CRITERIA
1 2 3 4 5 6

Age over 45 years Y N Y Y Y Y

No prior History of Seizure Disorder Y N Y Y N Y

New onset of Neurologic Symptoms in last

Y Y Y Y Y Y
24 hours

Patient was ambulatory at baseline Y Y Y Y Y Y

Blood Glucose between 60 and 100 Y Y N Y Y Y

Facial Grimace Y Y Y Y Y Y
Grip Y Y Y Y Y Y

Arm Weakness Y Y Y Y Y Y

Y Score out of 8 8 6 7 8 7 8
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 39

Discussion

Figure 1. : Average score obtained on each parameters in Concept Map based Prebriefing
versus Traditional Prebriefing Groups

As seen in figure 1. the students prebriefed by the concept map methodology scored better than their peers on a
number of parameters including key points in history taking.

Figure 2: Items pertaining to History Taking

Five out of 6 subgroups of students who had concept the event. Contrastingly the students who underwent
map prebriefing were successful in ascertaining the age of traditional prebriefing performed poorly on the history
patient as being over 45 years and history of past seizure taking with four of the six groups failing to inquire about
whereas all 6 groups were successful in seeking history history of prior seizure and ambulatory status while only
of existence of neurologic symptoms in last 24 hours and one group found it significant to inquire about the history
the information regarding ambulation of patient before of neurologic symptoms in last 24 hours.
 40 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Figure 3. Items determining unilateral weakness

As seen in figure 3, in terms of clinical examination all the concept map prebriefing subgroups performed
excellently and assessed all the three key parameters for unilateral weakness.

The traditional prebriefing subgroups weren’t far behind in accurate assessment. Although two subgroups missed
assessing the facial grimace and grip.

Figure 4. Blood Glucose Measurement

The concept map prebriefing subgroup did not cover Concept maps help users develop critical thinking
the aspect of blood glucose measurement in a suspected and clinical judgment to support informed decision-
stroke patient. This was reflected during the simulation making. It enables them to use pre-existing knowledge
activity when one subgroup failed to perform this action. and their assessment of a situation to develop clinical
All subgroups in the traditional prebriefing successfully decision-making skills. The cyclical, rather than linear
carried out blood glucose measurement. nature of learning, in terms of reflecting on prior
experience during prebriefing for example facilitates the
LAPSS is a reliable tool to assess competency
continual development of decision-making skills and
performance in an ischemic stroke patient. The above
competent judgment in practice, and contributes to a
findings emphasize the role of comprehensive concept
more meaningful experience.
map prebriefing in impacting the student performance as
measured by the LAPSS survey.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 41

Conclusion Connors jj, Demaerschalk BM. Et al Guidelines for

the early management of patients with acute ischemic
Traditional prebriefing orients the student to
stroke: a guideline for healthcare professionals
simulation environment but is found to be inferior
from the American Heart Association. American
to concept map prebriefing in terms of improving
Stroke Association Stroke. 2013;44(0): 870-947.
competency performance assessment in ischemic stroke.
Further studies involving more students and multiple 6. Meakim, C, Boese, T, Decker, S, Franklin, A.E,
simulation sessions would be required to reaffirm the Gloe, D. Standards of best practice: Simulation
findings. standared. Terminology Clinical Simulation in
Nursing. 2013;9(0): 3-11.
Source of Funding: Self 7. Kidwell, C.H.E.L.S.E.A.S, starkman, S.I.D.N.E.Y,
Conflict of Interest: Nil eckstein, M.A.R.C, weems, K.I.M.B.E.R.L.Y,
saver, J.E.F.F.R.E.Y.L. Identifying Stroke in the
Ethical Clearance: Taken from IEC, SIU Field Prospective Validation of the Los Angeles
Prehospital Stroke Screen (LAPSS) . Stroke.
References 2000;31: 71-76.
1. Hill, M.D, Liebeskind, D.S, Roberts, S. Case 8. Tyerman, J, luctkar-flude , M, graham , L, coffey,
fatality rates after hospital admission for Olsen-lynch , E. Pre-simulation preparation and
stroke. BMJ. 2003;326(0): 1085-1086. briefing practices for healthcare professionals
2. Welch, K.M.A. Statins for the prevention and students: a systematic review protocol. JBI
cerebrovascular disease: The rationale for Database System Rev Implement Rep . 2016
robust intervention. European Heart Journal Aug;14(8): 80-89.
Supplements. 2004;6(0): 34-42. 9. Page-cutrara , K, Turk, M. Impact of prebriefing
3. Tapas kumar banerjee, Shyamal kumar das. Fifty on competency performance, clinical judgment and
years of stroke researches in India. Ann Indian experience in simulation: An experimental study.
Acad Neurol. 2016;19(1): 1-8. Nurse Educ Today. 2017 Jan;48: 78-83.

4. Diener, H, Wong, P. Developments in secondary 10. Devine, D.A.N.I.E.L.L.E. Https://prezicom/

stroke prevention. European Neurological hgd8n0fspczk/stroke-concept-map/. [Online].
Review. 2008;3(2): 50-57. Available from: https://prezi.com/hgd8n0fspczk/
stroke-concept-map/ [Accessed 2011 February].
5. Jauch, E.C, Saver, J.L, Adams, H.P, Bruno, A,
 42 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Incidence, prevalence and mortality rates of malaria in India,

1990-2015: an analysis for the global burden of disease study

Ravi Prakash Jha1Krittika Bhattacharyya2 Nisha Tiwari1 Durgesh Shukla1Pawan Kumar Dubey1
1Research Scholar, Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University,
Varanasi, Uttar Pradesh, 2Research Scholar, Department of Statistical Genomics, National Institute of Biomedical
Genomics, Kalyani, West Bengal

Abstract
Introduction: Malaria is the most important parasitic diseases of humans and one of the leading causes of
morbidity and mortality in tropical countries as far parasitic disease is concerned. India is the most populous
country in which malaria is common. About 95% population in the country resides in malaria endemic areas
and 80% of malaria reported in the country is confined to areas consisting 20% of population residing in
tribal, hilly, difficult and inaccessible areas.

Data &Methods: In this study, the 2015 global burden of diseases, injuries and risk factors (GBD) data
were used to measure the incidence, prevalence, mortality, and disability-adjusted life years lost (DALY)
rates of malaria during 1990–2015.Age and gender-specific causes of death for malaria were estimated using
cause of death ensemble modeling.

Result: The number of new cases of malaria declined from 82.16million (95% UI 41.22–151.76 million)
in 1990 to 74.83 million (95%UI 34.72–144.45) in 2015.Age-standardized mortality rate of malaria has
declined by 41.07% between 1990 and 2015.The number of DALY due to malaria decreased from6.41
million (95% UI 5.52–7.42 million) in 1990 to 3.76million (95% UI 2.95–4.79 million) in 2015 with a total
reduction of 41.31%.

Conclusion: India has achieved the MDG target related to malaria. In order to achieve SDG target of
eliminating malaria by 2030, the Strategic Plan should aims at improving the availability and access to
health care primarily to people residing in high-risk geographic areas, women and children.

Key words: Malaria, Mortality, Incidence, Prevalence, DALY

Introduction is changing. The malaria-endemic countries with limited

health facility are still more prone to death due to
Malaria is the important parasitic diseases of humans
malaria.1-2
and one of the leading causes of morbidity and mortality
in tropical countries as far parasitic disease is concerned. India is the most populous country in which malaria
Once believed and preached that most serious and is common.1More than 90% of country population
life-threatening complications of malaria patients are settles in malaria endemic area. Also, 80% of malaria
caused only by Plasmodium falciparum infection, while reported in the country is constrain to area with around
Plasmodium vivax infections are relatively mild, run a 20% of population nest in tribal, hilly and difficult to
benign course and usually do not require hospitalization reach areas.3The cases and deaths reported by the Indian
Government are concentrated mainly in a few states in
east and northeast India.4 Because the Indian national
Corresponding Author: malaria Programme cures nearly all the cases it treats,
Pawan Kumar Dubey it detects only about 1000 malaria deaths each year, and
E-mail: [email protected] misses most deaths caused by malaria.5 WHO estimates
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 43

that malaria causes only about 15000 deaths each year population. The unique geographic position of India
in India (5000 children, 10000 adults), but this too in the world makes it one of the most topographically
depends indirectly on the low death rates in diagnosed and climatically diverse country. In India, malaria cases
patients.1Small studies in specific regions of India or in are reported almost throughout the year, since a perfect
special sub populations cannot directly estimate national combination of average temperature (15-30°C), rainfall
numbers of malaria deaths.5–13 and precipitation-inducing conditions persist across the
different parts of the country over all the seasons.22The
India has experienced malaria burden from the eastern and central regions of India are the most exposed
time long past. In 1950s India faces the worst period to malaria.23
of malaria incidences with 75 million estimated cases
and about 0.8 million deaths per year.3The launch of the Data sources
National Malaria Control Program (NMCP) resulted in
a drastic drop of malaria cases to less than 50,000 with The comprehensive source of data and rigorous
no reported malaria mortality in 1961. However, malaria analysis has been used by GBD 2015 to measure cause-
staged a dramatic comeback, with 6.45 million estimated specific mortality rates and risk factors for 188 counties.
20The key sources of data to model the burden of
malaria cases in 1976.14Since then, a downward trend of
reported cases has begun, though slowly, as confirmed malaria in India included verbal autopsy (VA), Medical
cases came down from 3 million in 1996 to 1.8 million certification of cause of deaths, National Family Health
cases with about 1,000 deaths in 200515 and 1.5 million Surveys (NFHS), other surveys on cause of death and
reported cases and 1173 deaths in 2007. published scientific articles.20

According to the World Malaria Report 2014, 22% Causes of death modelling
(275.5m) of India’s population live in high transmission Causes of death by age groups, gender and year
(> 1 case per 1000 population) areas, 67% (838.9m) live for malaria were measured using ensemble modeling
in low transmission (0–1 cases per 1000 population) (CODEm) by the GBD collaborators. A detailed
areas and 11% (137.7m) live in malaria-free (0 cases) description of CODEm is reported elsewhere.18,20,24-25.
areas.16 In 2013, 0.88 million cases have been recorded, CODEm tests a various models, for example mixed
with 128 million tests being conducted on the suspected effects linear models and spatial–temporal Gaussian
cases, with P. falciparum causing 53% and P. vivax process regression (ST-GPR)models and formulate an
causing 47% of the infections. The incidence of malaria ensemble model rest on the performance of the different
in India accounted for 58% of cases in the South-East models.20 In this model, uncertainty intervals (UI) are
Asia Region of WHO.16 generated by sampling the posterior distribution of
The World Health Organization (WHO) recently each component model in proportional to the weight of
launched the global technical strategy (GTS) for malaria, each model in the ensemble. Vital registration and VA
which aims to reduce the incidence and mortality rates data were reformed for debris codes based on the GBD
of malaria at least by 90% by 2030.To achieve the GTS algorithm.20
and SDG malaria targets, malaria endemic countries DALY, due to malaria, was measured by summing
should have robust surveillance and health management years of life lost (YLL) due to premature mortality and
information systems to monitor mortality and incidence years lived with disability (YLD), a measure of non-
rates of malaria.17 fatal health loss, in a single metric. One DALY can be
In the present article, global burden of diseases, considered as equivalent to one lost year of healthy life.
injuries and risk factors-2015 (GBD) data18–21were YLL were approximated by using classic GBD methods
utilized to estimate the incidence, prevalence, mortality, by which each death is multiplied by the normative
and disability-adjusted life years lost (DALY) rates of standard life expectancy at each age. YLD were
malaria for the period 1990–2015. determined utilizing sequelae disability weights and
prevalence, which is obtained from the general public (a
Method population-based study) of to earmark disability weights
to each sequela and combination of sequelae.26-27
India, with a population of nearly 1.25 billion, is the
second most populous country in the world with diverse
 44 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Results The reduction of age-standardized incidence and

mortality rates of malaria were more marked between
The number of new cases of malaria declined
2005 and 2010. Like mortality and incidence rates,
from 82.16million (95% UI 41.22–151.76 million) in
a reduction of (57.59%) was observed for the age-
1990 to 74.83 million (95%UI 34.72–144.45) in 2015.
standardized prevalence rate over the last 25 years (Fig.
Age-standardized incidence rate among all ages and
2).The number of DALY due to malaria decreased from
gender declined by 30.43% over the 25 years. Malaria
6.41 million (95% UI 5.52–7.42 million) in 1990 to
caused an estimated 87846.6 deaths (95% UI 77223.40–
3.76million (95% UI 2.95–4.79 million) in 2015 with
101061.07) in 1990 and 70703.34 deaths (95% UI
a total reduction of 41.31%. Similarly, age standardized
54588.13–94705.82) in 2015, a 19.52% reduction over
DALY rate declined by 52.59% during the same period
the 25 years. Age-standardized mortality rate of malaria
(Table 1).The reduction of age-standardized DALY rate
has declined by 41.07% between 1990 and 2015(Table
was marked during 2005 and 2010 (Fig. 3). The age-
1).Malaria mortality rate was highest among neonates
standardized DALY rate was higher among neonatal and
(7–27 days), post-neonatal infants (28–364 days)
post-neonatal period compared to the other age groups
and older individuals (≥65 years) and lowest among
(Fig. 1).
individuals 10–14 years in both gender (Fig. 1).

Table 1: Mortality, incidence, DALY and prevalence rates of malaria and percentage changes between
1990 and 2015

% change
Measure 1990 # or rate (95% UI) 2015 # or rate (95% UI) between 1990
and 2015

# deaths 87846.61 77223.40 101061.07 70703.34 54588.13 94705.82 -19.52

Age-standardized mortality
10.42 9.36 11.69 6.14 4.75 8.16 -41.07
rate/100000

Prevalent cases 39446323.56 29940863.77 49361653.26 20299055.61 14861291.89 28402355.56 -48.54

Age-standardized prevalence
3384.75 2612.86 4200.76 1435.40 1059.03 1993.78 -57.59
rate/100000

Incident cases 82163201.08 41227293.04 151767038.53 74838359.86 34724908.28 144455664.60 -8.91

Age-standardized incidence
7561.26 3801.66 13653.88 5260.15 2442.48 10235.79 -30.43
rate/100000

#DALY 6418034.82 5523235.78 7427264.73 3766703.30 2952781.84 4792343.30 -41.31

Age-standardized DALY
608.91 536.61 690.48 288.66 225.92 366.81 -52.59
rate/100000
 Deaths /100,000
DALYs /100,000

0
5
10
15
20
25

0
200
400
600
800
1000
1200
1400
0-6 days
0-6 days 7-27 days
7-27 days 28-364 days
28-364 days 1 to 4 years
1 to 4 years 5 to 9 years
5 to 9 years 10 to 14 years
10 to 14 years 15 to 19 years
15 to 19 years Male
20 to 24 years
20 to 24 years 25 to 29 years

Male
25 to 29 years 30 to 34 years
30 to 34 years 35 to 39 years
Female

35 to 39 years

Female
40 to 44 years
40 to 44 years
45 to 49 years
45 to 49 years
50 to 54 years
50 to 54 years
55 to 59 years
55 to 59 years
60 to 64 years
60 to 64 years
65 to 69 years
65 to 69 years
70 to 74 years
70 to 74 years
75 to 79 years
75 to 79 years

Fig. 1 Mortality and DALY rates by gender and age group in 2015
80+ years
80+ years
Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1
45
46 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

14
Mortality per 100,000 12

10

6 Male

4 Female

0
1990 1995 2000 2005 2010 2015
Year

6000

5000
Prevalence per 100,000

4000

3000
Male
2000 Female
1000

0
1990 1995 2000 2005 2010 2015
Year

9000
8000
Incidence per 100,000

7000
6000
5000
4000 Male
3000 Female
2000
1000
0
1990 1995 2000 2005 2010 2015
Year

Fig. 2Age- standardized malaria mortality, prevalence and incidence rates in males and females between 1990 and 2015
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 47

900
800
700
DALY per 100,000

600
500
400 Male
300 Female
200
100
0
1990 1995 2000 2005 2010 2015
Year

Fig. 3 Age-standardized DALY rates of malaria by gender and year

Discussion 2017.30Malaria control measures in India include

There is a targetDiscussion
(6C) in MDG which says of haltingimproved mortalityaccess
rate from malaria
to early by 2015
diagnosis, theand
involvement
begun
There istoa target
reverse (6C)the incidence
in MDG whichofsaysmalaria. This target
of halting have beensocial
of the accredited encouraging worldwide
health activists (ASHAs) at the
28
although
mortality ratethere
fromweremalariavariations
by 2015amongand regions
begun to community India
and countries. level, has shown someofprogress
the introduction artemisinin-based
in reversing
reverse the incidencethe burden
of malaria.of malaria in the
This target havelast two combination
been decades. Mortality
therapy,and andincidence
intensified rates of control,
vector
malaria declined
encouraging worldwide by although
around 41% thereand 30%,
were respectively,
variations between 1990 and 2015 [Table 1].
including long-lasting insecticidal nets (LLINs). In
amongAs per the report
regions of WHO,
and countries. in Southeast
28India
has shown Asia out of most
some totalof
malaria casestheIndia
the states, recentcontributes
declines in77%. malaria cases
Mostinofreversing
progress the population
the burdenhas little or no in
of malaria immunity
the last towards malaria due to the low and unstable
and mortality have been achieved chiefly through the
two transmission dynamic.
decades. Mortality andHowever,
incidence some
rates surveys have shown
of malaria thatcontrol
successful in someoffoci, P. mainly in forested
falciparum, though malaria
areas,
declined bythe transmission
around 41% and 30%, intensity is verybetween
respectively, intense with theprograms
control disease haveburden to a large
had footprint extent
on both Plasmodium
concentrated
1990 and 2015 [Table 1]. in children. Malaria is particularly entrenched in low-income
falciparum and P.vivax malaria, rural
31 areas of
eastern and north-eastern states, but important foci are also present in the central and more
As per
arid the report
western of WHO,
parts of theincountry.
SoutheastAbout
Asia out
95%of population
For prevention
in the country and control
resides of vector borne diseases
in malaria
totalendemic
malaria cases
areas India
and 80% contributes 77%.reported
of malaria Most of inthethe country is confined
(like malaria) to areas
the National Vector where
Borne 20% of Control
Disease
population has little or no immunity towards malaria due Programme
population resides in tribal, hilly, hard-to-reach or inaccessible areas. 29
(NVBDCP) is an umbrella programme. The
to theInlow and unstable transmission dynamic. However,
India malaria cases have consistently declined from attention of theinNVBDCP
2.08 million 2001 to about is on8.4 resource
lakhs inchallenged
some surveys
30 have shown that in some foci, mainly in
2017. Malaria control measures in India include improved access to early diagnosis,NVBDCP
settings and vulnerable groups. 29
the has
forested areas, the transmission intensity is very intense developed the national strategic Plan (NSP) with the
involvement of the accredited social health activists (ASHAs) at the community level, the
with the disease burden to a large extent concentrated support of WHO to provide a road map for making India
introduction of artemisinin-based combination therapy, and intensified vector control,
in children. Malaria is particularly entrenched in low- malaria free by 2027.30
including long-lasting insecticidal nets (LLINs). In most of the states, the recent declines in
income rural areas of eastern and north-eastern states,
malaria cases
but important foci areandalsomortality
present inhave been and
the central achieved
more chieflyHowever,
through the the malaria
successful control
control of P.also faces
strategy
falciparum, though malaria control
arid western parts of the country. About 95% population programs have had
several footprint
challenges to on both
achieve Plasmodium
WHO’s targets to reduce
endemic areas and 80% malaria mortality and incidence rates. Lack of service
31
falciparum
in the and P.vivax
country resides malaria,
in malaria
of malaria reported in the country is confined to areas providers, especially health workers and laboratory
where 20% of population resides in tribal, hilly, hard-to- technicians, compounded by shortage of health assistant/
reach or inaccessible areas.29 supervisors (Male), malaria inspectors and assistant
malaria officers is a main factor affecting surveillance
In India malaria cases have consistently declined and service delivery, particularly in remote areas. Also,
from 2.08 million in 2001 to about 8.4 lakhs in in many districts virtual absence of Rapid Response
 48 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Teams for epidemic/outbreak response is pronouncing. Malar J 2009; 8: 133.

There is still a large gap in allocation for scaling up 7. Tripathy R, Parida S, Das L, et al. Clinical
specific interventions like provision of RDTs, ACT and manifestations and predictors of severe malaria in
LLINs, and for positioning health care delivery and Indian children. Pediatrics 2007; 120: e454–60.
management staff both at district level and state levels
8. Jain V, Nagpal AC, Joel PK, et al. Burden of
to successfully attain universal coverage and impact.29
cerebral malaria in central India (2004–2007). Am
Moreover, inadequate malaria knowledge at J Trop Med Hyg 2008; 79: 636–42.
community and household level, inadequate community 9. Sharma SK, Tyagi PK, Padhan K, Adak T, Subbarao
mobilization, and inadequate appreciation of malaria as SK. Malarial morbidity in tribal communities living
a serious disease with related consequences hinders the in the forest and plain ecotypes of Orissa, India.
target. Ann Trop Med Parasitol 2004; 98: 459–68.
10. Gogoi SC, Dev V, Phookan S. Morbidity and
Conclusion mortality due to malaria in Tarajulie Tea Estate,
India has achieved the MDG target related to Assam, India.Southeast Asian J Trop Med Public
malaria. In order to achieve SDG target of eliminating Health 1996; 27: 526–29.
malaria by 2030, the Strategic Plan should aims at 11. Chaturvedi HK, Mahanta J, Pandey A. Treatment-
improving the availability and access of health care seeking for febrile illness in north-east India: an
primarily to women and children. As a further matter, epidemiological study in the malaria endemic zone.
improving surveillance and taking care of difficult to Malar J 2009; 8: 301.
reach areas play a crucial role in controlling spread of 12. Diamond-Smith N, Singh N, Gupta RK, et al.
the disease with a view towards achieving sustainable Estimating the burden of malaria in pregnancy:
development goal. a case study from rural Madhya Pradesh, India.
Ethical Clearance: Not required. Malar J 2009; 8: 24.
13. Hamer DH, Singh MP, Wylie BJ, et al. Burden of
Conflict of Interest: None malaria in pregnancy in Jharkhand State, India.
Malar J 2009; 8: 210.
Funding: None
14. Panda, M. and Mohapatra, A. (2004) Malaria control-
References An overview in India. J. Hum. Ecol. 15, 101–104

1. WHO. World malaria report 2008. Geneva: World 15. Sharma, V.P. (1996) Re-emergence of malaria in
Health Organization, 2008. India. Indian J. Med. Res. 103, 26–45

2. Nosten F, White NJ. Artemisinin-based combination 16. WHO. World Malaria Report 2014. WHO,
treatment of falciparum malaria. Am J Trop Med Geneva. 2014. Available at http://apps.who.int/iris/
Hyg 2007; 77 (suppl 2): 181–92. bitstream/10665/144852/2/9789241564830_eng.
pdf
3. Assessed from http://www.nvbdcp.gov.in on 28th
August 2017 17. WHO. Global technical strategy for malaria
2016–2030. Geneva: World Health Organization.
4. NIMR, NVBDCP. In-depth Review on Malaria for
http://www.who.int/malaria/publications/
National Vector Borne Disease Control Programme.
atoz/9789241564991/en .Accessed 12 June 2017.
New Delhi: National Institute of Malaria Research
and National Vector Borne Disease Control 18. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya
Programme, 2007. K, Aboyans V, et al. Global and regional mortality
from 235 causes of death for 20 age groups in
5. Kumar A, Valecha N, Jain T, Dash AP. Burden
1990 and 2010: a systematic analysis for the
of malaria in India: retrospective and prospective
Global Burden of Disease Study 2010. Lancet.
view. Am J Trop Med Hyg 2007; 77 (suppl 6): 69–
2012;380:2095–128.
78.
19. GBD 2013 Mortality and Causes of Death
6. Sarkar J, Murhekar MV, Shah NK, van Hutin Y.
Collaborators. Global, regional, and national age-
Risk factors for malaria deaths in Jalpaiguri district,
sex specific all-cause and cause-specific mortality
West Bengal, India: evidence for further action.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 49

for 240 causes of death, 1990–2013: a systematic AA, et al. Global, regional, and national disability-
analysis for the Global Burden of Disease Study adjusted life years (DALYs) for 306 diseases
2013. Lancet. 2015;385:117–71. and injuries and healthy life expectancy(HALE)
20. Murray CJ, Ortblad KF, Guinovart C, Lim SS, for 188 countries, 1990–2013: quantifying the
Wolock TM, Roberts DA, et al. Global, regional, epidemiological transition. Lancet. 2015;386:2145–
and national incidence and mortality for HIV, 91.
tuberculosis, and malaria during 1990–2013: 27. GBD 2015 DALYs and HALE Collaborators.
a systematic analysis for the Global Burden of Global, regional, and national disability-adjusted
Disease Study 2013. Lancet. 2014;384:1005–70. life-years (DALYs) for 315 diseases and injuries
21. Wang H, Liddell CA, Coates MM, Mooney MD, and healthy life expectancy (HALE), 1990–2015:
Levitz CE, Schumacher AE, et al. Global, regional, a systematic analysis for the Global Burden of
and national levels of neonatal, infant, and under-5 Disease Study 2015. Lancet. 2016;388:1603–58.
mortality during 1990–2013: a systematic analysis 28. WHO. Health in 2015, from MDG to SDG. Geneva:
for the Global Burden of Disease Study 2013. World Health Organization; 2015. Available
Lancet. 2014;384:957–79. athttp://www.who.int/topics/millennium_
22. Bhattacharya, S. et al. (2006) Climate change and development_goals/diseases/en/
malaria in India. Curr. Sci. 90, 369–375 29. Strategic Plan for Malaria Control in India 2012-
23. Singh, N. and Sharma, V.P. (2002) Patterns of 2017 :A Five-year Strategic Plan. Available at
rainfall and malaria in Madhya Pradesh, central http://nvbdcp.gov.in/Doc/Strategic-Action-Plan-
India. Ann. Trop.Med. Parasitol. 96, 349–359 Malaria-2012-17-Co.pdf
24. Foreman KJ, Lozano R, Lopez AD, Murray CJ. 30. Malaria control strategies in India. Available
Modeling causes of death: an integrated approach athttps://www.nhp.gov.in/world-malaria-
using CODEm. Popul Health Metr. 2012;10:1. day-2018_pg
25. Murray CJ, Ezzati M, Flaxman AD, Lim S, Lozano 31. Srivastava HC, Kant R, Bhatt RM, Sharma SK,
R, Michaud C, et al. GBD2010: design, definitions, Sharma VP, 1995. Epidemiological observations on
and metrics. Lancet. 2012;380:2063–6. malaria in villages of Buhari PHC, Surat, Gujarat.
Indian J Malariol 32:140–152.
26. GBD 2013 DALYs and HALE Collaborators,
Murray CJ, Barber RM, Foreman KJ, Ozgoren
 50 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Effectivness of Structured Exercise Protocol for Post

Menopausal Stress Urinary Inncontinence

Pooja Rajendra Mane1, S. Anandh2, G. Varadharajulu3

1MPTh(Community Health Sciences), 2Professor/Unit Head (Community Health Sciences), 3Dean/Professor/
HOD, Krishna College of Physiotherapy, Krishna Institute of Medical Sciences Deemed to be University, Karad,
Maharashtra, India

Astract
Aim: To study the effect of structured exercise protocol for post menopausal stress urinary incontinence .

Objectives: To evaluate the effectiveness of structured exercise protocol for post menopausal stress urinary
incontinence.

Methods:Ethical clearance was obtained from the Institutional Ethical Committee, KIMSDU, Karad.
Initially the awareness program was conducted in karad and nearby areas. The selected sample was then
studies at Krishna hospital, karad. 58 patients were equally divided into two group using convenient sampling
with random allocation.Group A ( n=29 ) , Group B (n= 29 ). Baseline treatment was IFT and bladder training
program. Group A was given structured exercises, Group B was given conventional exercises.Outcome
measures were analyzed after 6 weeks.

Result: Intergroup comparison in group A result showed improvement in pad test (p= <0.0001).Group
B was statistically extremely significant in improvement in pad test (p = 0.0002).Group A result showed
that improvement in pelvic floor muscle strength (p= <0.0001). whereas Group B showed improvement in
pelvic floor muscle strength (p=<0.0001). Group A result showed improvement in all parts of kings health
questionnaire (p=0.0001) and group B also showed improvement in kings health questionnaire (p= 0.0001)

Intra group analysis reviled one hour pad test, KHQ, PFM strength considered significant in both groups.

Conclusion : The study concluded that structured exercises protocol along with IFT and bladder training
was equally effective in reducing dribbling of urine, improvement in QOL, PFM strength.

Key Words : Urinary incontinence, Post menopausal women , Bladder training, Structured exercises
protocol , IFT

[5,6]
Introduction estrogen during the menopause Structured
exercises:
Post menopause is the final stage of climetric during
which stress urinary incontinence is more common. Specific goal oriented treatment used for treat urinary
Among the symptoms stress urinary incontinence incontinence such as breathing reeducation, functional
interferes in the ADL. Recurrent symptoms of vaginal exercises with use pelvic floor muscles, modified pilates
dryness, hot flushes, etc. lead to urinary tract infection. exercises and progressive vaginal cone exercises.
Prevalence of stress urinary incontinence is 16. 13 % [1].
Estimated age for menopause world widely accepted is Effect of structured exercises :
45-55 years[2,3,4]. Causes of stress urinary incontinence • Improve strength of pelvic floor muscles
are Pelvic floor muscle weakness or damage, Hyper
mobility of the urethra, Persistent heavy straining, • Reduced stress urinary incontinence
Chronic coughing, Neurologic damage, Decreases
• Improve quality of life
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 51

Interferential current therapy ( IFT ) • Subjects waiting for surgical treatment

Interferential therapy helps to improve control of • Subjects with spinal surgery

urination, interferential current stimulates the pudential
nerve which causes the detrusar muscle inhibition and • Subjects with grade 3 and grade 4 osteoarthritis
there is action of slow twitch muscle fiber which causes Rocedure
the control of urination [7].
An approval for the study was obtained from the
Bladder training Protocol committee and institutional Ethical Committee
Behavioral therapy has been used for urinary of KIMSDU. Awareness program was carried out
incontinence since 1940. The aim of behavioral therapy for women in karad and surrounding rural areas near
is to improve bladder control by changing the patient’s Krishna hospital.
behavior, especially patients voiding habits and by It was a comparative study conducted in the
teaching skills for preventing urine loss. There are Physiotherapy Department of Krishna Institute of
number of approaches for behavioral therapy which Medical Sciences. 58 patients were equally divided into
include bladder drill and bladder training, and promote two groups using convenient sampling with random
voiding [8] allocation . Baseline treatment was given both groups
which consist IFT and bladder training . Group A
Method was given structured exercise protocol , Group B was
• Study type: Experimental study given conventional exercises .The patient were selected
according to inclusion and exclusion criteria. Written
• Study design: Consecutive sampling with informed consent was taken and the whole study was
random allocation explained to them . detailed evaluation was done to
• Study duration: 1 year screen the patients.

• Sample size: 29+29 = 58 Group A – structured exercises , IFT , bladder

training ( with progression )
• Place of study: Krishna Hospital, Karad
Group B – conventional exercises , IFT , bladder
Criterion of the study training ( with progression )

Inclusion criteria: Exercises were gave for 6 weeks / 3 alternative days

• Age group of 45- 65 years. After completing 6 weeks with 3 sessions per week,
post-test assessment was taken by using one hour pad
• Subject having history of urinary stress test , kings health questionnaire , pelvic floor muscle
incontinence present at least 4 months. strength .
Exclusion criteria: The interpretation of the study was done on the
• Disable subjects basis of comparing pre-test and post-test assessment
using outcome measures and were statistically analysed.
• Psychiatric illness
52 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Following exercises were given for Group A and B:

Group A ( Structured exercises ) Group B(conventional exercises )

Breathing Reeducation Manual Facilitation

Functional Exrcises with Using Pelivic Floor Muscle Gravity Elimination Exercises

Modified Pilates Activation of Core Stabilization Exercises

Progressive Vaginal Cone Exercises Squatting Exercises

Results
Table No 1 : Comparison of one hour pad test within group

Pre Post P Value T Value Intererence

Considered Extremly
Group A 13.990±6.638 9.8955±6.757 <0.0001 7.233
Significant

Considerd Extremly
Group B 11.525±6.775 9.0187±5.725 0.0002 4.267
Significant

Table No :2 COMPARISION OF PELVIC FLOOR MUSCLE GRADINGS WITHIN THE GROUPS

Pre Post P Value T Value Intererence

Group A 2.0344±0.421 3.6551±0.552 <0.0001 17.674 Extremly Significant

Group B 2.586±0.7328 3.931±0.7987 <0.0001 6.519 Extremly Significant

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 53

Table No :3 Comparison of kings health questionnaire within group

Pre Post P Value T Value Intererence

GROUP A

Part 1 2.63±0.596 2.093±0.60 0.0009 3.679 Extremely significant

Part2 5.40±1.127 3.475±1.118 <0.0001 9.923 Extremely significant

Part3 2.103±0.5571 1.310±0.6038 <0.0001 6.327 Extremely significant

GROUP B

Part1 2.689±0.4100 2.103±0.3868 <0.0001 9.589 Extremely significant

Part2 4.862±1.031 4.137±0.7858 0.0048 3.065 Extremely significant

Part3 2.206±0.4123 1.793±0.4123 <0.0001 4.446 Extremely significant

Table no :4 Comparison of pre-pre and post-post one hour pad test score between the groups

Pre Test Post Test

Group A 13.990.±6.638 11.525±6.775

Group B 6.866±3.75 10.159±6.322

P Value 0.1672 0.0191

Inference Considered Not Significant Considered Significant

Table : 5 Comparison Of Pre-Pre And Post-Post Pelvic Floor Muscle Strength Score Between The Group

PRE TEST POST TEST

Group A 2.0344±0.4211 4.3796±0.5615

Group B 2.2068±0.4913 3.6895±0.7123

P value 0.11569 0.0001

Inference considered not significant considered extremely significant

 54 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table No:6 Comparison of pre-pre and post-post kings health questionnaire score between the groups part 1,2,3

PART 1 pre test post test

Group A 2.637±0.5961 2.0931±0.6307

Group B 2.689±0.4100 2.103±0.3863

P value 0.7017 0.940

Inference considered not significant considered not significant

PART 2

Group A 5.403±1.127 3.4758±1.118

Group B 4.862±1.031 4.137±0.7858

P value 0.0615 0.0116

Inference Not quite significant not significant

PART 3

Group A 2.103±0.557 1.310±0.6038

Group B 2.206±04123 1.793±0.4123

P value 0.4249 0.0008

inference Not significant extremely significant

Discussion In this study , 58 subjects with post menopausal

stress urinary incontinence fulfilling the inclusion and
SUI is serious medical condition that causes perineal
exclusion criteria , between age group 46-65 years were
rashes, pressure ulcers and urinary tract infection. . SUI
taken. Out of 58 subjects Group A had 29 females and
causes psychological stress, disability, social seclusion
Group B had 29 females The mean age of the participants
and economic burden , problems in sexual relationship,
in group A was 52.41±4.99 and in group B 52.62±5.63,
decreased quality of life
which shows there is no significant difference between
40% women suffering from menopause have the mean ages of participants in both groups,
problem of UI with vasomotor symptoms and termed as
Structured exercises with progression like
menopause syndrome.[9,10]
diaphragmatic breathing exercises which are useful to
Reviewing various studies , it was analyzed that the improve pelvic floor muscle strength is found significant
use of electrical nerve stimulation kegal exercises and in preventing urinary incontinence. In this the diaphragm
surgical intervention were the line of treatment routine moves caudally, enlarge thoracic cavity, anterior wall
used for urinary stress incontinence . bulges outward, this decreases urethral pressure and
prevent urinary incontinence which in turn helps to relax
The study was undertaken considering all the abdominal muscles.[11]
mentioned points, and the aim of the study was evaluate
effectiveness of structured exercise protocol for post Functional exercises such as hip abduction and
menopausal stress urinary incontinence . adduction combined with pelvic floor muscular
contractions help in increasing levator ani muscles to
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 55

produce force which may help to improve endurance In the present study, pelvic floor muscle strength
and strength of pelvic floor muscles. [12] Stability showed significant improvement in both groups,
exercises like dead bug exercise might have help to however the post session analysis between the groups
improve stability and coordination of the movements showed structured exercise protocol was better than
and maintain spinal stability [13] Modified pilates conventional exercises program. In structured exercises
exercises is an approach which involves slow controlled program subjects involvement was better because of
movements focusing on posture and breathing, these help of swiss ball, verbal stimulus and biofeedback , so
form of exercises help to increase flexibility of whole participants were able to initiate contract PFM.
body rather than specific muscles [14]A weighted vaginal
cone helps to improve strength of pelvic floor muscles The result from the statistical analysis of present
study supports alternative hypothesis which stated that
In the study, within group analysis of one hour there is equal beneficial effect to subjects treated with
pad test score reveled statically reduction in dribbling structured exercise protocol and conventional exercises
volume of urine after the intervention in both group. in post menopausal stress urinary incontinence. Hence
This test was done by using paired T test. Inter group above study showed that subjects treated with structured
analysis of one hour pad test score was done by using exercises and conventional exercises showed better
unpaired t test. Pre intervention analysis showed no strength, quality of life and reduces stress urinary
significant difference between group A and Group B ( incontinence . This study is simple , safe, and physical
p=0.1672). Post intervention analysis showed significant procedure like structured exercises adjunct with
difference between group A and group B ( P= 0.0191). interferential current therapy are helpful in trating
Thus in this study the dribbling of urine was reduced urinary incontinence in post menopausal women.
after session of both groups. So dribbling volume of urine
was reduced after the 6 week session treatment of both Conclusion
groups, the treatment method were similarly effective in Hence , on the basis of the results of our study , it was
both groups. The reduction of dribbling of urine can be concluded that structured exercise program along with
explained possibly due do stimulation of pudental nerve IFT , bladder training and conventional physiotherapy
which trigger long latency spinal cord reflex response. along with IFT , bladder training shows improvement
In addition to direct motor response, this reflex stimulus in quality of life, pelvic floor muscle strength ,volume
causes a contraction of pelvic floor muscle. These of dribbling of urine in post menopausal women who
contraction strengthen pelvic floor muscle, elevating suffering from stress urinary incontinence.
neck of bladder and resist the outflow of urine.
Conflict of Interest: The author declares that there
For assessing quality of life, kings health are no conflicts of interest concerning the content of the
questionnaire was used. Kings health questionnaire is present study.
a subject’s self administered self report and has 3 parts
consisting of 21 items. . Funding: The study was funded by Krishna Institute
of Medical Sciences Deemed to be University, karad.
In this present study, both groups showed significant
improvement in kings health questionnaire score. Ethical Clearance: The study was approved by
However there is no significant difference in part 1 and Institutional Ethics Committee, KIMSDU
part 2 and there is significant difference in part 3 .After
the 6 weeks subjects can self analyze the all component References
of kings health questionnaire and felt difference after the 1. Uma Singh , Pragati Agarwal Manju Lata Verma
treatment , Diwakar Dalela , Nisha Singh and pushpalata
Part 1,2,3 showed reduction in kings health Shankhwar : Prevalence and risk factors of urinary
questionnaire score , this could be possibly due to incontinence in Indian women : A hospital based
improvement In strength of pelvic floor muscle and survey : Indian journal of urology 2013 Jan – march
relaxation technique 29(1): 31-36
2. Biri , A., Bakar, C.,Maral, M.A(2005) women with
elvic floor muscle strength was evaluated by using or without menopause over age
oxford pelvic floor muscle grading .
 56 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

of 40 in turkry : Conseqenses and treatment 10 .Temml C , Haidinger G,Schmidbauer J,et al:

maturitas,50,167-176 Urinary incontinence in both sexes : Prevalence
3. Kaw, D., Khunnu , B.,& vasishta ,K,(1994), factors rates and impact on quality of life and sexual life.
influencing , the age of natural menopause . journal Neurol Urodyn 2000,19 :259-271.[ Medline] [cross
obstratics and gynecology of India, 44 ,279-277 ref ]
4. Ku,S.Y., Kang, J.W ., Kim, H,,Ku , P,S., Lee ,S 11 V .Zivkovic , M Lazovic , M Vlajkovic et al :
H,Suh.,C. S et al (2004) Reginol differences in digphragmatic breathing exercises and pelvic
age at menopause between Korean – Korean and floor retraining in children with dysfunction with
Korean –Chinese . Menopause ,11,569-574 dysfunctional voiding : EUP J Rehabilitation Med
2012 : 48; 413-21
5. Burns PA ,pranikoff k Nochajski TH , etal : A
comparison of effectiveness of biofeedback and 12 Amanda C Amrian1 Licia Cacclaria 1, Anica C.
pelvic floor muscle exercises treatment for stress Passaro 1 ,Simone R,B. Silveria , Cesar F. Amorian
urinary incontinence in older community dwelling , Jefferson f. Loss , isable C.N .Sacco : Effect of
women . J Gerontol Med Sci. 1993: 48: 167-174 combination action of hip abduction and adduction
on force generation and maintenance : PLOS One12
6. Fantal J ,newman D,colling J , DeLancey J, Keeys
(5) 2017 : May 24
C, McDowell B. urinary incontinence in adult :
Acute and chronic management . clinical practice 13 Farahnaz Emami 1 Soraya Pirouzi 1 Shohreh
Guidelines no 2 Rockville , Maryland : AHCPR Taghizadeh : Comparison of abdominal and lumbar
1996 muscles electromyography activity during two
type of stabilization exercise : Zahedan journal of
7. Shankarganesh A, Arthi M , and Siva Kumar VPR
research in medical sciences2015
:Ift therapy versus pfme for management of urinary
incontinence : journal of physiotherapy research 14 Patrick J culligan , Janet Scherer , Keisha Dyer .
2018:vol 2 : 1.11 Jennifer L., Pristly . Geri Guingon- white . donna
delvecchio , Maegi Vangeli : A randomized clinical
8. Kathryn L . Burgio :Behavioral treatment option
trail comparing pelvic floor muscles training ro a
for urinary stress incontinence : American
pilates exercises program for improving pelvic
Gastroenterology Association 2004; 126: S82-S89
floor muscle strength : international urology journal
9. Henella SM , Kirwan P, Casleden CM, hutchins (2010) 21; 401-408
cj, Breeson AJ (1998) significant improvement
in pelvic floor exercises alone patients having
incontinence . British j obstetric gynecology
95;602406
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 57

Treatment Success Rate among Multi-Drug Resistant

Tuberculosis Patients Registered Under Programmatic
Management of Drug Resistant Tuberculosis Services in
District Amritsar, Punjab, India

Pooja Sadana1, Vishal Verma2, Priyanka Devgun3

1
Associate Professor, Department of Community Medicine, Sri Guru Ram Das Institute of Medical Sciences and
Research, Sri Amritsar, 2District TB Officer, Office of Civil Surgeon, Tarn Taran, Punjab, 3Professor & Head,
Department of Community Medicine, Sri Guru Ram Das Institute of Medical Sciences and Research, Sri Amritsar

Abstract

Background: MDR-TB has become an urgent public health problem worldwide, threatening the global TB
control. The success rate of treating multi drug resistant remains very low.

Method: This cross-sectional study was conducted on all MDR-TB patients who were registered and
being treated under PMDT services in Amritsar district from 1st January 2015 to 31st December 2016. The
treatment outcome with their clinico-demographic determinants was ascertained. Data management and
analysis was done by using Microsoft excel and SPSS.

Results: Out of 110 registered MDR-TB patients, 88 (80.0%) were males and 22 (20.0%) were females. The
various treatment outcomes observed were- 36 (32.7%) cured, 20 (18.2%) treatment completed, 16 (14.5%)
defaulted, 22 (20.0%) died, 11 (10.0%) regimen changed or shifted to XDR TB regime, 5(4.5%) transferred
out. The success rate (cured+ treatment completed) was 50.9%.

Conclusions: On statistical analysis, it was observed that age (p=0.012), weight band of patients under
RNTCP (p=0.040) were significantly associated with the treatment outcome. Other factors like sex, residence,
type of tuberculosis and the HIV status of the patient did not affect the treatment outcome.

Keywords: Multi-drug resistant TB, Treatment outcomes, success rate.

Introduction substantially lower success rates than for drug-sensitive

TB.2
The emergence of Multidrug-resistant TB (MDR
TB) has created increasing constraints on effective Despite progress in tuberculosis (TB) control,
tuberculosis control and has caused tremendous the response to the multidrug- resistant TB continues
morbidity and mortality worldwide. Globally in to be limited. Treatment success remains low, at 55%
2017, there were an estimated 558 000 new cases of globally.1 This is considered to be one of the major
Rifampicin resistant TB (RR-TB), of which almost half challenges to progress towards the country’s targets to
were in three countries: India, China and the Russian end TB by 2025. While prevention of development of
Federation. Among RR-TB cases, an estimated 82% had drug resistance is of paramount importance for ending
multidrug-resistant TB (MDR-TB). Globally, 3.5% of TB, early detection and treatment completion are
new TB cases and 18% of previously treated cases had keys to interrupt on-going transmission.3 Therefore,
MDR/RR-TB, with the maximum proportions (>50% it is imperative to analyze the treatment outcomes of
in previously treated cases) in countries of the former MDR-TB patients treated by standardized 2nd line
Soviet Union.1 The treatment of MDR-TB, is long, chemotherapy. Hence the present study was planned
expensive and requires the use of toxic drugs and has to investigate the treatment outcomes and to assess the
impact of different demographic and clinical conditions
 58 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

on the outcome among MDR-TB patients. Failure: Treatment terminated or need for permanent
regimen change of at least two or more anti-TB drugs in
Method CP because of lack of microbiological conversion by the
The study was a cross-sectional study conducted on end of the extended intensive phase or microbiological
all MDR-TB patients registered and being treated with reversion in the continuation phase after conversion to
second line anti-tuberculosis drugs under Programmatic negative or evidence of additional acquired resistance to
management of drug resistant tuberculosis services in FQ or SLI drugs or adverse drug reactions .
Amritsar City. Died: A patient who dies for any reason during the
Study sample course of treatment.

All MDR-TB patients registered from 1st January Transfer out: A patient who has been transferred to
2015 to 31st December 2016. another reporting unit (DR-TB Centre in this case) and
for whom the treatment outcome is not known.
Inclusion criteria
Regimen changed/shifted to XDR: A TB patients
All drug sensitivity tested (DST) confirmed MDR- need for permanent regimen change of at least one or
TB cases who signed written informed consent. more anti-TB drugs prior to being declared as failed/A
MDR-TB patient who is found to have XDR-TB by
Exclusion criteria an RNTCP certified CDST laboratory and who has
Critically ill patients and pregnant females were subsequently switched to a regimen for XDR-TB
excluded from the study. treatment initiation.

Data collection and analysis Outcomes were classified as Favourable outcome

which includes cured and treatment completed patients
A total of 110 patients registered with District and Unfavourable outcome that includes cases with
Tuberculosis Centre (DTC), Amritsar and being treated outcome as defaulted, died, transferred out and those
with second line anti TB drugs were included in the who were shifted to XDR TB or changed regime. Cured
study. A pre-designed and pre – and treatment completed, these together define treatment
success.
tested proforma was administered to the subjects
after taking his/her consent. The consent of the caretaker All the information so collected was compiled,
or guardian/parent was sought on behalf of all child analyzed statistically with help of SPSS version 20.Chi-
participants. Questionnaire included questions regarding square test was used to evaluate differences in categorical
the socio-demographic and clinical profile, of the variables and p<0.05 was considered to be significant.
patients. The possible outcomes of the MDR TB patients
under DOTS can be: cured, treatment completed, died, Ethics: The research proposal was approved by the
failure, defaulted, regimen changed/shifted to XDR and college ethical committee at the time of commencement
transferred out.3 of the study.

Cured: Treatment completed as recommended by Source of Funding: Nil

the national policy without evidence of failure and three Conflict of Interest: Nil
or more consecutive cultures taken at least 30 days apart
during CP are negative including culture at the end of
treatment.

Treatment completed: Treatment completed as

recommended by the national policy without evidence
of failure but no record that three or more consecutive
cultures taken at least 30 days apart are negative after
the intensive phase.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 59

Table 1 Treatment outcome of multidrug resistant TB patients

Outcome Frequency Percentage

Cured 36 32.7

Treatment completed 20 18.2

Defaulted 16 14.5

Died 22 20.0

Regimen changed /Shifted to XDR 11 10.0

Transferred out 5 4.5

Table 2: Distribution of cases showing the demographic and clinical factors affecting the treatment
outcome.

Treatment Outcome Significance

Characteristics of patient Favourable* (n=56) Unfavourable** (n=54)

Age (years)
11-25 (n=43) 30 (69.8) 13 (30.2)
26-40 (n=41) 16 (39.0) 25 (61.0) χ2=10.892
df=3
41-55 (n=21) 9 (42.9) 12 (57.1) = 0.012
>55 (n=5) 1 (20.0) 4 (80.0)
Sex
Male (n=88) 43 (48.9) 45 (51.1) χ2= 0.737
df=1
Female (n=22) 13 (59.1) 9 (40.9) =0.391
Residence
Urban (n=67) 34 (50.7) 33 (49.3) χ2= 0.02
df=1
Rural (n=43) 22 (51.2) 21 (48.8) = 0.966
Type of TB
Pulmonary (n=107) 55 (51.4) 52 (48.6) χ2= 0.381
df=1
Extra-pulmonary (n=3) 1(33.3) 2 (66.7) = 0.537

Weight Bands
26-45 (n=48) 19 (39.6) 29 (60.4)
χ2= 6.42
46-70 (n=58) 36 (62.1) 22 (37.9) df=2
= 0.040
>70 (n=4) 1 (25.0) 3 (75.0)
HIV status
Non reactive (n=106) 55 (51.9) 51 (48.1) χ2=1.115
df=1
Reactive (n=4) 1 (25.0) 3 (75.0) = 0.291

*Favourable outcome included Cured and Treatment completed;

 60 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

**Unfavourable outcome included Defaulted, Died, The demographic profile of MDR-TB patients in our
Regimen changed/shifted to XDR . study was similar to other studies, with a majority of
patients, 62(56.4 %), in the economically productive age
Results group (26-55 years) with male patient predominance.5,6
A total of 110 patients with a diagnosis of MDR-TB Our study participants included 88 (80.0%) males and 22
were registered under PMDT services in Amritsar city (20.0%) females. The mean age of the patient was 33.13
during 2015–2016. The total sample comprised of, 88 years. A study conducted in Uttar Pradesh also revealed
(80.0%) males and 22 (20.0%) females. The mean age of that more than 2/3rd of patients were male and the mean
the patient is 33.13 years (SD ±12.4 years), ranging 11 age was 32 years.7 Similar male preponderance was
to 68 years. 84 (76.4%) cases were in the age group of observed in the study by a study on MDR-TB patients
11-40 years. Most of the patients 88(80.0%) were males in Cairo, Egypt and in Indonesia showing that out of the
and 67(60.9%) patients resided in urban areas. Almost total, 72.9% and 68.6% were males respectively. 8,9
all patients, 107(97.3%) had pulmonary tuberculosis
Table 1 revealed the outcome of the total 110
and only 3(2.7%) had extra-pulmonary tuberculosis.
patients, 36 (32.7%) were cured, 20 (18.2%) completed
Maximum patients 58(52.7%) belonged to weight band
treatment, 16 (14.5%) patients defaulted, 22 (20.0%)
of 46-70 kg .Only 4 (3.6%) patients were HIV positive.
died, in 11 patients (10.0%) regimen was changed or
7(6.3%) patients were resistant to both drugs Rifampicin
shifted to XDR TB regime and 5 (4.5%) patients were
and Isoniazid.
transferred out. In the present study, treatment success
Table 1 shows the distribution of cases according to rate, which consist of cured and treatment completed
their treatment outcomes. Out of the total 110 patients, was 50.9%. The result is consistent with reported global
36 (32.7%) were cured, 20 (18.2%) were categorized (52%) and national (56%) MDR-TB treatment success
as treatment completed, 16 (14.5%) patients defaulted, rates.10,11
22 (20.0%) died, in 11(10.0%) patients regimen was
MDR-TB treatment success rate recorded in a study
changed or shifted to XDR TB regime and 5 (4.5%)
conducted in patients from Chinese referral hospitals
patients were transferred out. Treatment success rate
also showed similar success rate.12 Another study
(cured and treatment completed) was 50.9% in the
done in china showed success rate of 57 %.13 A study
present study.
undertaken to analyze the clinical profile and treatment
Table 2 depicts the clinical and demographic factors outcome in pulmonary drug tuberculosis (TB) patients
affecting treatment outcome in MDR TB cases. It is under programmatic management of multidrug resistant
evident from the above table that favourable outcome tuberculosis (PMDT) at a tertiary care center in Mumbai
was seen in younger age group i.e. 11-25 yrs. Out of 110 showed 48.4% of MDR‑TB patients were successfully
patients,30 (69.8%) patients had favourable outcome. treated (cured +treatment completed), 43.47% were
Unfavourable outcome was seen in 80.0% of patients cured, 10.1% completed treatment, 13.04% died, 1.4%
of more than 55 yrs age. The results were found to be failed, 15.4% defaulted, 4.3% stopped treatment due to
statistically significant(p=0.012). 43(48.9%) males and adverse drug reactions and 11.5% transferred.14 Another
13(59.1%) females had favourable outcome. The results study in Karnataka showed that at the end of treatment,
were not found significant. Favourable outcome was 44.2% were cured, 12 defaulted, 9 died, 1 failure and 2
significantly higher among patients with weight band 46- were under XDR TB evaluation.15 Studies in Portugal
70 kg i.e 36(62.1%) as compared to patients belonging and China showed the treatment success of 62% and
to other weight bands (p=0.040). Sex, residence, type of 68.3% respectively.16,17
TB and HIV status of the patient were not significantly
Table 2 shows the clinic-demographic determinants
associated with treatment outcome.
of treatment outcome. Our study observed that
favourable outcome was significantly higher among
Discussion
the age group of 11-25 yrs. 30 (69.8%) patients had
In the present study it was observed that out of favourable outcome. Unfavourable outcome was seen
the total 110 patients, 76.4 % of patients were in age in 80.0% of patients of more than 55 yrs age. Studies
group of 11-40 yrs Similar study by Nair et al in Chennai by Dengkui et al in Shanghai, Nair et al in Chennai and
showed that 70% were in the age group of 15-44 yrs.4 Gafar et al in South Africa on predictors of treatment
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 61

outcome showed that unfavourable outcomes in MDR of MDR TB on DOTS plus regimen: An LG
TB cases were significantly higher among cases >45 hospital, TB Unit, Ahmedabad experience. GMJ.
years.18,4,19 2013;68(2):52-7.
6. Prasad R, Verma SK, Sahai S, Kumar S, Jain A.
Favourable outcome was significantly higher among
Efficacy and safety of kanamycin, ethionamide,
patients with weight band 46-70 kg i.e 36(62.1%) as
PAS, and cycloserine in multidrug-resistant
compared to patients belonging to other weight bands
pulmonary tuberculosis patients. Indian J Chest Dis
(p=0.040). A study by Agarwalla, et al on outcome of
Allied Sci. 2006;48:183-6.
MDR patients that majority of the patients in this study
are of low BMI (<18.5 kg/m2) and their success rate is 7. Venkatesh U, Srivastava DK, Srivastava AK, Tiwari
significantly less compared to patients having BMI more HC. Epidemiological profile of multidrug-resistant
than 18.5 kg/m2.20 tuberculosis patients in Gorakhpur Division, Uttar
Padesh, India. J Family Med PrimCare 2018;7:589-
Other factors like sex, residence, type of family and 95.
HIV status did not affect the treatment outcome. 8. Mohammad A. Tag El Din, Ashraf A. El Maraghly,
Abdel Hay R. Adverse reactions among patients
Conclusion being treated for multi-drug resistant tuberculosis
Treatment of MDR‑TB is major challenge due to at Abbassia Chest Hospital. Egyptian J Chest Dis
the prolonged regimens, multiple drugs used and high And Tuberculosis. 2015;64(4):939-52.
incidence of drug toxicities. This is, in turn, contributes 9. Manurung SMPF, Siagian P, Sinaga BYM, and
to poor treatment adherence and further exponential Mutiara E. Factors related to successful treatment
magnification of drug resistance which can have of drug-resistance tuberculosis in H. Adam Malik
devastating consequences. The treatment success rate hospital, Medan, Indonesia. IOP Conf. Series Earth
(cured and treatment completed) in the present study Environ Sci. 2018;125:012148
was 50.9% which is similar to global treatment success
10. World Health Organization. Global tuberculosis
rates of a 55%. Favourable treatment outcome was
report 2016.Available from: http://www.who.int/
present in 50.9% cases. The predictors of unfavourable
tb/publications/2019/en/. Accessed on Sep29, 2019
outcome were age ≥26 years and weight band of 26-45
under RNTCP 11. Zhao Y, Xu S, Wang L, Chin DP, Wang S, Jiang
G, Xia H, Zhou Y, Li Q, Ou X. National survey of
Bibliography drug-resistant tuberculosis in China. N Engl J Med.
2012; 366(23):2161–70.
1. World Health Organization. Global tuberculosis
12. Liu CH, Li L, Chen Z, Wang Q, Hu YL, Zhu B,
report 2018. Available from: http://www.who.int/
Woo PC. Characteristics and treatment outcomes of
tb/publications/2019/en/. Accessedon Sep29, 2019
patients with MDR and XDR tuberculosis in a TB
2. World Health Organization. Global tuberculosis referral hospital in Beijing: a 13-year experience.
report 2017.Avaailable from http://www.who.int/ PLoS One. 2011;6(4):e19399.
tb/publications/ 2018/en/. Accessedon Sep18, 2019
13. Alene, Kefyalew Addis, et al. “Treatment outcomes
3. Guidelines on Programmatic Management of of patients with multidrug-resistant and extensively
Drug Resistant TB in India. Central TB Division, drug resistant tuberculosis in Hunan Province,
Directorate General of Health Services, Ministry China.” BMC Infectious Diseases.2017;17:573.
of Health & Family Welfare, Government of India,
14. Waghmare MA, Utpat K, Joshi JM. Treatment
New Delhi, 2017
outcomes of drug-resistant pulmonary tuberculosis
4. Nair D, Velaytham B, Kannan T, Tripathy J under programmatic management of multidrug-
P, Harries AD, Natrajan M, Swaminathan S. resistant tuberculosis, at tertiary care center in
Predictors of unfavourable treatment outcome in Mumbai. Med J DY Patil Univ 2017;10:41-5.
patients with multi-drug resistant tuberculosis in
15. Neeta PN, Prashanth N, Ramaprasad G, Gangadhar
India. Int Union Against Tuberculosis and Lung
Goud T, Sameena A R B. A study on outcome of
Disease. PHA. 2017;7(1):32-8.
standardized treatment in multidrug resistance
5. Kapadia VK, Tripathi SB. Analysis of 63 patients tuberculosis patients. Int J Community Med Public
 62 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Health. 2016;3:257-63 Tuberculosis in Shanghai, 2009-2012. Procedia

16. Chen Y, Yuan Z, Shen X, Wu J, Wu Z, Xu B. Environ Sci. 2016;36:12 – 9.
Time to multi-drug-resistant tuberculosis treatment 19. Gafar MM, Nyazema NZ, Dambisya YM. Factors
initiation in association with treatment outcomes in influencing treatment outcomes in tuberculosis
Shanghai, China. Antimicrob Agents Chemother. patients in Limpopo Province, South Africa, from
2018;62:e02259-17. 2006 to 2010: A retrospective study. Curationis.
17. Oliveira O, Gaio R, Villar M, Duarte R. 2014;37(1).
Predictors of treatment outcome in multidrug- 20. Agarwalla A, Bhattacharya S, Dey A, Kar S,
resistant tuberculosis in Portugal. Eur Respir J. Chaudhuri AD. Study of outcome of management
2013;42:1747–9. of MDR-TB cases under programmatic condition
18. Lia D, Gea E, Shenb X, Weia X. Risk Factors of in India. J NTR Univ Health Sci 2019;8:1-4.
Treatment Outcomes for Multi-drug Resistant
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 63

Microbial Contamination of Tooth Paste Tube Orifice

Pooja.M.R1, Jithesh.Jain2, Ananda.S.R2, Bhakti Jaduram Sadhu3, Rohit A Nair4, Aparna H gopalakrishna5
1Post Graduate Student, 2Professor, 3Assistant Professor, Department of Public Health Dentistry, Coorg Institute
of Dental Sciences, Virajpet, Karnataka, India, 4PhD Scholar, A.B.Shetty memorial institute of dental sciences,
Mangalore, Karnataka, India, 5Researcher and Consultant Oral Pathologist, No 21, 11th block, SBM colony,
Srirampura, Mysore

Abstract
Introduction: Tooth brushes are a vital component of routine oral hygiene aids used in promotion of oral
health and prevention of oral diseases. Unfortunately, they are often stored in unsanitary conditions such
as bathrooms. These unsanitary conditions are the settings that harbour millions of different pathogenic
microbes.

Objective: To determine the microbial contamination of used toothpaste tube orifice.

Method: Sealed tooth brush and tooth paste tube were given to individual participants and to the families.
Toothpaste tubes were collected from each family and from individuals after 30 days of usage. Microbiological
samples were collected from the toothpaste orifice using sterile cotton swab. Organisms from swabs were
cultured on selective media (nutrient agar) for the identification of certain groups of microorganisms. Colony
Forming Units (CFU) was calculated using CFU counting unit. Gram staining was done to find out the
nature and character of the organisms.

Results: A Clinical In-vitro study, the mean number of colony forming units was 246.6± 305.73 among
single user and 709.5± 492.61 among multiple users as shown in Table 1. The distribution of microorganism
CFU (Colony Forming Units) among single user and multiple users was found to be statistically significant
(p=0.021).

Conclusion: In the present study, it was found that toothpaste tube can also be the possible source for
potential pathogens that can compromise not only the health of the individual but also the individuals using
the same toothpaste tube.

Keywords: Micro organisms, Toothpaste, Toothbrush, Cross contamination

Introduction has attracted many investigators to conduct clinical and

field trials to provide effective prevention at this level.
With the dawn of 21st century, dentistry has
The increased awareness of the need for good dental
witnessed advances in the arena of diagnosis, treatment
health and the emphasis on preventive procedures
and prevention. Primary level of oral disease prevention
by dentists and dental educators has made the role
of a tooth brush and tooth increasingly important1.
The neglect in the appropriate maintenance of tooth
Corresponding author- brushes is attributed to lack of public awareness on the
Dr. Pooja.M.R possibilities of tooth brush contamination while they are
Post Graduate, Department of Public Health Dentistry stored after brushing.2 The colonization of pathogenic
Coorg Institute of Dental Sciences, Virajpet. micro-organisms on toothbrush while being stored in
Karnataka, India. Pin-571218 unsanitary conditions represents a potential cause of re-
Phone number: 7760789009, 9164509009 contamination of the oral cavity.3 Tooth brushes can get
E-mail: [email protected] contaminated with microorganisms which are present
 64 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

in oral cavity and from the environment. Retention and prosthesis, any systemic diseases and undergone recent
survival of microorganisms on tooth brush after brushing periodontal therapy were excluded. Ethical clearance
represents a possible cause of recontamination of mouth was obtained from the Institutional Review Board.
and other toothbrushes4 Sample Size was calculated to be 40 individuals who
filled the inclusion and exclusion criteria were chosen
Numerous studies have shown that prolonged use and divided into Group I: Consisting of 20 individuals
of the tooth brush facilitates contamination by various and Group II: Consisting of 20 families with minimum
microorganisms such as Streptococcus, Staphylococcus, 3 members.
lactobacilli, Pseudomonas, Klebsiella, Escherichia coli
and Candida. These microorganisms are implicated Method of collection of data:
to cause dental caries, gingivitis and stomatitis in an
individual2. These bacteria are also found to be implicated Top brand of toothpaste which is commonly used
in the causation of many life threatening diseases such as by people was chosen as samples for the study. The
infective endocarditis besides influencing the occurrence average pack size of 200gms, packed in squeeze tubes
of oral diseases such as dental caries and gingivitis5. manufactured within past 6 months was used in the
study.
Microbiological contamination of the oral cavity
has long been a widely discussed topic and the subject of After obtaining the informed consent, a set of sealed
scientific publications; however, the same attention has tooth brush and tooth paste tube were given to individual
not been given to the contamination of toothbrushes6. M. participants and to the families, sealed single toothpaste
Svanberg7 conducted a study to assess the contamination tube and tooth brushes were given depending on number
of toothpaste and toothbrush by Streptococcus mutans of members in the family. All the participants were
and found that fifteen minutes after brushing > lO6 S. instructed to use it for 30 days once daily. Toothpaste
mutans were isolated from the toothbrushes and after tubes were collected from each family and from
ordinary storage for 24 h 104 were recovered. From two individuals after 30 days of usage.
out of 10 toothpaste tubes S. mutans was isolated from Study Procedure:
the orifice of the tube.
Microbiological samples were collected from the
Even though the use of the single toothbrush is mostly toothpaste orifice wearing gloves by using sterile cotton
confined to one individual, the same toothpaste tube is swab moistened with saline which were then kept in
generally used by several family members and hence test tubes containing Robertson’s Cooked Meat Broth.
there is a chance of spread of microorganism through Organisms from swabs were cultured on selective media
the toothpaste tube. There is complete lack of evidence (nutrient agar) for the identification of certain groups of
on contamination of toothpaste by microorganisms from microorganisms. All the agar plates are incubated at 370c
toothbrush or by environment. There is increased need for 24 hours. Agar plates of single users were coded as
to determine the contamination of toothpaste tube orifice SU (1-20) and multiple users were coded as MU (1-20).
by multiple users and by individual users. Hence the
Hypothesis of the study is that toothpaste tube orifice is After incubation, different patterns of colonies of
free of microorganism. microorganisms were identified by observing their colony
morphology on all the agar plates. Colony Forming Units
Materials and Method (CFU) was calculated using CFU counting unit. Gram
In the present Clinical In-vitro study, Subjects staining was done to find out the nature and character
residing individually in hostel rooms who used personal of the organisms. Sub culturing of the required samples
toothpaste tubes and families consisting of minimum 3 were done to isolate the microorganisms. Bio chemical
people who shared a common tooth paste tube.Subjects tests such as Catalase test which will demonstrate the
who brush at least once daily using toothpaste and presence of catalase, an enzyme those catalyses the
between the age group of 25-35 years. Toothpastes of release of oxygen from hydrogen peroxide (H2O2).
participants that are kept inside the bathrooms with It is used to differentiate those bacteria that produce
attached toilets were included.Subjects with history of an enzyme catalase, such as staphylococci, from non-
antibiotics usage 3 months prior to the study, undergoing catalase producing bacteria such as streptococci. 3%
orthodontic treatment or with extensive intraoral H2O2 has been used for the routine culture. Citrate tests
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 65

are used to differentiate among the Gram-Negative Statistical Analysis

bacilli in the family Enterobacteriaceae. Urease test
The data obtained was coded and fed into the
is used as part of the identification of several genera
SPSS (Statistical Package for Social Sciences) version
and species of Enterobacteriaceae including Proteus
17 for analysis. All statistical tests were performed at
and Klebsiella. Indole test is a commonly used
95% confidence interval. A p value less than 0.05 was
biochemical test (e.g. in IMVIC test) which was done
considered as statistically significant.
for 4 samples from each group. Indole test helps to
differentiate Enterobacteriaceae and other genera.

Table 1: Distribution of microorganism CFU among single user and multiple users

Groups Mean Std. Deviation t value Significance

SU 246.60 305.73
0.021
2.525
MU 709.50 492.61 S

<0.05, S – Significant

Table 2: Distribution of microorganism based on gram staining among single user and multiple users

Groups
Gram staining Total
SU MU

12 14 26
+ve
60.0% 70.0% 65.0%
χ2 = 0.220 p = 0.639 NS
8 6 14
-ve
40.0% 30.0% 35.0%

Table 3: Distribution of microorganism strains among single user and multiple users

Groups
Microorganism strains Total
SU MU

14 12 26
Staphylococcus species
70.0% 60.0% 65.0%

4 0 4
Klebsiella species
20.0% .0% 10.0%
χ2 = 5.077
0 2 2 = 0.279
Streptococcus species
.0% 10.0% 5.0% NS

0 4 4
Neisseria species
.0% 20.0% 10.0%

2 2 4
Escherichia coli species
10.0% 10.0% 10.0%
 66 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

The mean number of colony forming units was Staphylococcus, Escherichia, and Pseudomonas in used
246.6± 305.73 among single user and 709.5± 492.61 toothbrushes; while Contreras et al12 reported that the
among multiple users as shown in Table 1. Table 2 most frequent microorganisms found in toothbrushes
shows the distribution of microorganism based on gram used by parents and children for one month were
staining among single user and multiple users. Table 3 Enterobacteriaceae and Pseudomonadaceae. Kozai
shows the distribution of microorganism strains among et al13 also reported that Streptococcus mutans and
single and multiple users. pathogenic microorganisms can be transferred readily
when a toothbrush is used, increasing the risk of dental
Discussion caries and infectious diseases.
Contaminated tooth brush and tooth paste tubes In the present study, distribution of microorganism
have been characterized as a means of microbial strains among single and multiple users are presented
transport, retention and growth. It can be the cause of in the table, the organisms identified are in accordance
reinfection of a person with pathogenic bacteria or can with the study results of Onuorah Samuel et.al14
be the reservoir for environmental microorganisms.6,7 in which Staphylococcus aureus was isolated from
Toothbrushes can become contaminated through contact 60% of the samples while Pseudomonas aeruginosa,
with the environment and bacterial survival is affected by Staphylococcus epidermidis, Streptococcus mutans,
toothbrush storage containers. Dayoub et al.8 found that Escherichia coli and Enterobacter aerogenes was
toothbrushes placed in closed containers and exposure isolated from 50%, 45%, 25%, 20% and 10% of the
to contaminated surfaces yielded higher bacterial counts samples.
than those left open to air.
In the present study two freshly sealed packs were
The mean numbers of colony forming units were checked before the start of the study which did not
246.6± 305.73 among single user and 709.5± 492.61 show any colony formation. This is in contrast with
among multiple user samples. These results are in the study conducted by Efstratiou M et.al15, in which
accordance with the study conducted by M. Svanber73 multiplication of flora on usage at regular intervals and
conducted among 10 individuals, which showed that at different phase of time during the life of tooth paste
on the toothbrushes S. mutans represented 1.5 and 6.0 pack was analysed and the results showed that aerobic
X 10^ CFU 15 min after the cleaning of the teeth. The spores were identified on day 1, where in it was company
results are also in accordance with the study conducted sealed pack and was opened under sterile conditions in a
by Lais Kuhn Rodrigues et.al9, wherein 91% of the laboratory to dispense the sample for testing before any
toothbrushes had some type of microbial growth on use.
them.
Staphylococcus species was detected in 65% of the
In the present study, distribution of microorganism used toothpaste tubes examined, while Staphylococci are
based on gram staining showed that 26 (65%) were gram usually common skin inhabitants. Enterobacter species
positive and 14 (35%) were gram negative organisms. In were also found in 10% of the samples. Escherichia
the study conducted by Snezana Pesevska et.al10, there coli are coliforms and members of the family
was a high contamination of the used toothbrushes at 100% Enterobacteriaceae. They are also pathogenic to humans
of the analyzed samples, with a domination of coliform in significant numbers. The presence of Escherichia coli
bacilli. The results of the present study showed that both on the toothbrushes examined was indicative of fecal
single user and multiple user toothpaste tube orifices contamination. Streptococci species were found to be
were contaminated by different microorganism species 5% in the present study and these are aetiological agents
such as Staphylococcus, Klebsiella, Streptococcus, of tooth decay and are important bacteria found on the
Neisseria and Escherichia coli. These results are in teeth, buccal cavity and throat.
accordance with the study conducted by Jagadeeshwar
Rao Sukhabogii2, in which Pseudomonas, Candida, In the present study biochemical tests are used for
Streptococcus pyogens, Klebsiella, Staphylococcus identification of organisms. According to Holt et al16, the
aureus, Lactobacillus, Proteus and E.coli was morphological and biochemical method of identification
demonstrable in the tooth brush samples preserved in of bacteria is the classical method of characterization of
bathrooms with attached toilets. Bello et al11 reported bacteria. Classical identification of individual bacterial
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 67

species in environmental samples typically involves References

isolation, laboratory culture and then taxonomic
1. Naik R, Mujib BA, Telagi N, Anil BS, Spoorthi
characterization. But, biochemical tests have certain
BR. Contaminated tooth brushes–potential threat to
drawbacks such as less accurate, less discriminatory,
oral and general health. Journal of family medicine
phenotype may be unstable, induceable (i.e. influenced
and primary care. 2015 Jul;4(3):444.
by gene expression) and subjective interpretation (less
reproducible)16. Considering the available techniques 2. Sukhabogii JR, Chandrashekar BR, Haritha N,
for identifying LAB isolates, the advanced technique Gujjarlapudi SK, Ramana IV, Lakshmi LJ, Pavani
such as 16S rDNA sequencing and species specific PCR S, Vasundara D. Microbial Contamination of
reactions might give more specific results. Tooth Brushes Stored in Different Settings before
and After Disinfection with Chlorhexidine-A
Different brands of toothpastes are marketed to Comparative Study. Journal of Young Pharmacists.
the public every year. There is a little research and 2015 Oct 1;7(4):486.
information on their contamination by bacteria with use. 3. Wetzel WE, SCHAUMBURG C, ANSARI
In the field of Public Health Dentistry, it is important to F, KROEGER T, SZIEGOLEIT A. Microbial
understand that even though use of tooth brush is confined contamination of toothbrushes with different
to each individual, toothpaste tubes are shared between principles of filament anchoring. The Journal
multiple people especially among family members. of the American Dental Association. 2005 Jun
The use of uncontaminated toothpaste will assist in the 1;136(6):758-65.
maintenance of sound oral hygiene and reduce the health
4. Karibasappa GN, Nagesh L, Sujatha BK.
risk posed by the contaminating bacteria to humans. It is
Assessment of microbial contamination of
recommended to use individualized toothpaste tubes like
toothbrush head: an in vitro study. Indian Journal
the individualized toothbrushes.
of Dental Research. 2011 Jan 1;22(1):2.
Conclusion 5. Boylan R, Li Y, Simeonova L, Sherwin G,
Kreismann J, Craig RG, Ship JA, McCutcheon
In the present study, it was found that toothpaste tube JA. Reduction in bacterial contamination of
can also be the possible source for potential pathogens toothbrushes using the Violight ultraviolet light
that can compromise not only the health of the individual activated toothbrush sanitizer. American journal of
but also the individuals using the same toothpaste tube. dentistry. 2008 Oct 1;21(5):313.
As toothbrushes, Toothpaste tubes may also have an
6. Nelson Filho P, Macari S, Faria G, Assed S, Ito
important role in transferring microorganisms and
IY. Microbial contamination of toothbrushes
increasing the risk of infection, because they can be a
and their decontamination. Pediatr Dent. 2000
reservoir of microorganisms in healthy individuals, in
Sep;22(5):381-4.
those with oral diseases, as well as in those with impaired
general health. 7. Svanberg M. Contamination of toothpaste and
toothbrush by Streptococcus mutans. European
Since Public Health Dentistry underlines the Journal of Oral Sciences. 1978 Oct;86(5):412-4.
prevention and control of infection, it is very important 8. Dayoub MB, Rusilko D, Gross A. Microbial
that they create an awareness about the issue of choosing, contamination of toothbrushes. Journal of dental
keeping and maintaining the hygiene of the toothbrushes research. 1977 Jun;56(6):706-9
and toothpaste tubes, as well as their replacement in
9. Rodrigues LK, Motter CW, Pegoraro DA, Menoli
an optimal time intervals in healthy population and
AP, Menolli RA. Microbiological contamination of
especially in individuals affected with oral or systemic
toothbrushes and identification of a decontamination
diseases.
protocol using chlorhexidine spray. Revista Odonto
Conflict of Interest – No Ciência. 2012;27(3):213-7.
10. Pesevska S, Ivanovski K, Mindova S, Kaftandzieva
Source of Funding- No
A, Ristoska S, Stefanovska E, Pandilova M,
Ethical Clearance – Taken Georgieva S, Dirjanska K, Janeva IP, Koneski
F. Bacterial contamination of the toothbrushes.
Journal of International Dental and Medical
 68 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Research. 2016;9(1):6. Developmental Biology-Plant. 1999 Jul

11. Shin H, Pei Z, Martinez KA, Rivera-Vinas JI, 1;35(4):296-8.
Mendez K, Cavallin H, Dominguez-Bello MG. 14. Samuel O, Michael O. Microbial Contamination of
The first microbial environment of infants born Locally-Prepared Snuff Sold at Eke-Awka Market,
by C-section: the operating room microbes. Anmbra State, Nigeria. American Journal of Life
Microbiome. 2015 Dec;3(1):59. Science Researches. 2016 Jul 10;4(3).
12. Contreras A, Arce R, Botero JE, Jaramillo A, 15. Efstratiou M, Papaioannou W, Nakou M, Ktenas
Betancourt M. Toothbrush contamination in E, Vrotsos IA, Panis V. Contamination of a
family members. Revista clínica de periodoncia, toothbrush with antibacterial properties by oral
implantología y rehabilitación oral. 2010 microorganisms. Journal of dentistry. 2007 Apr
Apr;3(1):24-6. 1;35(4):331-7.
13. Kubota C, Tadokoro N. Control of microbial 16. Szymańska J. Bacterial contamination of water in
contamination for large-scale photoautotrophic dental unit reservoirs. Ann Agric Environ Med.
micropropagation. In Vitro Cellular & 2007 Mar 24;14(1):137-40.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 69

Effectiveness Bearing Down Techniques During Second

Stage of Labour on Maternal and Neonatal Outcome among
Primigravida Mothers

PoonamYadav1, Shital VWaghmare2, Seeta Devi A3, Manuacharoy4

1
Msc, II year M.Sc (N), 2Assistant Professor, 3Assistant Professor, 4Tutor, Symbiosis College of Nursing, Symbiosis
International (Deemed University)Pune, Senapati Bapat Road, Pune

Abstract
Background: Maternal bearing down efforts plays a vital role in expulsive phase of labor. Various types of
bearing down efforts has got its own advantages and disadvantages on mother and fetus. Various studies are
done to evaluate the best bearing down techniques and have different results .The investigator personally
felt there is a need to investigate the best bearing down technique with less complications to the mother
and newborn Objective: 1.To assess the effect of vulsalva bearing down technique during second stage of
labour on maternal and neonatal outcome among primigravida mothers admitted in selected hospitals of
pune city. 2.To assess the effect of spontaneous bearing down technique during second stage of labour on
maternal and neonatal outcome among primigravida mothers admitted in selected hospitals of pune city.3.To
compare the effectiveness of vulsalva bearing down techniques and spontaneous techniques and duration of
second stage of labour on maternal and neonatal outcome among primigravida mothers admitted in selected
hospitals of pune city Methodology: In the present study, Quantitative research approach is applied and
approach is applied and pre experimental ,Post test only control group design is used. The setting of the
study was selected hospital of Pune. The sample size for study was 60, selected by using Non Probability
Purposive Sampling Technique. The structured questionnaire and observation checklist was administered.
In order to establish the reliability of the tool inter rater method was used. The scores were calculated
and the reliability was established by Kappa method, which was 0.90. Results: On Comparison of the
Spontaneous and vulsulva bearing down techniques on various maternal and neonatal outcome. Since the P
values corresponding to the Maternal outcome, oxytocin given, Perineal laceration ,Type of episiotomy, size
of episiotomy ,mode of delivery and fatigue and Neonatal outcome Crown heel length of newborn ,Head
circumference of newborn, Neonate Resuscitation, Admission to NICU,APGAR score are small (less than
0.005) suggests that vulsulva bearing down technique is significantly different that spontaneous bearing
down technique in the above maternal and neonatal outcomes and good result for the health of mother and
newborn Conclusion: The Spontaneous pushing method has a negative effect on various factors related to
maternal and neonatal outcome factors according to the results in this study. Vulsalva pushing has various
benefits towards the better health of Mother and Newborn so it should be accepted as best clinical practice.

Keywords: Effectiveness, Vulsalva Bearing Down , Spontaneous Bearing Down Techniques ,Second Stage
of Labour Neonatal outcome , Maternal outcome

Introduction or back ground voluntary pushing is initiated. Several times this stage
is also referred to as the “pushing” stage . During the
Labor is a physiological process which is normal,
second stage, maternal bearing down efforts aid in fetal
which takes place with the expulsion of the fetus out
descent as the fetus completes the cardinal movements
from maternal uterus into the outside world. Labor is
of labor, rotating and descending through the maternal
divided into three stages. The most challenging stage is
pelvis Maternal bearing-down efforts and their effect on
the second stage .This stage refers to the passage of the
the mother and the fetus have been studied and debated
baby through the birth canal until delivery(6). The second
for decades. Maternal bearing down efforts plays a
stage begins when the cervix has fully dilated and
 70 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

vital role in expulsive phase of labor. Various types of bearing down technique with less complications to the
bearing down efforts has got its own advantages and mother and newborn and increase the knowledge of the
disadvantages on mother and fetus. Mothers who are mothers regarding maternal bearing down efforts.
in 2nd stage of labor must have a knowledge regarding
maternal bearing down efforts when and how to push Material and Method
because if she bear down in 1st stage it may slow down A Pre-experimental study design with quantitative
the FHR during pushing and it should come to normal approach was used, as this study was aimed, the
once the contraction is over and Even comfortable approach was found to be most appropriate. A post test
position during pushing also plays an important role in only control group research design was adopted for the
2nd stage of labor . present study. This study was conducted in selected
The investigator has observed primigravida mothers hospital of Pune city. The selection was based on easy
suffer from complications during 2nd stage of labour geographical accessibility, cooperation and availability
because of the following reasons like lack of knowledge of samples. Total 60 Primigravida mothers from
and practice about when to bear down, how to bear in Yashwantrao RaoChavan Memorial Hospital Pimpri
2nd stage and associated complication on both mother Chinchawad ,Pune city who met the inclusion criteria
and fetus. The researcher referred various research data were selected. Tool used for the collection of data was
conducted data and find that In the present situation a observational checklist and structured questionnaire.
mothers are encountering many problems during the Findings: The analysis and interpretation of the data
time of intra natal period Specially during second stage collected to determine the Effectiveness of bearing
of labour. One of the major problems is management down techniques is carried out based on objectives set
of maternal bearing down efforts. The investigator by the researcher taking the level of significance as 0.05
personally felt there is a need to investigate the best

Table 1: Effect of vulsalva bearing down technique during second stage of labour on maternal outcome
among primgravida mothers admitted in selected hospitals N=60,n30

Maternal outcome Vulsulva Bearing Down technique

Frequency
ercentage (%)

1 No of 10-20 contractions 3 10.00%

contraptions in
late 30 min of 30-40 contractions 6 20.00%
second stage
20-30 contractions 7 23.30%

40-50 contractions 14 46.70%

2 Oxytocin given 75-90 Drops 26 86.70%

91-100 Drops 4 13.30%

3 Fatigue Mild - 1- 3 25 83.30%

Extreme 7-9 4 13.30%

Moderate- 4-6 0 0.00%

Worst Fatigue -10 1 3.30%

4 Perineal IST Degree 3 10.00%

Laceration
IInd Degree 1 3.30%

IIIrd Degree 1 3.30%

No laceration 25 83.30%
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 71

Cont... Table 1: Effect of vulsalva bearing down technique during second stage of labour on maternal
outcome among primgravida mothers admitted in selected hospitals N=60,n30

Medio-Lateral 14 46.70%
Types of
5 Median 0 0.00%
episiotomy
Not given 16 53.30%

- 16 53.30%

2-3 cm 8 26.70%
Size of
6 1-2 cm 4 13.30%
episiotomy
3-5 cm 2 6.70%

5-7cm 0 0.00%

Normal vaginal delivery 17 56.70%

7 Mode of Delivery
Normal vaginal delivery with episiotomy 13 43.30%

Table 2: Effect of vulsalva bearing down technique during second stage of labour on neonatal outcome
among prim gravida mothers admitted in selected hospitals N= 60,n30

Neonatal outcome Vulsalva bearing down technique

Frequency
ercentage (%)

No depression 15 50.00%
1 APGAR score Mild depression 11 36.70%
Moderate depression 4 13.30%

Weight of New- 2.5 kg 24 80.00%

2
born 2.5 to 3.1 kg 6 20.00%
96.8 F 27 90.00%
Temperature
3 of new born 96.8 - 97.70 F 2 6.70%
(axillary)
<96.8 F 1 3.30%
50 cm 24 80.00%
Crown -heel
4 length of New- <50 cm 4 13.30%
born
50 to 52 cm 2 6.70%
35 cm 26 86.70%
Head
5 Circumference of 33 to 35 cm 2 6.70%
New-born
<35 cm 2 6.70%
Only suctioning done 26 86.70%
Neonate
6 Only bag and mask ventilation given 1 3.30%
Resuscitation:
Bag mask ventilation with stimulation 3 10.00%
< 24 hours 0 0.00%

Admission to >24 hours 1 3.30%

7
NICU: 24 hours 3 10.00%
Not required 26 86.70%
 72 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 3: Effect of spontaneous bearing down technique during second stage of labour on maternal outcome
among primigravida mothers admitted in selected hospitals N=60,n=30

Spontaneous bearing down technique

Maternal outcome
Frequency
ercentage (%)

10-20 contractions 5 16.70%

No of contraptions in 30-40 contractions 8 26.70%

1 late 30 min of second
stage 20-30 contractions 7 23.30%

40-50 contractions 10 33.30%

75-90 Drops 16 53.30%

2 Oxytocin given
91-100 Drops 14 46.70%

Mild - 1- 3 20 66.70%

Extreme 7-9 9 30.00%

3 Fatigue
Moderate- 4-6 1 3.30%

Worst Fatigue -10 0 0.00%

IST Degree 19 63.30%

IInd Degree 3 10.00%

4 Perineal Laceration
IIIrd Degree 0 0.00%

No laceration 8 26.70%

Medio-Lateral 27 90.00%

5 Types of episiotomy Median 1 3.30%

Not given 2 6.70%

- 2 6.70%

2-3 cm 6 20.00%

6 Size of episiotomy 1-2 cm 2 6.70%

3-5 cm 15 50.00%

5-7cm 5 16.70%

Normal vaginal delivery 2 6.70%

7 Mode of Delivery
Normal vaginal delivery with episiotomy 28 93.30%
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 73

Table 4: Effect of spontaneous bearing down technique during second stage of labour on neonatal outcome
among primigravida mothers admitted in selected hospitals N=60,n=30

Spontaneous bearing down technique

Neonatal outcome
Frequency
ercentage (%)

No depression 15 50.00%

1 APGAR score Mild depression 12 40.00%

Moderate depression 3 10.00%

2.5 kg 21 70.00%
2 Weight of New-born
2.5 to 3.1 kg 9 30.00%

96.8 F 27 90.00%
Temperature of new
3 96.8 - 97.70 F 3 10.00%
born (axillary)
<96.8 F 0 0.00%

50 cm 20 66.70%
Crown -heel length of
4 <50 cm 0 0.00%
New-born
50 to 52 cm 10 33.30%

35 cm 19 63.30%
Head Circumference
5 33 to 35 cm 0.00%
of New-born
<35 cm 11 36.70%

Only suctioning done 21 70.00%

Neonate
6 Only bag and mask ventilation given 8 26.70%
Resuscitation:
Bag mask ventilation with stimulation 1 3.30%

< 24 hours 7 23.30%

>24 hours 12 40.00%

7 Admission to NICU:
24 hours 0 0.00%

Not required 11 36.70%

Discussion of low 5 min APGAR score for neonates of nulliparous

women in a Swedish study from research group(1). Trauma
In this study analysis, there was comparison on
is an important factor to consider when assessing overall
various components of maternal and neonatal outcome
efficacy of vulsulva bearing down technique .Tears are
first The APGAR Score recorded of the newborns in
a measurable outcome, since they can be categorized in
Vulsulva Bearing Down Techniques have good score
terms of intact perineum, first, second or third degree
as compare to Spontaneous Bearing Down Technique A
tears and episiotomy (2) . Retrospectively requested
study suggesting that prolonged second stage of labour
information about perineal damage in 39 primiparous
is associated with low apgar was refred to compare the
women who had had spontaneous vaginal births.
result , Second stage of labor was Prolonged and it was
Similarly in this study the record of perinieal laceration
reported which were associated with an increased risk
in less when compared with the spontaneous bearing
 74 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

down techniques 2. Hollins Martin CJ. Effects of valsalva manoeuvre

on maternal and fetal wellbeing. British Journal of
Conclusion Midwifery. 2009 May;17(5):279-85.
Vulsulva pushing during in second-stage labour 3. Sampselle CM, Hines S. Spontaneous pushing
is a safe and less exhausting pushing technique, it was during birth: Relationship to perineal outcomes.
not associated with demonstrable adverse outcome .it is Journal of Nurse‐Midwifery. 1999 Jan 2;44(1):36-
significantly, decrease incidence of perineal laceration. 9.
Also it has good outcome in regard to maternal fatigue 4. Prins M, Boxem J, Lucas C, Hutton E. Effect of
and neonatal Apgar score and reduces the chances of spontaneous pushing versus Valsalva pushing in
neonatal resuscitation and fetal injury when compared to the second stage of labour on mother and fetus: a
Spontaneous pushing during the second stage of labour. systematic review of randomised trials. BJOG: An
International Journal of Obstetrics & Gynaecology.
Conflict of Interest – Nil
2011 May 1;118(6):662-70.
Source of Funding- Self 5. Başar F, Hürata SŞ. The effect of pushing
techniques on duration of the second labor stage,
Ethical Clearance – Obtained from Institute and mother and fetus: a randomized controlled trial.
Hospital International J. of Health Services Research and
Policy. 2018;3(3):123-34.
References
6. Dutta DC, Konar H. DC Duttas textbook
1. Sandström A, Altman M, Cnattingius S, Johansson of obstetrics: including perinatology and
S, Ahlberg M, Stephansson O. Durations of second contraception. New Delhi, India: Jaypee, The
stage of labor and pushing, and adverse neonatal Health Sciences Publisher; 2018.
outcomes: a population-based cohort study. Journal
7. Polit, D.F. and Hungler, B.P. (2004) Nursing
of Perinatology. 2017 Mar;37(3):236.
research-principle and methods Lippincott
Williams & Wilkins, Philadelphia.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 75
Review Article

Denture Identification Methods: A Review

Prabhjot Kaur1, Anchal Arora2, Navjot Kaur3

1FormerBDS Student, Genesis Institute of Dental Sciences & Research, Ferozepur, Punjab,
2
Tutor, Genesis Institute of Dental Sciences & Research, Ferozepur, Punjab, 3BDS Intern, Genesis Institute of
Dental Sciences & Research, Ferozepur, Punjab

Abstract
Denture marking is accepted as a means of identifying dentures and persons in geriatric institutions, during
war, crimes, and civil unrest, natural and mass disasters, post mortem and medico-legal investigations. This
review highlighted the various methods of denture marking and significance of placing identification marks
on dentures.

Key words:- Denture marking, Geriatric, Identification

Introduction e. To ensure the correct denture delivery to the

respective patient.
Denture marking is accepted as a means of
identifying dentures and persons in geriatric institutions, Medicolegal Importance of Denture Marking
or post-mortem during war, crimes, civil unrest, natural Systems2
and mass disasters. Due to the lack of a comprehensive
fingerprint database, dental identification is growing as 1. Identification of the dead or deceased when all
an essential part of forensic investigation. Prosthodontists other means have failed.
are playing very important role in forensic dentistry as
2. Identification of individuals for forensic, social
they are concerned with fabrication of various prostheses
and legal reasons.
which can serve as an important tool for identification.
The denture marking is important for the following 3. Victim identification in case of mass disasters like
reasons:1 terrorism, bombings, earthquakes, hurricanes, typhoons,
air crashes and other transportation mishaps.
a. It serves to identify an unknown denture wearer
in cases involving amnesia or senility, loss of memory, 4. Identification of mutilated and decomposed
psychiatric cases, homicide, suicide, victims of fire, bodies when all other parameters like scars, tattoos, and
explosion, floods, earthquake, plane crash, or war. facial features have failed.
b. In cases of lost and found, the denture can be Methods of denture identification
returned to the owner.
Various methods of denture marking have been
c. A rapid and accurate method other than finger reported in the literature. However, there are two main
printing is essential for identification of the individuals. methods in marking dentures, namely the surface
method and the inclusion method. As compared to
d. In the laboratory, the dental technicians will find
surface methods, inclusions methods are permanent but
it easy to identify a denture, especially at the deflasking
require more skills and are time consuming.3
stage, if it is marked / labeled.
Surface Methods
Corresponding author:
Prabhjot Kaur, Scribing or engraving method
Former BDS Student, Genesis Institute of Dental
In this method letters or numbers are engraved on
Sciences & Research, Ferozepur, Punjab
the denture surface with the help of a small round dental
 76 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

bur.4 rigidity of the laminated strip.

Disadvantage: Food entrapment occurs in the Lenticular card method

engraved grooves.
In this technique a lenticular lens is used to produce
Embossing method images with an illusion of depth, morph, or the ability to
change or move as the image is viewed from different
In this technique name and other particulars of angles. Lenticular printing is a multi-step process
the patient are scratched on the master cast. After consisting of creating a lenticular image from at least
processing it produces stamped or embossed letters on two or more existing images, and combining it with a
the impression surface of dentures.5 lenticular lens. Each image is sliced into strips, which
Disadvantage: This technique has been associated are then interlaced with one or more of the other images.
with malignancy, possibly due to continued tissue These are printed on the back of a synthetic paper and
irritation. laminated on the lens The most common materials used
for making lenticular images are polyvinyl chloride
Invisible Ink Method (PVC), amorphous polyethylene terephthalate (APET),
acrylic, spectra, and polyethylene terephthalate glycol
Harvey described a method wherein the patient’s (PETG). The lens is incorporated in the channel cut on
details are written with an invisible ink that is rendered the denture and auto-polymerizing clear acrylic resin is
visible by ultraviolet light. This is useful on acrylic resin added around and not on the identifier.9
dentures of those patients who object to normally visible
identification marks. Paper Strip method

Disadvantage: The mark is not readily visible and It utilizes onion skin paper. The acrylic resin fitting
examination under special conditions is required to surface situated adjacent palatally between the ridge and
determine its presence.6 the center of the palate is moistened with monomer on
a small brush. The strip of typed paper is laid on this
Fibre Tip Pen Method surface and the paper is moistened with the monomer.
atient’s details are written on the tissue-fitting Clear resin is then placed over the paper before final
surface or the polished surface of the denture with a closure of the denture flask.10
fibre-tip pen. The patient’s identification details are then RFID Tags
covered by at least two thin coats of varnish in order to
prolong the life of the marking.7 RFID stands for radio-frequency identification,
which is a wireless electronic communication
Disadvantage: This method resulted in an unesthetic technology. The radio-frequency identification (RFID)
denture. system consisted of a data carrier, or tag, and an electronic
Denture Bar Coding Method handheld reader that energizes the transponder by means
of an electromagnetic field emitted via the reader’s
A bar code consists of a machine-readable code of antenna. It then receives the coded signal returned by
a series of bars and spaces printed in defined ratios. The the transponder and converts it into readable data.11
technique described for denture bar coding involves
printing a number code on paper, photographing the Advantages
paper, making and transferring the negative to a piece of This method is a cosmetic, effective labeling method
silk. An image of the bar code appeared on a prepared permitting rapid and reliable identification of the wearer.
faience, by a machine that forced the paint through
the silk, when heated to 860 degree C for 30 min in b.) They are preferred because of their small size
an industrial porcelain oven. The bar code is directly (8.5×2.2 mm).
placed onto the denture surface and cyanoacrylate resin
is painted to conceal the marking.8 c.) A large amount data can be stored in them.

Disadvantage: Incorporating the bar code into the d.) No special training is required to set the tag in
curved denture flange is relatively cumbersome due to the denture.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 77

e.) The chip is resistant to disinfectants and solutions out for hospitalized patients, unconscious patients and
of 1% hypochlorite, 4% chlorhexidine, and 4% sodium patients in geriatric institutions. There is a strong need
perborate. to adopt an international policy for denture marking and
international collaboration should be encouraged, with
Photographic method different opinions from the world-wide community of
In this technique patient’s photograph is embedded forensic odontologists discussed and with the aim of
in the denture with the help of clear acrylic resin. reaching some kind of consensus for the future.

The name, age and geographic location of the patient Conflicts of Interest: The authors declare that there
are written on the obverse of the photograph using a is no conflict of interest regarding the publication of this
micro-tip graphite pencil. The marker is particularly paper.
useful in the countries with low literacy rate where a Source of Funding: Self
photograph is the easiest method of identification.12
Ethical Clearance: Ethical clearance has been
Advantage: taken from Institutional Ethical Committee
The identity is easily ascertained by lay persons
with the unassisted eye.
References
1. Woodward JD. Denture marking for identification.
Incorporation of Min. I. Dent J Am Dent Assoc 1979;99:59–60.
atient’s details are typed on Min. I. Dent denture 2. Pyke TF. Personal identification from artificial
identification strip and the strip is heated in an oven at dentures. Aust Dent J 1970;15:495–8.
325 degree C for 30 s to 1 min. This allows shrinkage of 3. Haines DH. Identification in mass disasters from
lettering or numbers and the strip becomes a chip. The dental prosthesis. Int J Forensic Dent 1973;1:11–5.
chip is trimmed to required size using carbide bur. A 4. Luthra R, Arora S, Meshram S. Denture marking
groove is cut into the denture and the chip is incorporated for forensic identification using memory card: an
into the groove and sealed with orthodontic resin.13 innovative technique. J Indian Prosthodont Soc
Lead Foil 2012;12(4):231-5.
5. Millet C, Jeanin C. Incorporation of microchips to
A piece of lead foil from a used IOPA radiographic facilitate denture identification by radio frequency
film is cut and patient’s details are engraved with a tagging. J Prosthet Dent. 2004;92:588-90.
sharp pointed pen or instrument and is embedded in the
6. Bali SK, Naqash TA, Abdullah S, Mir S, Nazir
denture with the help of clear acrylic resin.14
S, Yaqoob A. Denture Identification Methods: A
Advantage Review. International Journal of Health Sciences &
Research 2013;3(4):100-4.
This technique is easy to operate. b.) It is economical.
7. Kamath PG. Engraved fixed restorations and
c.) It is radiographically visible.
denture micro-labeling to facilitate identification
Ceramic Crown Engraving Method through forensic dentistry. J Indian Prosthodont
Soc 2005;5:79-81.
After baking the opaque layer of porcelain, dentin 8. Murray CA, Boyd PT. A survey of denture
porcelain is applied and initials of name of the patient or identification in United Kingdom. Br Dent J
letters are carved with the brush. Stains are applied on 2007;203(11):E24.
carved initials followed by enamel porcelain application
9. Reeson MG. A simple and inexpensive inclusion
shaped with soft brush so that the initials are maintained.
technique for denture identification. J Prosthet Dent
Few initials can be carved in crown and bridges due to
2001;86:441-2.
lack of available space.15
10. Agüloğlu S, Zortuk M, Beydemir. Denture
Conclusion barcoding: a new horizon. Br Dent J
2009;206(11):589-90.
Denture marking should be compulsorily carried
11. Rajendran V, Karthigeyan S, Manoharan S.
 78 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Denture marker using a two-dimensional bar code. 14. Nalawade SN, Lagdive SB, Gangadhar SA,
J Prosthet Dent 2012;107:207-8. Bhandari AJ. A simple and inexpensive bar-coding
12. Datta P, Sood S. The various methods and benefits technique for denture identification. Journal of
of denture labeling. J Forensic Dent Sci 2010; Forensic Dental Sciences 2011;3(2):92-4.
2(2):53-8. 15. Colvenkar SS. Lenticular card: A new method
13. Jain A, Mahoorkar S. Denture identification using for denture identification. Indian J Dent Res
unique identification authority of India barcode. 2010;21:112-4.
Journal of Forensic Dental Sciences 2013;5(1):60-
3.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1
Original article 79

Maternal Tobacco Use and Risk for Congenital Anomalies

Prabhuswami Hiremath1, R P Patange2, J A Salunkhe3, Vaishali R. Mohite4, Prakash Naregal1,

Ajit Pawar5, Tejas Bhosale5
1Lecturer, 2Professor and Head, Department of OBG, 3Professor,4Dean and Principal, 5Clinical Instructors,
Krishna Institute of Nursing Sciences, Karad

Abstract
Over a period of decades non genetic causes are controlled and mortality and morbidity is considerable
reduced due to malformation5,6. Although 50% of causes for malformation are unknown Origen, but,
with primary prevention 50% of birth defects could be prevented. Research for finding the risk factors are
continuous and such results would help to implement preventive strategies to improve maternal and child
health.

Methodology: This is cross sectional; hospital based study, conducted in Krishna Hospital Karad, included
all the Pregnant Mother diagnosed to have congenital birth defected fetus through antenatal examinations,
delivered baby with diagnoses of congenital malformation, who were admitted at Tertiary care hospital
Karad.

Results: Total 283 cases were diagnosed with birth defects. Parent’s history for tobacco use states that16
(5.7%) mothers and 149 (53%) of fathers of malformed babies used tobacco. Among these 16 (5%) tobacco
user mothers, maximum babies 5 (1.7 %) babies had born with neural tube defect and among fathers 149
(53%) maximum babies 41 (14%) Circulatory System defect.

Conclusion: There is a need to make the rural women aware about hazardous effects of use of mishri20
through health education sessions to wean them out of this addiction, which is passed from one generation
to the next as a tradition at an early age.

Key words: Maternal, risk factors, Tobacco Use, Congenital Anomalies

Introduction Use of smokeless tobacco is more prevalent in India

(21%).2 adverse effect of tobacco on human physiology
According to WHO, Nearly six million people die
is well documented. The effect of tobacco on growing
due to tobacco use per year in that five million deaths are
fetus when pregnant mother is exposed to tobacco is
the result of direct tobacco use and more than 600,000
matter of concern as it effect fetus in various ways and
are the result of non-smokers being exposed to second-
also leading cause for congenital malformations. This is
hand smoke1. In India, as per Global Adult Tobacco
true for the passive or second hand exposure to tobacco
Survey India (GATS) estimated number of tobacco users
also.
being 274.9 million where 163.7 million users of only
smokeless tobacco, 68.9 million only smokers and 42.3 Many etiological factors contribute for the
million users of both smoking and smokeless tobacco). malformation and these are either genetic or non-genetic
It means around 35% of adults (47.9% males and 20.3% (environmental) and some time combined. Non genetic
females) in India use tobacco in some form or the other. causes are exposure to any teratogenic substance or toxic
including harmful drugs, organic chemicals, nutritional
Corresponding author: deficiencies and radiations. The exact relation between
Prabhuswami Hiremath, birth defect and tobacco use is not clearly understood,
Krishna Institute of Nursing Sciences, Karad. although hypotheses states that nicotine has direct effect
Phone: 9665620425, Email: [email protected] on blood vessel. Nicotine causes Vasoconstriction which
 80 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

leads to decreased blood supply to placenta is major by Pediatric Ward 14 (0.3%) and pediatric Outpatient
reason for birth defect3. Other reason may be, carbon Department 45 (1%). 50856 patients were visited to
monoxide combines with hemoglobin and reduces Maternity Outpatient Department in that 131 patients had
the placental oxygen availability. Another reason of the diagnosis of having congenital malformation fetus
tobacco use is, it increases the repture of capillaries from contributing to 0.3% of prevalence. Whereas maternity
neovasculirisation of placenta leading to hypoxia to the ward had 3847 admission among those 52 (1.4%) had
fetus which results in abnormal fetal morphogenesis4. delivered congenital malformed babies. Total 283 cases
were diagnosed with birth defects.
Over a period of decades non genetic causes are
controlled and mortality and morbidity is considerable Table no: 01: Prevalence of tobacco use among
reduced due to malformation5,6. Although 50% of causes Mothers of malformed babies
for malformation are unknown Origen, but, with primary
prevention 50% of birth defects could be prevented. Maternal
Research for finding the risk factors are continuous Used Of Tobacco Frequency Percentage
and such results would help to implement preventive F %
strategies to improve maternal and child health.
No 267 94.3 %

Methodology Yes 16 5.7 %

resent descriptive, cross sectional; hospital based Total 283 100%

study was conducted in Krishna Hospital Karad, which
provides specialist’s tertiary care services to patients Total 283 malformation cases were identified.
largely belonging to lower/middle socio-economic strata Parent’s history for tobacco use states that16 (5.7%)
of the society with both rural and urban background. mothers and 149 (53%) of fathers of malformed babies
The study included all the Pregnant Mother diagnosed used tobacco.
to have congenital birth defected fetus through antenatal
2. System wise distribution of congenital
examinations, delivered baby with diagnoses of
malformation
congenital malformation, who were admitted at Tertiary
care hospital Karad or came for reference services Distribution of congenital malformation according
between September 2016 to august 2017. The study to International Classification of Disease (ICD –
was initiated after approval of the Institutional Ethics 10) carries out after collecting data which shows,
Committee of Krishna Institute of Medical Sciences maximum Congenital malformations of nervous system
Deemed University’s. Maternal and paternal data was 63(22%), followed by circulatory system 57 (20%) and
collected to evaluate the relation between parental deformations of the musculoskeletal system 47 (17%).
tobacco use and congenital malformations. Other deformities includes Cleft lip and cleft palate 29
(10%), malformations of the digestive system 23 (8%),
Results malformations of genital organs 19 (7%), malformations
Prevalence of congenital malformation of the urinary system 21 (7%), other congenital
malformations 2 (1%), Chromosomal abnormalities,
Data was collected from Pediatric and Maternity not elsewhere classified 15 (5%) malformations of the
unit. Total Babies 75136 visited to pediatric outpatient respiratory system 5 (2%) and Congenital malformations
department, 4092 kids admitted at pediatric ward and 774 of eye, ear, face and neck 2 (1%).
neonates identified in Neonatal Intensive Care Unit as
congenital malformations. Prevalence is being maximum Number of Congenital Malformation with Use of
in the Neonatal Intensive Care Unit 41 (5.3%), followed tobacco
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 81

Table no: 02: System wise classification of Congenital Malformation according to tobacco use

Maternal tobacco use

Total
ICD CODE System Of Congenital Malformation
malformations
No % Yes %

Q00-Q07 Nervous System 58 20.5 5 1.8 63

Q10-Q18 Eye, Ear, Face And Neck 2 0.7 0 0.0 2

Q20-Q28 Circulatory System 54 19.1 3 1.1 57

Q30-Q34 Respiratory System 5 1.8 0 0.0 5

Q35-Q37 Cleft Lip And Cleft Palate 29 10.2 0 0.0 29

Q38-Q45 Digestive System 22 7.8 1 0.4 23

Q50-Q56 Genital Organs 19 6.7 0 0.0 19

Q60-Q64 Urinary System 21 7.4 0 0.0 21

Q65-Q79 Musculoskeletal System 44 15.5 3 1.1 47

Q80-Q89 Other Congenital Malformations 2 0.7 0 0.0 2

Q90-Q99 Chromosomal Abnormalities 11 3.9 4 1.4 15

Total 267 94.3 16 5.7 283

The above table explains congenital malformation born to tobacco used mother must not be neglected in
and history of Use of tobacco. 267(94%) mothers stated concluding the effect of tobacco on birth defect.
no history of using tobacco and only 16 (6%) mother’s
found using tobacco during and before their pregnancy. In India, per capita smokeless tobacco consumption
Among these 16 (5%) tobacco user mothers, 5 (1.7 %) has increased among the poor population between 1961
babies had born with neural tube defect, 3 (1%) babies and 2000 in both rural and urban areas and both in males
with Circulatory System and Musculoskeletal System and females7. In India, the use of smokeless tobacco is
defects and 1(0.3%) with digestive deformities. common in various forms like chewed, sucked or applied
to teeth and gums 8. Maximum samples responded
As per fathers’ tobacco use concern, 149 (53%) that they use chewable or applied form of tobacco.
fathers of malformed babies gave history of tobacco These kinds of smokeless tobacco products contain
use. Among tobacco user, maximum babies 41 (14%) large amount of sodium (sodium bicarbonate) which is
Circulatory System defect, 25 (10%) Musculoskeletal necessary to facilitate nicotine absorption9. The effect of
System, 24 (9%) nervous system malformations, 14 sodium bicarbonate is not well understood but the effect
(5%) Urinary System, 12 (4%) Cleft Lip and Cleft Palate of nicotine on malformation is well documented. Parents
and Chromosomal Abnormalities, 11 (3.9%) Genital also reported that they use the powdered form of tobacco
Organs, 9 (3%) Digestive System and only 1 baby called a ‘MISHRI’, prepared by roasting tobacco leaves,
diagnosed with respiratory defect. and principal constituent being alkaloid nicotine in 1 to
7%10. The prevalence of tobacco use in this region is
Discussion 17 – 45%10.
In our study 283 congenital malformation were Despite these methodological differences, the
identifies. Among these, 267(94%) mothers stated no association of tobacco use during pregnancy and
history of using tobacco and only 16 (6%) mother’s malformation is well cited by many authors such as
found using tobacco during and before their pregnancy. Bird TM11, Bracken MB12, Cedergren MI13, Christensen
This pattern indicates that very few (6%) mother were K14, De Roo LA15, Dickinson KC16, Feldkamp ML17,
at risk due to tobacco use. Malformations other than Ramirez D18, and Williams LJ19. The results of these
tobacco use are major risk in our study, but, the babies research were similar in regards to the association
 82 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

between maternal smoking during pregnancy and defects 9. Benowitz N.L. — Sodium intake from smokeless
of the cardiovascular, respiratory, digestive, nervous, tobacco. N Engl J Med. 319:873– 874, .1988
Urogenital and musculoskeletal systems. 10. Pratinidhi A, Gandham S, Use of Mishri a smokeless
form of tobacco durng pregnancy and its outcome.
Conflict of Interest – NO Conflict of interest
Indian J Community Med 2010:35:15-18
Source of Funding- NO Self or other source 11. Bird TM, Robbins JM, Druschel C, Cleves
MA, Yang S, Hobbs CA. Demographic and
Conclusion environmental risk factors for gastroschisis
There is a need to make the rural women aware and omphalocele in the National Birth Defects
about hazardous effects of use of mishri20 through health Prevention Study. J Pediatr Surg 2009; 44:1546-51
education sessions to wean them out of this addiction, 12. Bracken MB, Holford TR, White C, Kelsey JL. Role
which is passed from one generation to the next as a of oral contraception in congenital malformations
tradition at an early age. of offspring. Int J Epidemiol 1978; 7:309-17.
13. Cedergren MI, Selbing AJ, Källén BAJ. Risk
Ethical Clearance: The study was initiated after
factors for cardiovascular malformation - a study
approval of the Institutional Ethics Committee of Krishna
based on prospectively collected data. Scan J Work
Institute of Medical Sciences Deemed University’s.
Environ Health 2002; 28:12-7.
References 14. Christensen K, Olsen J, Norgaard-Pedersen B,
Basso O, Stovring H, Milhollin-Johnson L, et al.
1. WHO. Available from http://who.int/mediacentre/
Oral clefts, transforming growth factor alpha gene
factsheets/fs339/en/. Accessed on 18th September
variants, and maternal smoking: a population-based
2014.
case-control study in Denmark, 1991-1994. Am J
2. GATS India Report 2009-2010. Available Epidemiol 1999; 149:248-55.
from http://mohfw.nic.in/WriteReadData/
15. DeRoo LA, Gaudino JA, Edmonds LD. Orofacial
l892s/1455618937GATS%20India.pdf. Accessed
cleft malformations: associations with maternal
on 18th September 2014.
and infant characteristics in Washington state. Birth
3. Leopércio W, Gigliotti A. Tabagismo e suas Defects Res A Clin Mol Teratol 2003; 67: 637-42.
peculiaridades durante a gestação: uma revisão
16. Dickinson KC, Meyer RE, Kotch J. Maternal
crítica. J Bras Pneumol 2004; 30:176-85.
smoking and the risk for clubfoot in infants. Birth
4. 198. Quinton AE, Cook CM, Peek MJ. The Defects Res A Clin Mol Teratol 2008; 82:86-91.
relationship between cigarette smoking, endothelial
17. Feldkamp ML, Alder SC, Carey JC. A case control
function and intrauterine growth restriction in
population-based study investigating smoking as
human pregnancy. BJQG 2008; 115:780-4.
a risk factor for gastroschisis in Utah, 1997-2005.
5. Horovitz DDG, Llerena Jr. JC, Mattos RA. Atenção Birth Defects Res A Clin Mol Teratol 2008; 82:
aos defeitos congênitos no Brasil: panorama atual. 768-75.
Cad Saúde Pública 2005; 21:1055-64.
18. Ramirez D, Lammer EJ, Iovannisci DM, Laurent C,
6. Neto PS, Zhang L, Nicoletti D, Munchen FB. Finnell RH, Shaw GM. Maternal smoking during
Mortalidade infantil por malformações congênitas early pregnancy, GSTP1 and EPHX1 variants,
no Brasil. Rev AMRIGS 2012; 56:129-32. and risk of isolated orofacial clefts. Cleft Palate
7. National Sample Survey Organization. NSS Report Craniofac J 2007; 44:366-73.
Nos. 184 and 461 (55/1.0/4). Reports covering 19. Williams LJ, Correa A, Rasmussen S. Maternal
1961- 62 and 1999-2000. lifestyle factors and risk for ventricular septal
8. Bhonsle R.B., Murti P.R., Gupta P.C. — Tobacco defects. Birth Defects Res A Clin Mol Teratol
habits in India. In Gupta PC. Hamner JE III, Murti 2004; 70:59-64.
PR, Control of Tobacco – Related cancers and 20. Gupta PC, Hamner J E, Murti PR. Control of
other Diseases, Proceedings of an International Tobacco Related Cancer and other Diseases. c1992.
Symposium, TIFR. Bombay, January 15-19, 1990. p. P327.
Oxford University Press, Bombay, 25-46, 1992.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 83

Repair of Cast Partial Denture Made Easy – An Alternative

Approach

Pradeep S
Additional Professor, Dept. of Prosthodontics, Manipal College of Dental Sciences

Abstract
Patients wearing cast partial denture might face breakage of denture due to any reasons. The ideal approach
for repair of broken cast partial is electrosoldering. This paper presents an alternative approach for repair of
cast partial denture using heat cure acrylic resin.

Key words: Repair of denture, Electrosoldering, Cast Partial Denture.

Introduction Procedure

Despite careful planning and competent construction An impression of maxillary arch was made using
with materials of good quality occasional breakage and alginate with the broken cast partial denture in place.
distortion of Cast Partial Denture is seen. After retrieving the impression, the cast partial denture
was removed from the impression and impression
Breakage can be either of the acrylic, major or minor
poured in die stone. After the cast had set the fractured
connectors, clasps or the tooth. Need for repair may arise
fragments of cast partial denture were approximated
due to careless handling by the patient, inadequate mouth
on the cast (Fig.2). Once approximated, mechanical
preparation, poor construction, metal fatigue, loss of fit,
grooves were made on both ends of the broken cast
careless handling in the laboratorary(1). Ideally electro-
partial denture using a disc and a mandrel to enhance
soldering is used to repair cast partial denture which
mechanical bonding between metal and acrylic resin
is a process of building up of a localized area with a
(Fig.3). Wax up of the cast partial denture was completed
filler metal or joining two or more metal components by
and it was acrylized in usual manner (Fig.4). The final
heating them below their solidus temperature and filling
product was finished and polished to prevent affinity
the gap between them using a molten metal. (2,3)
towards food debris (Fig.5). When seen through light the
This clinical report describes an alternative approach thickness of acrylic resin and the joint can be appreciated
for repair of cast partial denture using heat cure acrylic (Fig.6). The repaired cast partial denture was then placed
resin. intraorally and checked for the fit (Fig.7). Any difficulty
in placement or any occlusal discrepancy was eliminated.
Clinical Report
Advantages
A 51-year-old male reported to the department
of Prosthodontics with the chief complaint of broken 1. Comparatively easy to repair
maxillary cast partial denture. On examination, a
2. Less technique sensitive
fracture was observed on both ends of the longitudinal
component (strap) of the major connector that was 3. Economical
joining the anterior and posterior palatal strap (Fig.1).
To repair this cast partial denture the ideal procedure was 4. No complicated equipment required
electro soldering, but an alternate approach was planned. Disadvantages
This clinical report describes an alternate approach to
repair the broken cast partial denture using heat cured 1. Only major & minor connectors can be repaired
acrylic resin.
84 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

2. Can be bulky 5. Less strength compared to metal

3. Less thermal perception 6. If not polished, then can cause irritation

4. Shrinkage can cause distortion

Fig. 1 – Broken cast partial denture Fig. 2 – Broken Partial denture on cast

Fig. 3 – Mechanical grooves for retention Fig. 4 – Wax up

Fig. 5 – After acrylization Fig. 6 – Through light

Fig. 7 – Intraoral Placement of Cast Partial

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 85

Discussion equipments are required. The disadvantages include

bulkiness to the cast partial denture, shrinkage of heat
Breakage of cast partial denture is very uncommon
cure resin can cause distortion, less strength than metal
which can be a result of careless handling by the patient,
and if not polished well can cause irritation.
inadequate mouth preparation, poor construction, metal
fatigue, loss of fit, careless handling in the laboratory. Conflict of Interest – None
Electro soldering is the process by which broken cast
partial dentures are repaired which involves the process Source of Funding – Self Funded
of building up of a localized area with a filler metal joining
Ethical Clearance – Ethical clearance was not
two or more metal components by heating them below
required hence so was not obtained
their solidus temperature and filling the gap between
them using a molten metal. Advantages of this technique References
includes adequate strength in thin sections, less bulky,
non-irritating and light weight, whereas disadvantages 1) Grasso J, Miller E. Removable partial
include technique sensitivity and is expensive. prosthodontics. St. Louis: Mosby Year Book; 1991.
2) Kenneth J. Anusavice, Phillips Science of Dental
The technique described in this paper uses heat cured Materials. 11th Edition, Elsevier:2003
acrylic resin for the repair of broken cast partial denture.
3) McCracken’s, Removable Partial Prosthodontics.
The advantages include less technique sensitivity
8th Edition: CBS Publishers.2005.
hence easy to repair, economical and less complicated
 86 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Role of Demographic, Cognitive, Social Factors and

Personality Trait on Treatment Modality Related Decision
Making: A Conceptual Framework

Praheli Dhar Chowdhuri1, Kaushik Kundu2

1
PhD Scholar, 2Associate Professor, Both from Department of Management and Business Administration,
Aliah University, Kolkata

Abstract
Purpose: Understanding individual’s treatment modality related preference and choice-behavior is
prerequisite for equitable distribution of community medicine and Health Human Resource planning.
Standard models emphasize on demographic determinants and need-based perception, loosely incorporating
social affecters, cognitive components and personality trait. This study addresses these factors separately
and integrates into a statistically valid model.

Methodology: Cross sectional study with sample size n=300 and 30 point questionnaire. Items are treated
with exploratory factor analysis and regressed with preference and choice. Maximum likelihood estimates
led to a path model.

Results: 40.3% prefer CAM and 51.3% used it in last 12 months. Male, people with higher education, low
disease burden and making decision in-group, choose CAM and believe Conventional Medicine has side
effect, CAM cures all disease, cheaper and usage along-with Conventional Medicine, is better. Extraversion
has positive (B=0.693,p<0.001), Conscientiousness (B=-.306,p<0.001) has negative effect on CAM
usage. The integrated model shows 12 months usage score has strong negative prediction to stated CAM
preference, whereas cognitive component is strongest predictor of CAM preference and conscientiousness
acts negatively on choice and preference. Disease burden acts as need factor and social effect as external
influence over CAM preference.

Conclusion: Separately, demographic, cognitive, social factors, disease burden and personality traits
influence treatment decision but the integrated path model shows factors act differently on preference and
choice behaviour and also at different levels. This understanding will contribute to modify the existing
conceptual models of healthcare utilization, facilitating the healthcare strategic planning and distribution
system, related to health human resource management.

Keywords: CAM, Human Resource for Health, Treatment Decision, Big 5 personality trait, Path analysis,
Behavioral Choice Model

Introduction including their treatment modality related preference,

decision making process and choice behavior. The
With the objective of ‘leaving no one behind’, the
National Comprehensive Cancer Network Guideline
developmental policies of the United Nations aim at
states that even for end-of-life care, optimal management
“universal access to good quality health care services,
should incorporate psycho-social and spiritual aspects
without anyone having to face financial hardship as a
of not only the patients alone, but also of their family
consequence” [1]. Towards materializing such equitable
members and care givers as per their need, value, belief
distribution of healthcare service, it has to be meaningful
and culture (NCCN Palliative care guideline)[2]. Hence,
and more importantly acceptable, which largely depends
a systematic research is of paramount importance to
upon understanding of people’s healthcare preferences,
identify the significant aspects, influencers and factors
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 87

partaking treatment related decision making process at and their social values[5,6]. While choosing a treatment
both macro and micro level. modality, studies show that an individual’s choice may be
affected by external factors like demographic, financial
Treatment modalities are broadly diverged into two condition, peer pressure, treatment availability, culture,
categories; Conventional Medicine, based on principles belief, habit[7] etc. or internal factors like personality
of physics, chemistry and biology and Complementary trait, cognitive ability, philosophical congruence[8]
and Alternative Medicine (CAM) in form of Ayurveda, etc. However, for conceptualization and prediction of
Homeopathy, Chiropractic, Reiki, Acupuncture, Kampo, individual’s choice of treatment modality, these data
etc. Choosing whether to use Conventional Medicine need to be presented in a structured, systematic flow.
or Complementary Medicine is a “Nonlinear Complex Though, behavioural healthcare utilization models
Dynamic procedure”[3]. loosely describe the choice making process of treatment
Decision-making is defined as a cognitive process modality, doesn’t validate it with quantization. Among
(Princeton University definition, 2006). During the the existing conceptual models of healthcare related
treatment related decision making process patients decision making, the Andersen Healthcare Utilization
seek information on treatment alternatives and want to Model has been widely accepted, (Anderson, 1995)[9]
be involved in treatment decisions [4], which is in turn demonstrating three determinants- predisposing factors,
highly intervened by the community, family members enabling factors, and need. (Figure 1)

Figure 1. Andersen Healthcare Utilization Model (1995)

Another prominent model, i.e. Charles’ Healthcare effect of previous choice behaviour in current preference
Decision model[10] shows Information exchange, would change the healthcare utilization pattern greatly.
Deliberation and Decision Control are the main
Thus, a gap is observed in terms of integration of all
determinants. Most healthcare utilization models
treatment modality related decision making factors into
emphasize on need based perception and demographic
a statistically validated model and measuring relative
determinants, vaguely incorporating social affecters and
importance of each factor. From existing literatures, we
cognitive components, with no reference of individual’s
have Social and community based decision modifiers
personality trait. On the other hand, modern workers have
along with cognitive, personality and need based factors
emphasised on personality trait in all treatment related
acting as major contributors in decision function. In
decision making (Flynn and Smith, 2007; Sorensen,
view of this, the study aims to identify the factors
2008)[11,12]. Besides, as previously discussed, apart
determining individual’s preference and choice towards
from need (perceived disease burden), philosophy and
a particular treatment modality and separately addresses
 88 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

each factor to understand their relative importance by personality trait effectors. For social and personality trait
factorising the external influencers and regressing the items, with factor scorings as independent variables,
internal cognitive elements with the decision outcome. parametric regression analyses have been done taking
Further, this study also tries to integrate the identified CAM usage as dependent variable. Cognition being an
factors into a statistically valid structure, by assimilating all or none process is itemised with dichotomous scale.
them through a path model, where some influencers Items for different cognitive components are used as
have been observed not to play significant role while independent variable for binary logistic regression.
acting simultaneously with other variables. From the significant variables, cognitive factor score has
been calculated. From statistically significant regressive
Methodology factors, likelihood estimates were done on prevalence
This cross sectional study includes responses from and preference alongwith covariances and is plotted for
a pretested and pre-structured 30 point questionnaire path analysis through AMOS ver.20.The final model has
from a sample of 300 responders distributed in been tested for fitness with validation methods.
the rural and urban setting of Kolkata and 25 km
Results
surroundings area, as collected from December’2016
to May’2017. Responders belong to age group of above Demographic outcomes
18; having basic idea of both Conventional Medicine
and Complementary and Alternative Medicine. 121 responders (40.3%) prefer CAM at the point
The questionnaire having 7 point Likert scale and of study where 51.3% people have actually used in last
dichotomous scale (yes/no) as sub-structured into twelve months, which, in this study has been considered
demographic variables, disease burden, social, cognitive as CAM prevalence. There is thus, a significant
and personality trait items, which are later factorised. difference between preference and prevalence of choice
Results are analyzed using IBM SPSS ver.23. The behaviour over CAM related decision making (p=.007).
questionnaire has been tested with a pilot study of 50 With different demographic variables such preference
samples for reliability with Crohnbach alpha (>.7 for all and prevalence have been tested for dependence (chi
subparts with Likert scale items) and validity with inter- square test for 2 X n contingency tables). Unlike the
correlation coefficients. The 7 point Likert scale value usage, preference pattern is independent of age. Male
of CAM usage has been tested and shown to be similar responders prefer (p=.001) and use (p=.026) CAM.
to normal data (Shapiro Wilk test Normalcy= 0.908, People with higher education and higher socioeconomic
p<0.001) and hence is taken into parametric analysis. status are using CAM (p=<0.001). Responders with
Chi square test has been done on demographic variables higher disease burden of self and family tend to prefer
determining their dependence on choice behaviour and conventional medicine (p=<0.001) and people taking
preference. The responses of the disease burden items decision in group prefer and choose CAM. Table 1
are transformed linearly to disease burden score. Factor depicts the summary of the demographic outcomes.
analysis is done on items related to social, cognitive and

Table 1: Significance of demographic variables in CAM spreference and prevalence

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 89

The Personality Factor

Exploratory factor analysis extricated three underlying factors as per big five personality trait model; neuroticism,
extroversion and conscientiousness. After rotation, cumulative sum of squared loading on three factors came to be
64.23%, i.e. well explanatory. The component weights are summarized in table 2.

Table 2

Factor Explanation of personality traits (From rotated component matrix)

To estimate the effects of the factors on decision making towards CAM usage, a linear regression analysis has
been done. The model shows CAM usage is driven by Conscientiousness negatively (beta= -0.462, P<0.001) and
Extroversion positively (beta=0.693, p<0.001). Neuroticism has not been proved contributing (vide table 3). The
equation of this regression is-

Y (CAM usage) = 2.930 – 0.306 X1 (Conscientiousness) + 0.693 X2 (Extraversion)

Table 3: The regression table of CAM usage and personality traits

Social Effect Effect of Cognitive components

The social effect questions are factorized. Component Cognitive factors are tested with logistic regression.
matrix reveals only one underlying factor, i.e. pro-CAM It is identified that individual’s perception that
Social Influence Factor. The regression analysis shows conventional medicine has side effect [OR=8.178, 95%
decision making of CAM usage is positively influenced CI= 2.91-22.97], CAM can treat all diseases [OR=4.158,
by pro-CAM social influence factors (beta= 0.538 95% CI= 1.85-9.31], it’s cheaper [OR=2.612, 95%
±0.074, p=<0.001), with linear equation as, Y [CAM CI= 1.18-5.76] and usage alongwith Conventional
usage] = 2.930 + 0.538 X [Social Factor] Medicine entails is better [OR=6.199, 95% CI= 2.66-
14.41], are the significant mobilisers of CAM use. The
logistic regression table showing influence of cognitive
 90 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

components on CAM usage is depicted in Table 4. From the significant factors a cognitive factor score has been
computed which is later used in integrated model.

Table 4: The logistic regression table of cognitive effect on CAM usage

The integrated decision path

The maximum likelihood estimates of the path are calculated and demarked in the figure of the decision model.
Path variables, only with significant regression weights are taken. Covariance among the factors is estimated and
found to be significant and included in the path diagram. While testing fitness of the model, it is observed that chi
square value is 0.19, goodness of fit index (GFI)= 0.989 and other model fit indices are at par. The integrated path
diagram lucidly emulates the factors and their effects on CAM preference and usage. As per the maximum likelihood
estimates, the relative importance can be quantised in form of regression weights.

Conscientiousness has negative effect on both CAM preference and choice. Similarly, higher disease burden
opposes preference towards CAM and is not significant component of 12 months usage of CAM. Past CAM usage
has strong negative influence on current CAM usage (standardised weight= -0.21, p=<.001). Strongest predictor of
choice behaviour is extraversion and that for preference is cognitive factor. The Integrated Path Model is shown in
Figure 2.

Figure 2. The integrated path model

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 91

Discussion care needs. This study obviates the statistical significance

of neuroticism but emphasises positive effects of
Choosing a treatment modality, in contrast to
extraversion and negative effect of conscientiousness,
utilitarian consumer choice, involves people’s overall
along with quantising their effects, which has not
wellbeing and quality of life. This study has taken into
been done in other studies. Background knowledge,
consideration the important components of healthcare
philosophical attitude and perception about cost are
decision making process, illustrated in studies of
the major components of cognitive factor, determining
shared decision making. The classical linear model
treatment related preference and proving most important
of healthcare utilization, based on need – preference-
predictor of stated preference. This supports the findings
choice behaviour triad has been scrutinised through an
of Astin (1998)[17] and MacFadden (2010)[18]
integral analysis of multiple factors. This cross sectional
study takes two dependent variables in form of 12 month In comparison to Anderson’s Healthcare Utilization
CAM usage, which is considered as individual’s choice model, in this study the disease burden plays as need
behaviour and current ‘Stated Preference’. factor; cognitive factor, social effect and personality
trait as enabling factors for preference, leading to usage.
CAM is found to have significant taking among
However, the Anderson’s model is unidimensional and
people (40.3% preference and 51.3% usage). This is
essentially hypothesises preference to be congruent with
significantly higher than western countries, which is
usage. But in the neo-classical studies in economics,
26% (Coelho et al., 2010)[13] – 38% (Barnes, 2008)[14].
preference and choice are often described as independent
However, according to WHO (2002)[15], the incidence
identities. The integrated path model described in this
of CAM prevalence can be as high as 70%. The 11%
study aptly delineates this multidimensionality and
difference in choice behaviour and preference score
treats choice and stated preference as different entity.
(p=0.069) may be explained by post choice dissonance
This finding is at par with the calculated predictions by
which has been proved to be strong predictor of current
Sirois and Purc -Stephenson, (2008)[6] who modelled
preference. Epidemiologic trends are highly intertwined
social factor, symptom burden and post decision
with social effect, in form of decision making practises
dissatisfaction to be the major players of CAM choice
by discussion within the community. Strikingly, this
and Wapf and Busato (2007)[8] who emphasised on
does not differ among the socio-economic strata.
post-choice behaviour. Hence, this study conceptualizes
Although Flynn, Smith and Vanness (2006)[16] argue
a new multi-strata decision making model integrating
that socio-demographic factors and current health status
preference-choice model and post-choice holistic
are poor predictors of patient’s preference, current study
preference model.
differs from this view. Rather, demographic factors
can be assumed as predecessor of social effect. Social
Conclusion
effect has highly significant dependence on Community
based decision making practice (R2=0.103, F=34.37, Apart from identifying a novel trend of integrating
p=<.001). Again, in contrast to studies of Sirois[6], different factors into the preference and choice based
Coelho[12] where female responders are prone to CAM, healthcare utilization, this study also attempt to bridge
this study shows that male responders preferred CAM. the gap between behavioural models and economic
As decision in group is found to be a major contributor theories of preference-choice discordance. Besides,
of CAM preference, acting through pro-CAM social the findings can be useful for the social researchers to
factors, such gender inequality may be caused by less understand the physician-patient dynamics. Architecture
female participation in community meetings. of the integrated model will contribute to betterment of
existing conceptual models of healthcare utilization,
Personality trait, as a factor of individual’s facilitating the healthcare strategic planning and
treatment related decision making process, has rarely distribution system related to health human resource
been described till date. The role of personality factor management.
has been discussed by Flynn and Smith (2007)[11]
showing increased conscientiousness most active Conflict of Interest: Nil
decision-making style. Whereas, Sörensen et al. (2008)
[12] Source of Funding: Self
found higher levels of neuroticism, openness, and
agreeableness were associated with greater awareness of
 92 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Ethical Clearance: The study is done by voluntary 2007 Dec;7(1):41.

community-based survey. Hence, no Ethical Clearance 9. Andersen RM. Revisiting the behavioral model and
was required. access to medical care: does it matter?. Journal of
health and social behavior. 1995 Mar 1:1-0.
References
10. Charles C, Gafni A, Whelan T. Decision-making
1. Sharma DC. Concern over private sector tilt in in the physician–patient encounter: revisiting the
India’s new health policy. The Lancet. 2015 Jan shared treatment decision-making model. Social
24;385(9965):317. science & medicine. 1999 Sep 1;49(5):651-61.
2. Dans M, Smith T, Back A, Baker JN, Bauman 11. Flynn KE, Smith MA. Personality and health
JR, Beck AC, Block S, Campbell T, Case AA, care decision-making style. The Journals of
Dalal S, Edwards H. NCCN guidelines insights: Gerontology Series B: Psychological Sciences and
palliative care, version 2.2017. Journal of the Social Sciences. 2007 Sep 1;62(5):P261-7.
National Comprehensive Cancer Network. 2017 12. Sörensen S, Duberstein PR, Chapman B, Lyness
Aug 1;15(8):989-97. JM, Pinquart M. How are personality traits related
3. Weeks L, Balneaves LG, Paterson C, Verhoef to preparation for future care needs in older
M. Decision-making about complementary and adults?. The Journals of Gerontology Series B:
alternative medicine by cancer patients: integrative Psychological Sciences and Social Sciences. 2008
literature review. Open Medicine. 2014;8(2):e54. Nov 1;63(6):P328-36.
4. Guadagnoli E, Ward P. Patient participation in 13. Hunt KJ, Coelho HF, Wider B, Perry R, Hung SK,
decision-making. Social science & medicine. 1998 Terry R, Ernst E. Complementary and alternative
Aug 1;47(3):329-39 medicine use in England: results from a national
5. Hlubocky FJ, Ratain MJ, Wen M, Daugherty CK. survey. International journal of clinical practice.
Complementary and alternative medicine among 2010 Oct;64(11):1496-502.
advanced cancer patients enrolled on phase I trials: 14. Barnes PM, Bloom B, Nahin RL. Complementary
a study of prognosis, quality of life, and preferences and alternative medicine use among adults and
for decision making. Journal of Clinical Oncology. children; United States, 2007.
2007 Feb 10;25(5):548-54. 15. Bodeker G, Ong CK. WHO global atlas of
6. Sirois FM, Purc-Stephenson RJ. Consumer traditional, complementary and alternative
decision factors for initial and long-term use medicine. World Health Organization; 2005.
of complementary and alternative medicine. 16. Flynn KE, Smith MA, Vanness D. A typology of
Complementary Health Practice Review. 2008 preferences for participation in healthcare decision
Jan;13(1):3-19 making. Social science & medicine. 2006 Sep
7. Arthur K, Belliard JC, Hardin SB, Knecht K, Chen 1;63(5):1158-69.
CS, Montgomery S. Practices, attitudes, and beliefs 17. Astin JA. Why patients use alternative medicine:
associated with complementary and alternative results of a national study. Jama. 1998 May
medicine (CAM) use among cancer patients. 20;279(19):1548-53.
Integrative cancer therapies. 2012 Sep;11(3):232-
18. McFadden KL, Hernández TD, Ito TA. Attitudes
42.
toward complementary and alternative medicine
8. Wapf V, Busato A. Patients’ motives for choosing influence its use. Explore: The Journal of Science
a physician: comparison between conventional and and Healing. 2010 Nov 1;6(6):380-8.
complementary medicine in Swiss primary care.
BMC Complementary and Alternative Medicine.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 93

Factors Associated with Use of Dental Sealants among Dental

Professionals in Mangalore- A Cross Sectional Study

Hussain Lokhandwala1, Prashanthi S Madhyastha2, G Rajesh3, Srikant N4, Ravindra Kotian5

11st
Year Post Graduate, Department of Orthodontics & Dentofacial Orthopaedics, Dr R Ahmed Dental College
& Hospital, West Bengal Health University, Kolkata, 2Selection Grade Lecturer, 3Professor, Department of Public
Health Dentistry, 4Professor and Head, Department of Oral Pathology, 5Professor and Head, Department of
Dental Materials, Manipal College of Dental Sciences, Mangalore, Affiliated to Manipal Academy of Higher
Education, Manipal, Karnataka, India

Abstract
Introduction: Dental caries is one of the most infectious diseases in the world. Dental sealants have been
proved as effective way to prevent caries, hence can play a vital role in preventing caries.

Objective: The primary objective of the study is to obtain insight into dental sealant status and factors
associated with sealant use among dental professionals in Mangalore, by a questionnaire method.

Method: A cross sectional, questionnaire based study was done on both private practitioners and professionals
working in various colleges in Mangalore, to assess knowledge, attitude, behaviour, perceived effectiveness,
willingness to apply sealants, familiarity with recent guidelines and barriers to the use dental sealants in
Mangalore city.

Results: A total of 134 respondents took part in study. Half of the respondents (50%) said that they had never
applied sealants. A majority (96.3%) of them said that they were willing to apply sealants as a preventive
measure. On correlation analysis there was a statistically significant association between knowledge and
attitude (p=0.001, r=0.296), behaviour (p=0.001, r=0.280) and perceived effectiveness (p=0.001, r=272).
There was also statistically significant association between attitude and behaviour (p<0.001, r=0.433),
perceived effectiveness (p<0.001, r=0.521) and barriers (p=0.014,r=0.228).Overall 86.6% of the respondents
reported that dental sealants are underused with poor attitude of patients towards sealants being the major
barrier for their use followed by unawareness of treatment choice in patients.

Conclusion: The present study highlights the need to change the dental curriculum regarding dental sealants
and has definite policy implications for preventive re orientation of dental education and dental practice for
long term oral health benefits to the populace. The results also throw light on a number of barriers to the use
dental sealants in a developing nation like India, thus indicates the need for patient education and awareness
programs for the population in terms of oral health.

Keywords: Sealants, Pit and Fissure Sealants, Preventive Dentistry, Caries, Caries Prevention, Barriers,
knowledge, Willingness, Attitude, Behaviour, Perceived effectiveness

Corresponding Author:
Dr. Prashanthi S Madhyastha, Introduction
Selection Grade Lecturer, Department of Among the childhood infections, the prevalence of
Dental Materials, Manipal College of Dental dental caries is ubiquitous in most developing countries.
Sciences, Mangalore, Affiliated to Manipal Academy of Over the years, even though the prevalence and severity
Higher Education, Manipal, 576104, Karnataka, India. of dental caries has declined, yet significant population
Mob: 9880804623 remains at high caries risk 1, 2. The first global map with
Email: [email protected] data on DMFT for 12 year olds was presented in 1969
 94 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

by WHO. A data base was established over the number Materials and Method
of years showing increase in prevalence of caries in the
Study area: Mangalore city, Karnataka, India.
developing countries3. Voluminous literature exists on
the status of the dental caries in India. A very extensive Study population: The survey’s target population is
and comprehensive National Oral Health Survey dental professionals of Mangalore.
conducted in 2004 throughout India has shown dental
caries prevalence of 51.9% in 5-year-old children, Study design: A cross sectional descriptive study
53.8% in 12-year-old children and 63.1% in 15-year-old was employed in the present study
teenagers4. In 2005, prevalence record of dental caries in
Sampling Methodology: Purposive sampling
Mangalore, was: 5-7 year ~ 94.3%; 8-10 year ~ 82.5%;
technique
11-13 year ~ 82.5%.5
Ethical approval: The ethical approval was obtained
Deep pits and fissures are vulnerable to caries as
from the Institutional Ethical Committee of Manipal
they are virtually impossible to clean, owing to the
College of Dental Sciences, Mangalore.
tooth anatomy, leading to accumulation of plaque and
eventually caries6. About 44% of caries in primary teeth ilot study: The questionnaire with 46 questions
are on pits and fissures and about 90% of carious lesions was reviewed for clarity, validity and pretesting of
are found in the pits and fissures of the permanent teeth. questionnaire was done on 10 dentists - 5 M.D.S & 5
Pit and fissure sealants can be used effectively as a part B.D.S. from 1 dental college and 2 individual practice
of a comprehensive approach to caries prevention on clinics. Questionnaire with minor corrections after the
an individual basis or as a public health measure for pilot study was slightly modified and final questionnaire
at risk populations. Over more than 11 guidelines and was prepared.
systematic reviews have recommended pit and fissure
sealant use for at-risk populations7,8,9. In spite of the Sample size: The sample size was assessed based on
scientific evidence supporting their effectiveness,10 they convenient sampling technique.
have been underutilized by dental profession11. In latest
Inclusion Criteria:
data available indicates just 15 % of children ages 6-17
years have dental sealants11. • Dentists practicing part time or full time in
dental colleges and private clinics in the selected areas
Although there are many reasons for the sparse
use of sealants in caries prevention, lack of knowledge • Dentists who were willing to participate in the
about sealants has frequently been cited as a possible study were included.
determent to its adoption12,13,14. It has also been
found that the theoretical frame for behavior change Exclusion Criteria:
is an assessment of knowledge and attitudes affecting
• Post graduates & Interns working in these
practice. However, the adoption of pit and fissure
clinics and colleges.
sealants for preventive purposes by the dentists’ in
Mangalore has not been evaluated. The present study Samples:
aimed to provide information about sealants to the
dentists working in dental colleges and in private dental • Teaching faculty (with and without private
practices in Mangalore City and to determine whether practice) from different dental colleges in Mangalore
dentist’s knowledge, attitude and practice of sealants
• Dental clinics with individual setup and multi-
could truly be an added link to reduce the prevalence
specialty setups were visited for the survey. 1 dentist per
of dental caries. The objectives were to obtain insights
clinic to more than 5 dentists per multi-specialty setups
into dental sealants status and factors associated with
practiced in these clinics was taken in the survey.
sealant use among dental professionals in Mangalore
by accessing the knowledge, attitude, practice and • 4 dental colleges in Mangalore were selected.
perceived effectiveness by a questionnaire method.
Data collection: The knowledge, attitude and
behavior of the study subjects regarding pit and fissure
sealants was assessed by means of a self-administered
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 95

questionnaire. Overall, a total of 46 items were included and willingness, previous training, application of
in the questionnaire, with 11 items assessing knowledge, sealants and familiarity with recent guide lines. Pearsons
12 assessing attitude and 11 behaviors respectively. correlation was done to correlate the variation among the
Information pertaining to perceived effectiveness of domains.
respondents in applying pit and fissure sealants was also
collected by employing 3 questions. Information related Observations and Results
to willingness to apply pit and fissure sealants, prior A total of 134 respondents in the present study
training and familiarity with recent guidelines on pit and were distributed 64 were ≤ 30 years, 60 were male, 85
fissure sealants was collected by employing 3 questions. were MDS, 110 respondents were having ≤ 10 years
Information related to inhibitory factors (barriers) of experience and Majority of the participants were
regarding the use of pit and fissure sealants was collected both dental institution and private practice (n=51).
by 5 questions. Information regarding demographic The mean(sd) knowledge, attitude and behaviour
details of the study subjects was also collected. scores of the respondents were 5.88(1.85), 49.27(7.07)
Scheduling the Survey: and 32.31(9.95) respectively. The mean perceived
effectiveness and barriers score were 12.90(1.88) and
• For dentist in dental colleges: Preferably during 17.97(1.88) respectively.
working hours of the college (in morning).
The results showed that respondents who had
• For private practitioners: Preferably evening completed their masters training (MDS) had higher
time was chosen to visit the clinics as evening time is mean knowledge, attitude, and behavior & perceived
considered to be the peak time of clinics which would effectiveness scores. Respondents with ≤10 years
ensure inclusion of most of the part time/ full time of experience had higher mean knowledge scores.
practicing doctors in the survey. Respondents working in dental institutions or combined
practice/institution had significantly higher mean
Data management: Complete questionnaire was perceived effectiveness scores than the ones working
coded and spread sheet was created for data entry. in private practice (p=0.001 and P =0.007 respectively).
The range of possible scores for knowledge, attitude, Similarly behaviour scores was also significantly higher
behaviour, perceived effectiveness and barriers were in individuals attached to an institution compared to
0-11, 12-60, 11-55, 3-15 and 5-25 respectively. The those working in private practice(p<0.05). Half of the
range of scores for willingness to apply sealants, respondents (50%) had applied pit and fissure sealants,
familiarity with recent guidelines and previous training however 96.3% were willing to apply pit and fissure
were 0-1. Correct answers for knowledge were scored sealants as a preventive measure. Majority, 52.2% had
as 1 whereas wrong answers were scored as 0. Five not undergone any previous training in pit and fissure
point Likert scale was employed for attitude, behaviour, sealants and 64.9% were not aware of any recent
perceived effectiveness and barriers. However before guidelines for pit and fissure sealants. (Figure 1)
answering the questions on barriers respondents were
asked if pit and fissure sealants are underused, those
who answered yes were then asked to answer the barrier
section. Score of 1 was given to those who answered yes
for willingness, familiarity with guidelines and previous
training. Score 0 was given to those who answered no.

Data analysis: Data analysis was conducted by

employing Statistical Package for Social Sciences
(SPSS), version 20.0 (SPSS Inc, Chicago IL).
Demographic variables like age, gender, qualification
and work experience were assessed with knowledge,
Figure 1: Application, willingness, previous traning and
perceived effectiveness, attitude, behaviour and barrier
familiarity of pit and fissure sealants
using T test. Association between work place and the
domains was calculated using One way anova test. Chi Willingness was significantly associated with
square test was done between demographic variables educational qualification of the respondents, while
 96 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

previous training was significantly associated with the in the prevention of dental caries7,8,9. The present study
type of work place. Familiarity with recent guidelines was can pave the way for optimizing the use of sealants
significantly associated with educational qualification among dental professionals in India.
and the type of work place in the present study. It can
also be observed that application of pit and fissure The mean knowledge score percentage of the dentists
sealants was significantly associated with educational was observed as 53.46% in the present study. This is
qualification and the type of work place. The results in agreement with the findings of Govindaiah et al15,
of the correlation analysis indicated that there was a who reported low knowledge about sealant use among
statistically significant association between knowledge dentists in Florida. In a similar study conducted by San
and attitude (p=0.001, r=0.296), behavior (p=0.001, Martin et al16, the respondents had neutral to favourable
r=0.280) and perceived effectiveness (p=0.001, r=272). knowledge, which is contrasting to that observed in the
There was also statistically significant association present study. The findings were also in contrast to a
between attitude and behaviour (p<0.001, r=0.433), similar study carried out by Asawa et al17, who reported
perceived effectiveness (p<0.001, r=0.521) and barriers sufficient knowledge amongst the dentists in Bhatinda,
(p=0.014, r=0.228). Statistically significant association India. It was observed that the mean knowledge scores
was also seen between behaviour and perceived were higher in professionals with a post-graduate degree
effectiveness (p=0.001, r=0.479) of the study subjects. A as compared to those without a post-graduation degree.
majority of the respondents (86.6%) in the present study This may be due to knowledge and training regarding pit
reported that dental sealants were under used. Various and fissure sealants being imparted to the post graduates
potential barriers to the use of sealants were also probed during their course. It was also observed that knowledge
among the study subjects. Cost factor as a barrier was was higher among respondents with an experience of
considered by 64.7% of respondents. On being asked ≤10 years. This could be due to the respondents having
if unawareness of treatment choice in patients was a cleared their qualifying examination in the recent years
barrier, a majority (81.0%) said yes, 12.0% were neutral and being familiar with various aspects of sealants. With
and 7.0% said no. They were asked if poor attitude of the increasing experience among the respondents, they may
patients towards pit and fissure sealants was a barrier, to tend incline themselves to more practically issues rather
which a majority (83.6%) said yes, 8.6% were neutral than those related to knowledge.
and 7.8% said no. The mean attitude score percentage was 82.11%
Respondents considered lack of good retention of which is an indication of positive attitude among the
pit and fissure sealants was a barrier to their use (43.9%). respondents. This is in contrast to that reported by
Poor attitude of patients towards pit and fissure sealants San Martin et al16, who reported neutral to favourable
emerged as a major barrier for sealant use among the attitude scores among Spanish dentists. It was noticed
study subjects. Figure 2 that the attitude was more positive in dentists holding a
post graduate degree. This could imply that the further
training received in the form of post-graduation would
have had a positive influence on the attitude of the
respondents.

The mean behaviour and perceived effectiveness

percentage score among the study subjects were
58.75% and 85.97% respectively. San Martin et al16
have reported neutral to positive behaviour scores
among Spanish dentists. It was seen that respondents
Figure 2: Barriers to pit and fissure sealant use with a post graduate degree had higher mean behaviour
and perceived effectiveness scores than those without
Discussion a post graduate degree. There was statistically
The present study was conducted to explore various significant difference in mean behaviour and perceived
issues related to the use of pit and fissure sealants among effectiveness scores amongst the different categories
dental professionals in Mangalore. Numerous systematic of workplace. Respondents working in dental college
reviews have established its clinical efficacy of sealants had higher mean perceived effectiveness than the ones
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 97

working in private practice. Respondents working in of accreditation systems after graduation might be one
both private clinics and dental institutions had higher of the factors influencing the aforementioned results.
perceived effectiveness scores than those working Willingness to use sealants was significantly associated
only in private practice. Involvement in teaching and with educational qualification and previous training was
imparting knowledge to students might have influenced significantly associated with the type of work place of the
mean perceived effectiveness scores in the present study. respondents. Similarly, familiarity with guidelines was
Besides, playing the role of a teacher might impart significantly associated with educational qualification of
greater perceived effectiveness among the respondents. the study subjects.

Respondents working in both private clinics and Knowledge showed significant correlations with
dental institutions had higher mean behaviour scores attitude, behaviour and perceived effectiveness, while
than those working only in private practice. Academic attitude showed significant correlations with behaviour,
environment provided in dental institutions does have perceived effectiveness and barrier scores. Results also
a role to play in the observed results. However, further revealed significant correlations between behaviour and
studies are required to shed more light into the potential perceived effectiveness scores among the respondents.
role of workplace on sealant use. Application of pit and fissure sealants was also associated
with workplace and educational qualification. Greater
On being enquired if they applied pit and fissure academic exposure might favourably influence various
sealants, only half, 50% of the respondents reported that aspects of use of sealants among the study subjects.
they apply sealants. This is in contrast to that reported Being involved in training students might entail dental
by Main et al18, who reported that 90% of respondents in professionals themselves undergoing some form of
Ontario apply sealants in their practices. The results are training in sealant use. Preventive measures might not
also in contrast to that reported by Govindaiah et al15, be cost effective in the short term, but they are cost
who reported that 98% of respondents in Florida apply effective in the long term. Employing dental auxiliaries
sealants as a routine preventive measure. The results of to provide sealants might further offset the cost of sealant
the present study indicate that pit and fissure sealants are application.
underused in Mangalore. The potential role of barriers
to the use of sealants should be further explored to When asked if unawareness of treatment choice
address the reasons for the same. The study subjects in patients was a barrier, a majority of 81% of the
were also enquired if they were willing to apply pit and respondents reported in the affirmative. This in indicative
fissure sealants, to which a majority of 96.3% of them of the lack of awareness about preventive dentistry
responded in the affirmative. This reflects the positive amongst the patients. It becomes imperative on the part
attitude of respondents towards the use of sealants. of dental professionals to explain to their patients about
The results of the present study are thus encouraging, the benefits of pit and fissure sealants.
and act as a facilitating factor for further training and
implementation of sealant use among the respondents. Poor attitude of patients towards pit and fissure
sealants has been the most significant barrier with 83.6%
When enquired if they had undergone any previous of the dentists agreeing to the same. Dental professionals
training for the application of dental sealants a majority help is sought only if there is pain to the patient. They
of 52.2% replied in the negative. This might be due may fail to appreciate the value of using pit and fissure
lack of emphasis on pit and fissure sealants during sealants when there is no pain in the teeth. Sealant
their undergraduate and/or postgraduate training. This use is also compounded by the fact that milk teeth are
might also be due to lack of continuing professional lost anyhow. Spending money and time on the care
development programs and/or workshops on pit and of painless milk teeth might be perceived to be of no
fissure sealants. apparent importance. The present study highlights the
potential role that dentists can play in informing the
On being asked if they were familiar with the patients about the potential benefits of sealant use.
recent guidelines for pit and fissure sealants a majority
of 64.9% replied that they were not familiar with the A majority, 43.9% of the respondents reported that
same. This is in agreement with the findings reported lack of good retention of pit and fissure sealants was a
by O’Donnell et al19 among American dentists. The lack barrier to their use. This could be because application of
 98 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

pit and fissure sealants is technique sensitive and requires in general and sealants in particular will have to be
previous training. In a study conducted by Olmsted et conducted on a regular basis for dental professionals.
al20, simple clinical practices using 4-handed dentistry The present study has definite policy implications for
and strict isolated techniques led to 95% or higher preventive re-orientation of dental education and dental
cumulative sealant retention rate. The respondents were practice for lo long term oral health benefits of the
also asked if fear of sealing over carious lesions was a populace. The results of the present study are especially
barrier, to which a majority of the respondents, 35.3% did relevant in the context of a developing nation like India
not concur. This is in contrast with the finding reported with an increasing burden of oral diseases and a definite
by Govindaiah et al19 in which 44% of the respondents paucity of resources. Dental professionals might be
agreed that the possibility of sealing in decay was a more receptive towards further training in sealant use
major concern in using dental sealants as a preventive and other aspects of preventive dentistry. The study
measure. Results of the present study are also in contrast also throws light on various barriers to the use of pit and
with those reported by Asawa et al18 who reported that fissure sealant, out of which poor attitude towards the
80% of the respondents were avoiding sealants out of application of sealants was the most significant. Thus,
fear of sealing over caries. the role of awareness programs for populations regarding
preventive dentistry should be assessed in details.
The results of the present study represent to one
geographical area. Further, research related to sealant Acknowledgement: This study was funded and
use among dental professionals in various parts of the supported by the Indian Council of Medical Research
nation is thus warranted to have a representation of all (ICMR), under the Short Term Student Research (STS)
dental professionals in India. scheme. The research proposal number: 2015-00444.

The present study has definite implications for Conflict of Interest: NIL
curriculum changes in dental education in India.
Appropriate modifications in dental curriculum might References
be one of the ways in which issues related to low 1. Holm AK. Diet and caries in high-risk groups in
knowledge scores on sealant use among the respondents developed and developing countries. Caries Res.
can be addressed. The present study highlights the need 1990; 24 Suppl 1:44-52; discussion 53-8.
for greater emphasis on preventive care of the patients
2. Farsi NM .The effect of education upon dentists’
during undergraduate and postgraduate training. Regular
knowledge and attitude toward fissure sealants..
continuing professional developmental programs which
Odontostomatol Trop. 1999 Jun; 22(86):27-32.
highlight the long term benefits of sealant use are also
the need of the hour. High attitude and willingness scores 3. Leclercq MH, Barmes DE, Sardo-Infirri J. Oral
of the respondents towards sealant use are encouraging Health: Global trends and projections, World
and might indicate that the respondents have favourable health statistics quarterly (Wld hlth statist quart),
disposition towards further training regarding the same. 1987; 40: 116-128.
4. National Oral Health Survey and Fluoride
Policy changes regarding the need for greater Mapping, “An Epidemiological Study of Oral
emphasis on the longterm benefits of preventive care Health Problems and Estimation of Fluoride Levels
is of critical importance. This is of special relevance in in Drinking Water,” Dental Council of India,
the context of developing and underdeveloped nations, NewDelhi, India, 2004, 32: 67–78.
which face greater disease burden as well as a definite
5. Sudha P, Bhasin S, Anegudi RT. Prevalence of
shortage of resources.
dental caries among 5-13-year-old children of
Conclusion Mangalore city. J Indian SocPedodPrev Dent 2005;
23:74-9.
The present study highlights the need for changes
6. Beauchamp J, Caufield PW, Crall JJ, Donly
in the dental curriculum regarding the use of pit and
KJ, Feigal R, Gooch B, Ismail A, Kohn W,
fissure sealant. Policy makers and decision makers
Siegal M, Simonsen R Evidence-based clinical
should consider placing greater emphasis on preventive
recommendations for the use of pit-and-fissure
dentistry in the dental curriculum in India. Continuing
sealants: a report of the American Dental
dental educational programs on preventive dentistry
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 99

Association Council on Scientific Affairs. Dent 14. Rubenstein LK, Dinius A..Dental sealant usage in
Clin North Am. 2009 Jan; 53(1):131-47 Virginia. J. Public Health Dent. 1986; 49: 147-51.
7. Mickenautsch S, Yengopal V. Caries-preventive 15. San Martin L, Castaño A, Bravo M, Tavares M,
effect of glass ionomer and resin-based fissure Niederman R, Ogunbodede EO. Dental sealant
sealants on permanent teeth: An update of knowledge, opinion, values and practice of Spanish
systematic review evidence. BMC Res Notes. 2011 dentist. BMC Oral Health. 2013 Feb 8; 13:12.
Jan 28; 4:22. 16. Asawa K, Gupta VV, Tak M, Nagarajappa R,
8. Hiiri A, Ahovuo-Saloranta A, Nordblad A, Mäkelä Chaturvedi P, Bapat S, Mishra P, Roy SS. Dental
M. Pit and fissure sealants versus fluoride varnishes Sealants: Knowledge, Value, Opinion, and Practice
for preventing dental decay in children and among Dental Professionals of Bathinda City,
adolescents. Cochrane Database Syst Rev. 2010 India. AdvPrev Med. 2014; 2014:469738. Epub
Mar 17; (3):CD003067. Article ID CD003067, 2014 Apr 10
2006. 17. Govindaiah S, Bhoopathi V. Dentists’ levels of
9. YengopalV, MickenautschS. Resin-modified glass- evidence-based clinical knowledge and attitudes
ionomer cements versus resin-based materials as about using pit-and-fissure sealants. J Am Dent
fissure sealants: a meta-analysis of clinical trials. Assoc. 2014 Aug;145(8):849-55.
European Archives of PaediatricDentistry2010; 18. Main PA, Lewis DW, Hawkins RJ .A survey of
11(1):18–25. general dentists in Ontario, Part I: Sealant use
10. Ahovuo-Saloranta, A. Hiiri, A. Nordblad, H. and knowledge. J Can Dent Assoc. 1997 Jul-Aug;
Worthington, and M. M¨akel¨. Pit and fissure 63(7):542, 545-53.
sealants for preventing dental decay in the 19. O’Donnell JA, Modesto A, Oakley M, Polk
permanent teeth of children and adolescents The DE, Valappil B, Spallek H. Sealants and
Cochrane Library 2004. Vol 4, Issue 4. dental caries: insight into dentists’ behaviors
11. Simonsen RJ. Pit and fissure sealant: review of the regarding implementation of clinical practice
literature. Pediatric Dentistry 2002, 24: 5. 393-414 recommendations. J Am Dent Assoc. 2013
12. Gift HC, Frew R, Hefferren JJ. Attitudes toward Apr;144(4):e24-30.
and use of pit and fissure sealants. ASDC J Dent 20. Olmsted JL, Rublee N, Kleber L, Zurkawski E.
Child. 1975 Nov-Dec; 42(6):460-6. Independent analysis: efficacy of sealants used
13. Hunt RJ, Kohout FJ, Beck JD. The use of pit and in a public health program. J Dent Hyg. 2015
fissure sealants in private dental practices. ASDC J Apr;89(2):86-90
Dent Child. 1984 Jan-Feb; 51(1):29-33.
 100 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

In Vitro Comparative Study of Dimensional Stability of

Three Different Polyvinyl Siloxane Interocclusal Recording
Matereials after Storage for Different Time Intervals of
12Hours, 24Hours, and 48Hours

Priscilla Shalini.S1, Narayana Reddy2, Sanjna Nayar3

1
PG Student, 2Professor, 3Professor and Head of the Department, Department of Prosthodontics,
Sree Balaji Dental College and Hospital, Chennai

Abstract
Background: Interocclusal recording materials are generally used in prosthetic dentistry to register the
jaw relationship. These materials have a wide range of viscosity, elasticity, and volumetric changes within
various material groups. Newer elastomeric interocclusal materials are chemical modifications of elastomers
whose comparative properties relevant to clinicians are yet to be studied.

Aims: To compare the dimensional change between the polyvinylsiloxane bite registration materials
manufactured by different brands within the duration of 12hours,24hours, and 48 hours storage.

Methodology: The dimensional changes of the different polyvinylsiloxe bite registration pastes were
compared three - dimensionally in different time intervals with the standardised die measurement was 25mm
between the vertical lines .

Conclusion: Within the limitations of the study, it was found that all 3 interocclusal recording materials
NEOSILK, CADBITE, AND O-BITE showed no significant distortion when stored in-vitro for 12 hours. All
Materials showed significant distortion when stored in-vitro for 24 hours and 48 hours. All three materials
showed more distortion when stored in 48hours compare to 24 hours. Among polyvinyl siloxane interocclusal
recording materials NEOSILK showed better dimensional stability when compared with CADBITE and
O-BITE when stored in-vitro 24hours and 48hours. Hence we recommend Neosilk bite material for better
dimensional stability when compare with other materials.

Keywords: Dimensional stability, comparison, bite registration pastes

Introduction excursions. To achieve proper occlusion in a dentate or

edentulous patient, the precise articulation of patient’s
The stomatognathic system in humans is a complex
diagnostic or working casts is a required. Recording and
that combines the organs, structures and nerves involved
transferring of accurate existing occlusal records is of
in a multitude of functions like speech, mastication and
prime importance for a successful restoration.
deglutation. Functions of occlusion can influence the
overall pattern and the foundation of the stomatognathic Interocclusal recording material should ideally
system. Long term success of any restoration is become rigid enough to resist distortion that might result
dependent on maintenance of harmony between various from the weight of the dental casts and exhibit minimal
components of stomatognathic system. The goal of any dimensional change after setting before mounting of the
restorative treatment is to establish posterior occlusal casts in the articulator.
contacts that stabilize the occlusion and to provide
anterior guidance which will provide predictable The basic principle approach should be that the
amount of disocclusion during protrusive and lateral interocclusal record must be at the correct vertical and
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 101

horizontal relation with an accurate, dimensionally 30mm diameter surface. According to above-mentioned
stable recording material and recording of eccentric specifications a total 2 dies were prepared.
maxillomandibular relations an appropriate method of
mandibular guidance.1 Among the errors in interoclusal Each die had a highly polished surface and also
recording, only iatrogenic and material based ones are contained a ring that surrounds the periphery of it, which
preventable by the operator. Hence, it is essential to serves as a tray or as a container for the interocclusal
know properties of interocclusal recording material.1 recording material.

Earlier interocclusal recording materials were 2. Manipulation of Materials:

impression plaster, bite waxes and zinc oxide eugenol olyvinyl siloxane materials were supplied in the
pastes. The newer materials polyvinyl siloxane and form of cartridge containing base and accelarator paste.
polyether are being used commonly due to their Manufacturer’s instructions were meticulously followed
elastic properties and dimensional stability. The for manipulation and the material which extruded from
polyvinylsiloxane bite registration materials have the gun was uniformly spread over the surface of the die.
advantages of less rigidity with easy removal from Glass plate covered with polyethelene sheet was placed
undercuts compare to polyether materials. on the die over with a weight of 500g was kept and
Hence, this study was done to study the dimensional allowed to set for 4-5mins.
change between the different polyvinylsiloxane 3. Specimen fabrication:
interocclusal recording materials commonly used in
clinical practice namely CADBITE, NEOSILK AND Each material was manipulated as mentioned
OBITE at different time intervals. above and total force of 5.55N was applied. The whole
assembly was then submerged into a water bath for
Materials and Method the setting time suggested by manufacturer plus 3mins
The following polyvinylsiloxane interocclusal to ensure polymerization. After removal from water
recording materials were selected for the study: Viz. bath the material was separated from the die by using
Virtual CADBITE, NEOSILK, and O-BITE interocclusal brass disk or Riser to remove the excess flash trimmed
recording materials. using scalpel. Thus prepared specimens were measuring
30mm in diameter 3mm in thickness and had lines
Armamentarium used for the study were X,Y,Z,CD,C’D’ lines on it . Similarly all the 40 bite
Stainless steel die (ADA specification – 19), OPUS registration record samples were obtained.
Nikon profile projector, Auto mixing gun with mixing
tips and permanent marker. In between the days of observation, the samples
were stored in moisture free polyethylene bags at room
1. Preparation of stainless steel die: temperature of 28±2 oC.

For the present study 2 stainless steel dies were 4. Testing of specimens:
prepared according to ADA specification No.19 for
preparation of test specimens with different polyvinyl The distance between the lines, CD and C’D’
siloxane bite registration materials. According to ADA reproduced on the sample, was measured at three different
specification 19 each die consisted of a cylindrical points PP’, QQ’ and RR’ (i.e. intersections of these lines
stainless block of 38mm diameter, with 30mm diameter with the lines XYZ) by using Nikon Profile Projector
step on its superior surface. The die was scored with V-12 with 10X magnification. Readings were obtained
3 horizontal lines and 2 vertical lines on the top of for each sample, and the mean of these three values were
impression surface . The horizontal lines were marked noted. Likewise, readings were made at different time
as X, Y, Z and vertical lines were marked as CD and intervals, viz. immediately after removal of the material
C’D’ for ease in making measurements. The distance from die, 12hours, 24hours and 48hours, respectively
between two horizontal lines was 25mm and between for each of the samples. All the readings thus obtained
two vertical lines was 25mm. The die was subjected to were tabulated and subjected to statistical analysis for
Nd-YAG Laser treatment and 3 horizontal and 2 vertical the comparison and correlation of dimensional stability.
line were scribed, with the width of 0.016mm on top of
 102 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Statistical Analysis using Wilcoxon Signed Rank test (Paired). At every time
interval, the groups were analysed by Kruskal Wallis test
The descriptive statistics was given by mean and
with post hoc Dunn test, where values were significant.
standard deviation. The dimensional change over
P < 0.05 was considered significant. Analyses were
time was analysed by Friedman’s repeated measures
performed with IBM-S
(ANOVA). For significant values, post hoc test was done

Result
Table 1 – Dimensional Stability of the Bite Registration Pastes

Brand 12HRS 24HRS 48HRS P Value

CAD-BITE 24.72 ± 0.0424 24.70 ± 0.0759 24.66 ± 0.0884 0.1224*

NEO SILK 24.73 ± 0.0297 24.72 ± 0.0272 24.71 ± 0.0352 0.2019*

O-BITE 24.73 ± 0.0282 24.62 ± 0.1325 24.51 ± 0.2161 0.0055*$

P Value 0.8866** 0.4682** 0.1636** ----

P value (PostHoc) NA 0.05876# 0.01242#$ ----

*-Friedman’s Repeated Measures ANOVA; **-Kruskal Wallis Test; #-Wilcoxon Signed Rank Test (Post Hoc);
$-Statistically Significant.

Figure – 1: Metallic master die with riser

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 103

Figure–2. View of the sample seen through Opus Nikon Profile projector (Representative photograph)

Discussion The distortion of the material is expected when the

The properties of the dental materials vary with upper and the lower casts are tied using the rubber bands
the temperature and humidity. Most of the materials with the interocclusal material interposed and transferred
used in prosthodontic procedures should be stored in to the laboratory. This distortion is due to the constant
the ambient temperatures to maintain their shelf life. pressure till the casts are mounted in the articulator by
The operator skill in the manipulation of the material is the laboratory technician.
very important apart from the storage conditions of the The time elapsed between the interocclusal recording
material. and the casts mounted in the articulator will cause
The dimensional changes in the recording materials distortion due to the prolonged setting or polymerisation
will not transfer the true maxilla-mandibular relation and the variation of the temperature between the dental
from the mouth to the articulator and the prosthesis office and the laboratory. The average time for mounting
fabricated will have occlusal contacts in the mouth of the casts using the interocclusal record varies from
different from the one fabricated in the articulator. The few hours when the laboratory is situated locally to two
time elapsed between the interocclusal record, and the days when sent to distant place.
mounting in the articulator extends up to three days as The current study was done to assess the distortion
the work is sent to distant laboratory. The casts and the of the interocclusal record at the intervals of 12 hours,
interocclusal record are sent to laboratory in different 24 hours and 48 hours similar to the normal clinical
conditions as separately with the casts, casts tied with the situations. The study was done with the interocclusal
rubber bands or mounted immediately. The dimensional record without any pressure application to check
changes in the interocclusal recording materials can be distortion at different time intervals.
expected when the material is removed from the mouth
due to the variation in the temperature between the oral Poly vinyl silicone and poly ether materials, when
cavity and the dental office and the plastic deformation used as interocclusal materials solved most of the
when the material is removed from the mouth. This problems associated with the earlier materials. These
distortion is possible even when the casts are mounted materials are elastic with moderate stiffness (elastic
immediately. modulus) so that they can be removed from the mouth
and mounted in the articulator without breakage.
 104 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

These materials are supposed to high dimensional Balthazar-Hart et al, (1981) had done a study with
stability, as they do not release any by-product during polyether and zinc oxide eugenol paste and concluded
polymerisation. Polyvinyl siloxane materials have that Polyether shows the least distortion, and zinc oxide
lower stiffness with the comfortable removal from the eugenol paste presents higher distortion.9 Lassila et al,
mouth and mounting with articulator than the polyether in 1986 had done a study with acrylic resin, zinc oxide
so that poly vinyl siloxane interocclusal materials are eugenol pastes and elastomeric materials and concluded
commonly used as interocclusal record. that elastomeric materials have good dimensional
stability when compared with acrylic resin and zinc
Direct interocclusal record is the most commonly oxide eugenol paste.10 Karthikeyan et al, in 2007 has
used technique to record maxilla-mandibular done a study with polyvinylsiloxane bite material, zinc
relationship. The recording material is soft initially, and oxide eugenol pastes, and bite registration wax (aluwax)
it fills the space between the teeth, hardens, and records and concluded that Polyvinylsiloxane (Virtual, Group
the specific relationship of the arch. The set material is A) was dimensionally more stable followed by zinc
transferred to cast and mounted on the articulator.3 oxide eugenol paste (Superbite, Group C) and then Bite
Nisan et al. observed that addition type registration wax(Alumax, Group B).11
polyvinylsiloxane was the most accurate and stable According to the results obtained in a study done by
interocclusal recording material. Previous studies have Sampath Kumar Tejo et al in 2012, Polyether was found
also demonstrated that handling PVS bite materials to be more dimensionally stable than polyvinylsiloxane
remain dimensionally stable up to 7 days.4 Many followed by zinc oxide eugenol.12 They recommended
authors have evaluated the dimensional change of the use of polyvinylsiloxane recording material should
bite registration materials by means of stone casts and be articulated within 24 hrs. They also recommended
different devices such as three dimensional Zeiss meter, that polyether should be articulated within 48 hrs and
digital caliper, microscope, and stereomicroscopes and Zinc oxide eugenol within 1 hr to prevent distortion.
Profile Projectors.4, 5, 6 In the current study Nikon Profile Polyvinylsiloxane bite registration material is popular
Projector was used for the evaluation of dimensional contemporary bite registration material along with
stability due to its higher precision combined with ease polyether material.
of use.
The newer polyvinyl siloxane bite registration
The stainless steel die used in the present study was materials used in this study Cadbite, Neosilk and O-bite
similar to the standard die given by ADA specification have a major composition of vinyl polysilaxone, methyl
No 19.7 The surface of this die is smooth and shiny; hydrogen siloxane, silicone dioxide. They polymerize by
therefore, it is easier to evaluate dimensional changes addition polymerization and do not form any by-product
compared to tooth surface with cusps and fossa. In in the reaction. They have longer polymerization period
the standard ADA dies, the diameter and angles of the resulting in sustained contraction period. These are the
flutes are important for evaluation of the accuracy of reasons for these materials being more dimensionally
impression materials.8 This study evaluated the distance stable than earlier materials.
between the vertical lines at different time intervals with
different interocclusal recording materials. The test die Conclusion
has 25mm distance between the vertical lines.
Within the limitations of the study following
The distance between vertical lines for Cadbite poly conclusions were drawn. Polyvinyl siloxane interocclusal
vinyl siloxane interocclusal material in the present study recording materials NEOSILK, CADBITE, and O-BITE
was 24.71 mm for 12 hours, 24.72 mm for 24 hours and showed no significant distortion when stored in-vitro
24.62 mm for 48 hours. In Neosilk poly vinyl siloxane for 12 or 24 hours, but showed significant distortion
interocclusal material the measured values between the when stored in-vitro for 24 hours and 48 hours. Among
vertical lines was 24.74 mm for 12 hours, 24.71 mm for polyvinyl siloxane interocclusal recording materials
24 hours and 24.68 mm for 48 hours. In O-Bite material NEOSILK showed marginally better dimensional
it was 24.72 mm for 12 hours, 24.30 mm for 24 hours stability when compared with CADBITE and O-BITE
and 24.31 mm for 48 hours. when stored upto 48 hours.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 105

Conflict of Interest: No conflict of interest 6. Dixon LA. Overview of articulation, materials and

Source of Funding: Self methods of prosthodontic patient, J Prosthet

Dent. 2000; 83(2):235-47.
Ethical Clearance: Taken
7. Millstein PL, Hua C. Differential accuracy of
References elastomeric recording materials and associated
weight change. J Prosthet Dent; 71(4): 400 - 403.
1. Mullick SC, Stackhouse JA Jr, Vincent GR. A
8. Hatzi P, Tzakis M, Eliades G. Setting characteristics
study of interocclusal record materials. J Prosthet
of vinyl-polysiloxane interocclusal recording
Dent. 1981 Sep;46(3):304-7.
materials. Dent Mater. 2012; 28(7):783-91.
2. Gurav SV, Khanna TS, Nandeeshwar DB.
9. Balthazar-Hart Y, Sandrik JL, Malone WF, Mazur
Comparison of the accuracy and dimensional
B, Hart T. Accuracy and dimensional stability of
stability of interocclusal recording materials -An
four interocclusal recording materials. J Prosthet
in-vitro study. International Journal of Scientific
Dent. 1981; 45(6):586-91.
and Research Publications. 2015; 5(7): 1-9.
10. Lassila V. Comparison of five interocclusal
3. Mangano FG, Veronesi G, Hauschild U, Mijiritsky
recording materials. J Prosthet Dent. 1986;
E, Mangano C. Trueness and Precision of
55(2):215-8.
Four Intraoral Scanners in Oral Implantology:
A Comparative in Vitro Study. PLoS One. 11. Karthikeyan K, Annapurni H. Comparative
2016;11(9):e0163107. evaluation of dimensional stability of three types of
interocclusal recording materials: An in vitro study.
4. Tripodakis AP, Vergos VK, Tsoutsos AG.
J Indian Prosthodont Soc 2007;7:24-7
Evaluation of the accuracy of interocclusal records
in relation to two recording techniques. J Prosthet 12. Tejo SK, Kumar AG, Kattimani VS, Desai PD,
Dent. 1997; 77(2):141-6. Nalla S, Chaitanya K. A comparative evaluation of
dimensional stability of three types of interocclusal
5. Chai J, Tan E, Pang I. A study of surface hardnesss
recording materials-an in vitro multi-centre study.
and dimensional stability of several intermaxillary
Head Face Med. 2012; 8:27.
registration materials J Prosthet Dent. 1994; 7:538-
548.
 106 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Factors of Happiness among Indian adolescents

Priyamvada Shrivastava1, Gayatri Jay Mishra2, Mahendra Kumar1

1Professor and Head, 2Research Scholar, Department of Psychology, Pt. R.S.U. Raipur, C.G. India

Abstract
The main objective of the study was to explore the factor of happiness among the adolescent’s students the
other objective was to formulate the theoretical structure of the happiness for the adolescent’s population
of Chhattisgarh India. For these purpose 250 adolescents studying in different schools of Chhattisgarh
constituted the sample for the study. The students were asked to give an open-ended answer to a question
“what makes them happy” analysis was performed for their responses 28 common responses after analyzing
the responses were identified. A hypothetical exploratory factor analysis (EFA) and confirmatory factor
analysis (CFA) was computed to find out the factors of happiness among adolescents. The results of the EFA
revealed 5 factors of happiness for adolescents. The results of CFA reveal a low correlation between the 5
factors.

Keywords: Happiness, EFA, CFA,

Introduction identified individual-level factors of happiness, such as

biological, personality, lifestyle, socio-demographic and
In psychology, happiness is a mental or emotional
socio-economic factors(7-11). Definitions of happiness
state of well-being which can be defined by positive or
vary with respect to region culture. It is reported that
pleasant emotions ranging from contentment to intense
various definitions are available worldwide(12). In
joy. Happiness has been considered a major life goal
contemporary psychology, there is much emphasis on
in common philosophy(1). In the present generation,
well being, contentment and Happiness. People are
happiness is an amazing thing. We all want to experience,
healthy normal but feel discontentment. Happiness issue
for the reason that happiness is one of the most important
is major public health situation it differs according to
values in life for all human(2). Happy mental states may
different stages of life. The adolescent stage is a transition
reflect judgments by a person about their overall well-
stage adolescents suffer from emotional turmoil and
being. Happiness is when what you think, what you say,
stress(13-14). It is important to explore the factors of
and what you do are in harmony. Happiness is defined
happiness among Indian adolescents. Development of
as a multi-dimensional component of unconscious,
a screening tool of happiness among adolescents in the
cognitive, and motivational processes that are unique
Indian context is essential. There is a dearth of studies on
to how life is interpreted and received by individuals(3).
happiness factors of Indian adolescents’. Hence, there
A commonly used definition of happiness is the degree
is a need to find out the factors of happiness in Indian
to which an individual judges the overall quality of his/
cultural contexts and to develop culturally appropriate
her life as a whole favourably(4-6). Happiness is when
assessment measures for happiness. For this purpose, the
what you think, what you say, and what you do are in
main objective of the study was to find out the factors of
harmony. The concepts of happiness affected by the
happiness and to examine the theoretical structure of the
cultural and historical variations, many studies have
happiness of the Indian adolescent population. Therefore
a study exploring happiness among adolescents has been
Corresponding Author: undertaken which highlights the factors contributing to
Priyamvada Shrivastava happiness reactions of adolescents and can provide a
Research Scholar Department of Psychology, Pt. baseline for the development of the tool.
R.S.U. Raipur, C.G. India.
Contact-Email:[email protected] /
Tel.: +09669891505
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 107

Method Statistical Analysis

Sample The data were analyzed by excel, SPSS 16.0 version
and ADANCO (advanced analysis of composites)
The total 250 (125 male & 125 female) adolescent’s version 2.0.1(15). Responses from participants were
participants of the study were selected from Raipur, coded and entered into SPSS. Missing data were
Bhilai and Durg, cities of Chhattisgarh. Mean age of excluded from the relevant analysis. To have an idea of
the was =19. Incidental random sampling technique was the basic factors of the happiness in Chhattisgarh state,
used for the selection of the participants. India, maximum likelihood method was performed
The adolescents who fulfilled the following criteria to explore the links between the observed and latent
were included in the study: variables, and to identify the factor structure. The nature
of the principal component analysis is exploratory rather
Inclusion criteria than confirmatory(16). The factors with eigenvalues
greater than 1.00 were retained. Factor coefficients of
o Students of class 10, 11 and 12. 0.40 or greater can be used for the interpretation of the
o Able to communicate, read, write and factor structure(17). The factors showing more than .40
comprehend in English. coefficient were interpreted as a factor structure(18).
Confirmatory factor analysis (CFA) was used with
o Willing to participate. ADANCO.

Exclusion criteria Results

o Students below 10th class and above 12th class Mainly two types of factor analysis were used
were not included in the study. in the study: exploratory factor analysis (EFA) and
confirmatory factor analysis (CFA). The EFA approach
o Not present at the time of the study.
describes how and to what extent the observed variables
o Not willing to participate in the study. are related to their latent constructs.

o Those with any chronic disease were excluded. Exploratory Factor

Design To conduct the exploratory stage of factor analysis,

extraction methods in Principal Analysis Factoring
The survey research design was used. technique (PAF) was used. The method was chosen
from the available methods because it is a good method
Procedure
for assessing the underlying dimension of a domain.
Participants, who met inclusion criteria, were Varimax rotation was used for factoring methods. Five
contacted individually, it was essential to making factors were identified from the initial domain run that
rapport with the participants, to win their trust. They exhibited eigen values greater than one.
were ensured that their information will be kept strictly
Varimax rotation was done to clarify the loading
confidential. The information given by them would be
on these factors. There were 28 domains which had
used for research purpose only. After getting consent
significant loadings on any of the five factors. Obtained
in writing from the participants, they were interviewed.
loading of items on the five factors is presented in the
Qualitative information related to the happiness of the
figure-1. Kaiser – Mayer - Olkin (KMO) value for
adolescents was gathered by putting one Question “What
eighteen domains were found to be .652 which indicates
are the events that make you feel happy. 28 dimensions
the sample is adequate. Education 10.36%, Sociability
were observed in the responses of the adolescents further
10.13%, Health 9.66%, Entertainment 8.82% and
the 28 dimensions were put to exploratory factor analysis
Sensation Seeking 8.14% overall responses explained
and confirmatory factor analysis the results of which are
47.12% of the variance. In the field of social sciences
given in the figure.
factor loading is considered minimum 0.30 or 0.35 when
sample size less than 100, but above 200 minimum cut
– off above 0.40 was considered(19). Also in the field of
 108 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

social science research Communalities (h2) is generally Model fitting – Model fit analysis was performed
considered between a range of 0.40 to 0.70,(20). for a decision on the goodness of fit. The fitness of the
model was excellent with the data it was evaluated with
Confirmatory Factor Analysis guideline [{the Unweighted least squares discrepancy
A measurement model was tested for all samples (dULS) P < .01, The geodesic discrepancy (dG) P <
using confirmatory factor analysis (CFA) after the EFA. .01(15) and the standardized root mean squared residual
Model fit was excellent in all samples: (SRMR) P < .01}].

Table 1. Confirmatory factor analysis (Decision on model goodness of fit)

The goodness of model fit

Value HI95 HI99
(saturated model)
SRMR 0.0863 0.0632 0.0661

dULS 1.4144 0.7592 0.8299

dG 0.4193 0.2603 0.2805

Figure 1 SEM explaining factorial validity and regression weight of factors for happiness
(6.0=Academic Achievement, 7.0=work completion, 9.0=study, 15=obey the teacher, 23.0=learning, 17=purchasing,
19.0=surprises, 20.0=shopping, 11.0=food, 13=independence, 27.0=hygiene, 28.0=health, 5.0=trawling, 22.0=nature,
26.0=adventure, 4.0=t.v. movie, 8.0=music or dance, 10.0=outdoor work, 25.0=festival).
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 109

A measurement model was tested for all samples social capital have consistently been positively
using confirmatory factor analysis. In this model, factor associated with happiness and related constructs such as
educations explain the five subcomponents: Academic subjective well-being(21-23). Some aspects of the physical
Achievement, work completion, study, obey the teacher environment have also been studied extensively; found
and learning. Factor sociability explains the three that settings that were aesthetically more attractive and
subcomponents: purchasing, surprises and shopping. had more green space have consistently been related
Factor Health explains the four subcomponents: food, to higher levels of happiness(24-27). Perceived access to
independence, hygiene and health. Factor Sensation public transport, culture and leisure facilities have been
Seeking explains the three subcomponents: trawling, positively related to happiness(24). while another study
nature and adventure. Entertainments explain the four found that happiness to be more closely associated with
subcomponents: television. movie, music or dance, cultural, sporting, shopping and transport amenities
outdoor work and festival. (Figure 1) shows the (place variables) among young people and with quality
regression weights. All values depicted in Fig.1 for all of government services (performance variables) among
adolescents students- Academic Achievement, work older people(28).
completion, learning, purchasing, surprises, shopping,
food, hygiene, health, trawling, nature, t.v. movie, music Thus the results of the present study are important in
or dance, outdoor work, and festival show the largest understanding adolescent’s happiness and accordingly
values (>.68). The study, obey the teacher, independence help them to overcome the stress. Various studies have
and adventure show the lowest weight for the sample (.59 revealed that students who have high-stress levels are
to .35). The results of CFA also indicate low correlation less likely to report high perceived happiness(29). The
between the 5 factors. study suggested that students were least happy about
their financial situation, at work, and at school, low
The result of factor analysis revealed five important perceived happiness reported higher stress levels and
factors namely- Education, Sociability, Health, lower emotional closeness to others(30). The finding of
Entertainment and Sensation Seeking, which are predicts the present study are in line with the findings of the
5 domains in Education, 6 domains in Sociability, 4 study reported that adolescents who reported sufficient
domains in Health, 5 domains in Entertainment and 06 time spent with family members and the highest level
domains in Sensation Seeking. The statistical properties of love and connectedness were happiest(31). Those
reveal that the all happiness factor is reliable in the living in a two-parent family were happiest, followed by
Indian population. those living with a married father or a married mother
(in a single parent family). Those living in an unmarried
Discussion mother family were unhappiest, controlling for household
The result of the present study revealed 5 factors of economic status. These findings highlight the important
adolescents’ happiness is. Education, Sociability, Health, role of a father in a country with a matriarchal family
Entertainment and Sensation Seeking, by sociability system. Regarding non-family factors, adolescents with
it is meant that adolescents feel happy when they are the highest school attendance, highest self-esteem, and
free to purchase, give surprises to others and they love highest economic status who also regularly participated
shopping. For adolescents education also matters, in extracurricular activities were happiest. Adolescents
particularly good performance in academics, studying who were older and who had to do chores regularly
obeying the teachers make them feel happy when they tended to be less happy than their peers. The reason
are acknowledged. The young adolescents enjoy food for the findings of the study can be included as every
and are also more pleased in hygienic conditions. They adolescent belongs from different family environment,
also like adventurous activities, traveling, and nature, the family attention, parents’ time to share care, parental
they like thrilling experiences. Many adolescents love cooperation and conversation with their children, drug
entertainment, enjoy music, movies & festivals. addiction, and financial condition, etc., of the family, is
important factors for adolescent happiness. The factors
The finding of the various researches provides identified for happiness among adolescents provide a
support for an association between social and physical base for the development of happiness scale.
environmental factors and happiness. For example,
social environmental factors such as neighborhood
 110 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Conclusion 7. Grant N, Wardle J, Steptoe A. The relationship

between life satisfaction and health behavior: a
The happiness among adolescents is an area which
cross-cultural analysis of young adults. Int J Behav
is a major concern among society members and requires
Med. 2009;16: 259–68. doi: 10.1007/s12529-009-
exploration of happiness factor for adolescents in the
9032-x.]
present study. 280 adolescent students responded to
their happiness reasons. The results of CFA reveal 5 8. Dfarhud D, Malmir M, Khanahmadi M. Happiness
domains which lead to happiness among adolescents. & Health: The Biological Factors- Systematic
The present work has application in understanding the Review Article. Iran J Public Health. 2014;43:
factors of happiness among adolescents and accordingly 1468–77.
their behaviours can be dealt. The work is also helpful 9. Prasad M. An Analysis of Relationship between
in the development of tools for the measurement of Happiness and Personality: A Literature Review.
happiness among Indian adolescents’ population. The Asian J Multidiscip Stud. 2016;4: 41–46.]
measurement of happiness would be helpful in the health 10. Brereton F, Clinch JP, Ferreira S. Happiness,
sector because happiness can increase physical activity geography and the environment. Ecol Econ. 2008;65:
and significantly decrease depression(32). Physical 386–396. doi: 10.1016/j.ecolecon.2007.07.008.
activity makes us look better, feel better, and sleep better 11. Inglehart R. Gender, Aging, and Subjective Well-
by releasing dopamine into the brain. Being. Int J Comp Sociol. 2002;43: 391–408. doi:
Acknowledgment: The author appreciates all those 10.1177/002071520204300309.
who participated in the study and helped to facilitate the 12. Oishi S, Graham J, Kesebir S. Concepts of
research process. Happiness Across Time and Cultures. Personality
and Social Psychology Bulletin. 2013; 39 (5),
Source of Funding: None https://doi.org/10.1177/0146167213480042.
Conflict of Interests: The author declared no 13. Kumar M, Shrivastava P. Effect of mobile phone
conflict of interests. use on stress parameters. International journal of
basic and applied research. 2018; 8 (6), ISSN 2249-
Note-The study was approved by departmental 3352 (P) 2278-0505 (E).
research committee.
14. Kumar M, and Shrivastava P. A Study of
Psychological factor discriminating diabetic and
References
non-diabetic patients. Indian journal of health and
1. Anic P, Toncic M. Orientation to happiness, wellbeing 8(8); 2017: 881-884.
subjective well-being and life goals. Psychological 15. Henseler J, Dijkstra TK. ADANCO 2.0. Kleve,
Topics. 2013; 22(1),135-153. Germany: Composite Modeling 2015.
2. King LA, Napa CK. What makes a life good? J Pers 16. Tabachnick BG, Fidell LS. Using Multivariate
Soc Psychol. 1998;75: 156–65. Statistics. 2014; 6th edn Harlow: Pearson.
3. Lyubomirsky S, Tkach C, DiMatteo MR. What are 17. Hogarty K, Hines C, Kromrey J, Ferron J, Mumford
the differences between happiness and self-esteem? K. The Quality of Factor Solutions in Exploratory
Social Indicators Research. 2005; 78(3), 363-404. Factor Analysis: The Influence of Sample Size,
4. Diener E. Subjective well-being. The science of Communality, and Over determination. Educational
happiness and a proposal for a national index. Am and Psychological Measurement. 2005; 65(2), 202-
Psychol. 2000; 55: 34–43. 26.
5. Helliwell JF, Layard R, Sachs J. World Happiness 18. Costello A, Osborne J. Best practices in exploratory
Report 2015. New York; 2015. factor analysis: Four recommendations for getting
6. Veenhoven R. The Concept of Happiness. the most from your analysis. Practical Assessment,
Conditions of Happiness. Dordrecht: Springer Research and Evaluation. 2005; 10 (7), 281-286.
Netherlands; 1984. pp. 12–38. doi: 10.1007/978- 19. Dijkstra TK, Henseler J. Consistent partial least
94-009-6432-7 squares path modeling. MIS Quarterly. 2015; 39
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 111

(2), 297–316. 27. MacKerron G, Mourato S. Happiness is

20. Norman GR, Streiner DL. Biostatistics: The bare greater in natural environments. Glob Environ
essentials. St. Louis, MO: Mosby 1994. Chang. 2013;23: 992–1000. doi: 10.1016/j.
gloenvcha.2013.03.010.
21. Rodríguez-Pose A, von Berlepsch V. Social Capital
and Individual Happiness in Europe. J Happiness 28. Hogan MJ, Leyden KM, Conway R, Goldberg A,
Stud. 2013; 15: 357–386. doi: 10.1007/s10902- Walsh D, McKenna-Plumley PE. Happiness and
013-9426-y. health across the lifespan in five major cities: The
impact of place and government performance.
22. Delhey J, Dragolov G. Happier together. Social
Soc Sci Med. 2016;162: 168–176. doi: 10.1016/j.
cohesion and subjective well-being in Europe.
socscimed.2016.06.030.
Int J Psychol. 2015; 51: 163–176. doi: 10.1002/
ijop.12149. 29. Schiffrin HH, Nelson SK. Stressed and happy?
Investigating the relationship between happiness
23. Veenhoven R. Social conditions for human
and perceived stress. Journal of Happiness Studies.
happiness: A review of research. Int J Psychol.
2010; 11(1), 33-39.
2015;50: 379–91. doi: 10.1002/ijop.12161.
30. King, KA, Rebecca A, Vidourek, Ashley, L.,
24. Leyden KM, Goldberg A, Michelbach P.
Merianos & Singh M. A study of stress, social
Understanding the Pursuit of Happiness in Ten
support, and perceived happiness among college
Major Cities. Urban Aff Rev. 2011; 47: 861–888.
students. The Journal of Happiness & Well-Being.
doi: 10.1177/1078087411403120.
2014; 2(2), 132-144143.
25. Marselle MR, Irvine KN, Lorenzo-Arribas A,
31. Gray R, Chamratrithirong A, Pattaravanich U,
Warber SL. Moving beyond green: exploring the
Prasartkul P. Happiness among Adolescent Students
relationship of environment type and indicators
in Thailand: Family and Non-Family Factors,”
of perceived environmental quality on emotional
Social Indicators Research: An International
well-being following group walks. Int J Environ
and Interdisciplinary Journal for Quality-of-Life
Res Public Health. 2015;12: 106–30. doi: 10.3390/
Measurement. 2013; 110 (2), 703-719.
ijerph120100106.
32. Kumar M, Pandey D, Shrivastva P. Effect
26. White MP, Alcock I, Wheeler BW, Depledge
of GSR Biofeedback Relaxation Training on
MH. Would You Be Happier Living in a Greener
Blood Glucose and Anxiety Level of Type 2
Urban Area? A Fixed-Effects Analysis of Panel
Diabetic Patients. International Journal of Indian
Data. Psychol Sci. 2013;24: 920–928. doi:
Psychology. 2016; 4, (1), No. 82; ISSN:2348-
10.1177/0956797612464659.
5396 DIP:18.01.160/20160401, ISBN:978-1-365-
59365-9.
 112 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Clinical Decision Making For Biopsy of Oral Mucosal Lesions

Priyanka.S.R1, M.Arvind2
1Post Graduate Student, 2Professor & Head, Department of Oral Medicine and Radiology, Saveetha Dental
College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, India

Abstract
Accurate diagnosis and treatment of oral diseases is an essential component of a comprehensive oral care
practice. Accurate diagnosis also helps formulate the appropriate treatment plan and helps to avoid further
complications from inadequate treatment and to avoid adverse effects from treatment that is not necessary
for the particular patient. Obtaining an oral biopsy allows the clinician to diagnose many precancerous
conditions and ensure early treatment. Biopsy may be the gold standard for final tissue diagnosis but any
invasive procedure comes with its own risks and side effects. When a clinician is faced with a patient with
signs and symptoms that are suggestive, but not diagnostic of a disease, he/she has the responsibility to
decide between the option to treat empirically or not to treat or to perform further diagnostic tests. This
paper aims to review the basic indications and contraindications of performing an oral tissue biopsy and to
identify different oral mucosal lesions that may benefit from empirical therapy better than a biopsy in the
early stages. Knowledge of these lesions will help the clinician avoid the undesirable outcomes that may be
associated with an oral biopsy.

Keywords: Biopsy, Oral lesions, Decision analysis, Oral Mucosa, Oral Medicine

Introduction The patient’s main concern is for a quick and painless

procedure which serves the diagnostic purpose. The
“Biopsy” is the process of obtaining a sample of
pathologist always appreciates receipt of an undamaged
tissue from a living body with the objective of providing
specimen that is properly labeled and handled by the
a confirmatory histopathological diagnosis following
clinician. So, the clinician performing the biopsy has
microscopic examination of the tissue sample. Biopsies
the responsibility to ensure that all parties involved are
are important diagnostic tools for the diagnosis of
satisfied.[2] This can be done only with the appropriate
lesions ranging from periapical lesions to benign
knowledge of the indications, contraindications, pros &
mucosal lesions to malignancies. In general, when the
cons of performing a biopsy and also knowledge of the
clinician is well-versed with anatomy, biopsy will be a
situations where biopsy may not be initially necessary in
safe and reliable diagnostic tool. But, biopsies should
order to satisfactorily treat a patient.
only be performed by the clinician if a thorough clinical
examination has been done and all prior investigations Types of Biopsy
have been performed. This will help avoid untoward
consequences or iatrogenic induction of complications. The different situations which might warrant a
[1] biopsy in a dental setup include oral mucosal lesions,
apical lesions associated with teeth, lesions associated
with jaw bone, mucocutaneous lesions, suspected
malignancies and precancerous conditions.
Corresponding Author:
Dr.M.Arvind, Direct biopsy is when the lesion lies superficially
Professor & Head, with ease of access. Indirect biopsies will have to be
Department of Oral Medicine and Radiology done in lesions which are located in deeper tissues and
Saveetha Dental College, 162, Poonamallee High Road, are covered by normal appearing mucosa or tissue.[3] The
Velappanchavadi, Chennai – 600077 incisional technique involves removal of a representative
Email: [email protected] part of the lesion along with a part of the healthy tissue. It
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 113

is indicated when the lesion is large, difficult to remove procedure and may cause delay in healing. Biopsies are
in entirety, in a complicated location or if it is part of also avoided when there is an acute, virulent, pyogenic
a systemic disease process. The excisional technique infection in order to avoid spread of infection. Lesions
is used when the lesion can be removed in toto with of vascular origin and those in patients who have a
a peripheral safety margin.[4] Intraoperative biopsies history of blood dyscrasias may complicate the situation.
[9]
are speedily processed and diagnosis is received in Biopsies may require medical clearance in the case of
the operating room in a short period of time, which medically compromised patients. In addition, they may
allows the clinician to continue as required. The various cause iatrogenic worsening of the condition in certain
procedures involved in processing the biopsy specimen patients. These include patients on radiotherapy, patients
includes, fresh examination, frozen sectioning and in bisphosphonates. Biopsies should also be avoided
paraffin/methacrylate embedded examination. [5] in patients whose lesions may resolve when allowed
a benefit of doubt after removal of any local causative
Approach to Lesions: factors. Biopsy at the first visit should be avoided unless
A systematic approach should be sought for every the clinician has substantial evidence for suspicion
oral lesion with the chief complaint as the starting point of malignancy or other serious lesion which require
of the investigation. There are certain points which mandatory biopsy.[5]
would help the clinician decide whether biopsy is the Pros and cons of empirical therapeutic trial
right investigation. Biopsy should be done to confirm versus an immediate biopsy of oral mucosal lesions:
clinical and radiographic findings and for the purpose
of determining the type of treatment to be instituted In certain cases of oral mucosal lesions, like
in certain diseases or it should be for the purpose of vesiculobullous lesions, certain precancerous lesions,
teaching, for eliminating cancerophobia or for the infective, traumatic and other inflammatory lesions, a
purpose of medico-legal records if needed.[6] therapeutic trial offers many advantages over immediate
biopsy on the first visit. The basic formula for treatment
Indications And Contraindications Of Oral Biopsy: of any disease is accurate diagnosis which would indicate
the appropriate treatment plan. But, there are situations
Indications where empirical treatment of non-specific lesions on the
Biopsies should be taken for lip and oral lesions basis of history, clinical features or a provisional diagnosis
that do not originate from apparent local irritating may be acceptable or preferable. If the empirical therapy
factors (trauma or inflammation). Lesions which given for a 2-3 week period sufficiently clears the lesion,
persist for more than 3 weeks and lesions suspected of the biopsy can be avoided. In addition, in precancerous
malignancy should also be biopsied. Rapidly expanding conditions, dysplasia may be present in only localized
lesions and those that cause pain, paresthesia and other areas. If these areas are overlooked and other areas
ominous symptoms and lesions that were considered biopsied at the initial visit, the diagnosis will be missed.
benign but have subsequently undergone significant When empirical therapy is given, if the lesion does not
changes in the appearance should also be biopsied. respond or if a particular localized area is refractory to
Biopsies are also useful in confirming cases of certain treatment, biopsy of the refractory area is more likely to
lesions resulting from infections such as syphilis, give the correct diagnosis.[10] Certain benign lesions may
tuberculosis, deep fungal infections, and some lesions sometimes bear resemblance to premalignant lesions
of mucocutaneous vesiculobullous type.[7] Rapid bone or even resemble malignancy. The clinician must be
loss, irregular widening of the periodontal ligament, aware of the history, clinical features and other features
spiking root resorption and tooth mobility in the absence which will help differentiate these conditions. Some
of identifiable traumatic or inflammatory causes are the clinicians may feel more comfortable having the results
ominous signs that warrant a biopsy.[8] of an immediate biopsy before treatment. But, clinically
practical patient management favours a therapeutic trial
Contraindications: of drugs first and biopsies to be performed for refractory
Oral biopsies may be contraindicated in patients lesions.[11]
when the general health condition is very poor, which On the other hand, a more confident diagnosis and
keeps the patient unable to cope with the invasive treatment plan can be done when the results of a biopsy
 114 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

are also used. A biopsy of representative tissue must be of correlation between the clinical signs and symptoms
obtained when lesions don’t adequately respond to a and the histological picture may be observed, especially
therapeutic trial. Histopathological diagnosis also helps when unrepresentative tissue samples are submitted.
to reassure the patient and helps instill a greater degree Incorrect handling and fixation can induce artefacts and
of confidence in the treatment modalities. Sometimes, a render the tissue non-diagnostic.[16] Meticulous surgical
lesion may heal with a therapeutic trial, and a therapeutic techniques should be used during biopsy procedure to
diagnosis may be made. But if the disease recurs, then avoid clot disruption, wound dehiscence, and bleeding
the clinician is again in a dilemma about the diagnosis. problems. Some patients may also report paresthesia
Malignant transformation is also a risk in certain oral following biopsy which may last several days to months.
mucosal lesions. Due to this possibility, confirmation [7]

with a biopsy is a good approach.[12]

Some lesions where empirical treatment can help
Patient preferences and behavior regarding/ avoid immediate invasive biopsy:
following oral biopsies:
Presence of Candida in oral potentially malignant
Patients’ participation in the decision making disorders has been researched frequently. The epithelial
process is an important part of healthcare. People who changes seen in mucosa with a leukoplakic lesion allows
are given information about the planned investigations Candida to infiltrate and invade the mucosal surface.
and treatment are usually less anxious. When patients [17] In addition to its effect on carcinogenesis, Candida

are told that they require a biopsy they are usually in a leukoplakic lesion may also interfere with the
concerned about both the procedure and the results. histopathological examination and may not provide
Any invasive/surgical procedure is linked to stressors an exact picture of the degree of dysplasia. An initial
such as pain, cost of treatment, fear of needles, failure exfoliative cytology done to detect the presence of
of the surgeon and fear of infectious diseases[13] . So, the Candida can help to prescribe a topical antifungal agent
decision to perform a biopsy should be based on sound for an initial period of 2 weeks following which a biopsy
evidence from examination and other investigations in can be done. This would provide a more accurate picture.
order to avoid putting the patient through unnecessary
stress associated with the invasive procedure [14]. Oral Lichenoid reactions may be induced by either
a systemic medication or topical antigen exposure.
Pitfalls and complications associated with a Withdrawal of the drug or removal of the triggering
biopsy: agent usually resolves the condition. Lichenoid reactions
associated with dental amalgam restorations are very
In spite of being the gold standard, histopathology common. Common anatomical sites include the lateral
is subjective and results may not accurately represent border of tongue and the buccal mucosa which may be
severity of lesions. Since sample is taken only from in direct contact with the surface of the restorations. The
a localized area, the results may overdiagnose or lesion is usually well demarcated and fits the outline
underdiagnose the lesion. Histological assessment alone of the restoration. They may also be caused by use of
cannot predict the transformation of an oral lesion into a systemic medication and substances like cinnamon.
malignancy.[15] Rapid proliferation in a malignant lesion [18] Sometimes, the lesion may not exhibit a close
can outgrow the nutrient supply and result in ulceration topographical relationship and may have similarities to
or necrosis. Similar ulceration, necrosis and epithelial a leukoplakia or erythroplakia. It is therefore essential
sloughing may be present in vesiculobullous disorders. for the clinician to be familiarized with the individual
These lesions can be a challenge when selecting a biopsy variations in the clinical presentation of a lichenoid
site. Palatal and gingival biopsies heal by secondary reaction in order to avoid an unnecessary invasive
intention and may cause delayed healing, exposure of biopsy.
denuded bone for several weeks or may result in unesthetic
gingival recession and root exposure. Local haemostasis Mucosal ulcerations are common lesions
and tissue stabilization can be a challenge in lip biopsies. encountered in daily practice. The most common cause
Improper technique can compromise esthetics. Tongue of a solitary ulcer is chronic trauma resulting from sharp
lesions cause difficulties in stabilization, suturing with cusp margins, broken teeth or ill-fitting dentures. Other
increased risk of the wound reopening.[5] Further, lack less common causes include a traumatic ulcerative
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 115

granuloma, infections like tuberculosis, late stage of Conclusion

syphilis, fungal infections like histoplasmosis. Some
This paper highlights some clinical points that could
cases may eventually be diagnosed as a squamous cell
help a clinician to give a good clinical diagnosis based on
carcinoma. Usually ulcers of traumatic origin are soft on
history and examination before performing an invasive
palpation and may have rolled margins and keratinization
biopsy. If these situations are encountered clinically, the
in the surrounding mucosa. The lesion may sometimes
dentist can render invaluable service to the patients with
be firm with indurated margins, thereby mimicking a
diagnosis and prompt treatment.
malignancy. This may be due to continuous trauma or
chronicity.[19] But lesions may show a dramatic response Ethical Clearance: Not required
when extraction of broken teeth is done or when the
probable local causative factor is removed. A period Conflicts of Interest: None
of 2-3 weeks can be given for the chance to heal after
Source of Funding: Self
elimination of the local factor.

Necrotizing sialometaplasia is a benign self-limiting, References

inflammatory lesion of the salivary gland tissue where 1. Mota-Ramírez A, Silvestre FJ, Simó JM. Oral
there is squamous metaplasia of the ducts and acini biopsy in dental practice. Med Oral Patol Oral Cir
after ischaemic necrosis of the salivary gland lobules, Bucal. 2007;7.
most frequently occurring on the hard palate. Diagnosis 2. Agha R, Mirowski GW. The art and science of
is usually based on a thorough and complete clinical oral examination: The art and science of oral
history.[20]. It may clinically mimic a malignant ulcer examination. Dermatol Ther. 2010 May;23(3):209–
but a history of local trauma like administration of local 19.
anaesthetic, ill-fitting dentures, intubation or surgical
3. Kar S, MC P, Saraf K. Oral biopsy: Techniques and
procedures will be present.[21] Usually the lesion heals
their importance. Am J Adv Med Sci. 2014;2(3):42–
by secondary intention in 3-4 weeks. The hassle of an
6.
invasive biopsy may be avoided in such cases.
4. Lynch DP, Morris LF. The oral mucosal punch
Socket Granuloma / Overhanging Clot occur biopsy: indications and technique. J Am Dent
as post-operative complications 1-3 days following Assoc 1939. 1990 Jul;121(1):145–9.
a tooth extraction, usually as a consequence of not 5. Avon S-L, Klieb HBE. Oral soft-tissue biopsy: an
following post-operative instructions. They may give overview. J Can Dent Assoc. 2012;78:c75.
the appearance of a proliferative lesion arising from
6. Chan MH, Wolf JC. Biopsy Techniques and
the socket, prompting the clinician to perform a biopsy.
Diagnoses & Treatment of Mucocutaneous Lesions.
An overhanging clot may need to be removed followed
Dent Clin N Am. 2012;56:43–73.
by placement of sutures along with local haemostatic
measures or it may resolve on its own. The dentist should 7. Zargaran M. A Review of Biopsy in Dentistry:
therefore be familiar with the incidence of post-operative Principles, Techniques, and Considerations. :8.
complications and their management.[22]Medication 8. Rosebush MS, Anderson KM. The Oral Biopsy:
induced oral ulceration like Nicorandil-induced Indications, Techniques and Special Considerations.
ulceration may appear as a large, deep, persistent ulcer. J Tenn Dent Assoc. 2010;90(2):17–9.
They are poorly responsive to steroids and only respond 9. Karkera BV. Biopsy: Clinical implications. J Dent
to discontinuation or reduction in the dose of the drug. Oral Hyg. 2011;3(8):106–8.
Therefore, careful probing about the history is important
10. Brown RS, Bottomley WK, Abramovitch
to diagnose these cases.[23] Vesiculobullous diseases
K, Langlais RP. Immediate biopsy versus a
may cause generalized ulcerations in the oral mucosa.
therapeutic trial in the diagnosis and treatment of
When the history and clinical presentation is “classic”,
vesiculobullous/vesiculoerosive oral lesions. Oral
biopsy can be deferred until a therapeutic trial is given
Surg Oral Med Oral Pathol. 1992;73(6):94–7.
in the initial visits. This could help avoid adverse effects
or inducing more ulceration.[10] 11. Holmstrup P, Thorn JJ, Rindum J, Pindborg JJ.
Malignant development of lichen planus-affected
oral mucosa. J Oral Pathol. 1988 May;17(5):219–
 116 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

25. 18. Hiremath SK, Charantimath S, Kale A. Oral

12. Murti PR, Daftary DK, Bhonsle RB, Gupta PC, lichenoid lesions: Clinico-pathological mimicry
Mehta FS, Pindborg JJ. Malignant potential of oral and its diagnostic implications. Indian J Dent Res.
lichen planus: observations in 722 patients from 2011;22(6):827.
India. J Oral Pathol. 1986 Feb;15(2):71–7. 19. Bhavthankar JD, Patil AA, Singh P, Mandale M.
13. Hakeberg M, Hägglin C, Berggren U, Carlsson SG. Malignant vs. Traumatic Tongue Ulcer: A Clinical
Structural relationships of dental anxiety, mood, Approach. J Evol Med Dent Sci. 2014;3(14):3758–
and general anxiety. Acta Odontol Scand. 2001 Jan 63.
1;59(2):99–103. 20. Joshi SA, Halli R, Koranne V, Singh S. Necrotizing
14. López-Jornet P, Camacho-Alonso F, Sanchez-Siles sialometaplasia: A diagnostic dilemma! J Oral
M. Patient information preferences and behaviour Maxillofac Pathol. 2014 Sep 1;18(3):420.
in relation to oral biopsies. Br J Oral Maxillofac 21. Yagihara K, Ishii J, Katsurano M, Tsuchida E,
Surg. 2012 Dec;50(8):e115–8. Okamura T, Ishikawa A. A case of necrotizing
15. Wu KY, Laronde DM. Oral cancer and biopsy sialometaplasia clinically mimicking a malignant
protocol: A primer for the dental hygienist. Can J tumor of the palate. Oral Sci Int. 2018 Jul
Dent Hyg. 2014;48(1):34–9. 1;15(2):73–7.
16. Logan R, Goss A. Biopsy of the oral mucosa 22. Hunasgi S, Koneru A, Manvikar V, Vanishree
and use of histopathology services: Biopsy and M, Surekha R. Massive clot formation after tooth
histopathology services. Aust Dent J. 2010 extraction. J Orofac Sci. 2015 Jul 1;7(2):132.
Jun;55:9–13. 23. Healy CM. Persistent nicorandil induced oral
17. Awadallah M, Idle M, Patel K, Kademani D. ulceration. Heart. 2004 Jul 1;90(7):e38–e38.
Management update of potentially premalignant
oral epithelial lesions. Oral Surg Oral Med Oral
Pathol Oral Radiol. 2018;125(6):628–36.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 117

Role of Oral Physicians in Special Care Dentistry

Priyanka.S.R1, M.Arvind2
1Post Graduate Student, 2Professor & Head, Department of Oral Medicine and Radiology, Saveetha Dental
College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, India

Abstract
Over 15% of the world’s population has some form of disability with 110-190 million people experiencing
functional difficulties, which includes people with physical, sensory, intellectual, medical, mental or social
impairments. WHO has emphasized the need for oral health care in these patients as they generally have
greater levels of oral disease. Poor oral health can complicate the underlying systemic condition and cause
deterioration of general health. Dental treatment of people who are medically compromised, disabled or older
poses challenges as they might require multiple interventions and are less likely to receive adequate care
compared to their apparently normal counterparts. The solution is to have a speciality designed specifically
to treat these patients by training professionals in treatment of patients with special needs. Oral Medicine is
the speciality concerned with dental and “medical” related disorders of the oro-facial region, including oral
manifestations of systemic disease and management of medically complex patients. One of the competencies
of an Oral Medicine graduate is the ability to effectively manage patients with medically complex conditions
and special needs. Oral Medicine specialists may be considered the best choice for integration with the
field of Special Care Dentistry as they have knowledge on medical diseases and their effect on oral health.
This paper highlights the need for Special Care Dentistry in the Oral Medicine Curriculum and why Oral
physicians are best suited for provision of dental care in this population.

Keywords: Special Care Dentistry, Oral Medicine, Oral Physician, Special Needs, Medically Compromised.

Introduction the poorest levels of oral health. Oral health in these

people as they are often unemployed, earn less, have
WHO international classification of Functioning
difficulties in communication, transport and usually
describes “Disability” as an “Umbrella term”,
depend on caretakers for help and support. So, they may
which includes impairments, activity limitations and
require additional and specific care when compared to
participation restrictions. Disability is diverse and
the general population. As professionals, we have the
includes any condition that restricts everyday activities,
responsibility to ensure that the oral health care needs of
an impairment that may be cognitive, intellectual,
these people are met and treatment is best when provided
physical, mental, and sensory or a combination of
by a professional with adequate training in handling
the above. Disability rates continue to rise around
patients with special health care needs.[3]
the world due to the increase in life expectancy, the
ageing population and increased likelihood of acquiring Special Care Dentistry Around the World
chronic diseases.[1] As more people grow older and
more retain their teeth, this presents challenges to the “Special care dentistry” (SCD) is concerned with
dental professionals in providing care to the medically the improvement of oral health of individuals who have
compromised and the multiply disabled. Global oral physical, sensory, intellectual, mental, medical and
health goals to be achieved by 2020 by FDI/WHO/ emotional or social impairment and a combination of
IADR have emphasized the importance of promoting the above. It also includes people with complex health
oral health in the populations with the greatest disease conditions, people under long term hospitalization and
burden.[2] Although improvements in oral health care critical care and people in residential care units.[4]
have occurred across all sections of the community,
As this need for SCD is recognized, we have seen
disadvantaged and disabled people continue to have
the development of various undergraduate curricula
 118 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

and postgraduate courses in countries like U.S, Canada, This is also augmented by the scarcity of dentists that
Europe, Oceania and the UK. Dental schools in the UK provide appropriate care. A more important factor
(Dublin, King’s College, Cardiff, Birmingham) conduct is dental students not being exposed to caring for the
workshops and lecture series before students spend time disabled during undergraduate or postgraduate training.
in the departments and it is also required as a part of Most of the work with disabled persons is estimated to
the curriculum for dental nurses and hygienists, which be treatable by general practitioners but the issue here is
enables them to participate in provision of dental care their little experience in handling these patients.[9]
for disabled people.[5]
There are a number of barriers to oral health care for
There are a variety of postgraduate programs people with special needs that have to be overcome in
currently being offered in the UK and Ireland. Bristol order to address their needs. Scully et al have classified
University, King’s College, London, Eastman Dental these barriers as – barriers with reference to the individual
institute and Trinity College, Dublin are among the which include a lack of perception of need difficulty
institutions which offer full time and part time courses. following instructions and access problems, barriers
The General Dental Council of the UK has formally with reference to the dental profession which include
recognized SCD as a dental speciality in 2008. The lack of training and a lack of time and resources, societal
United States has founded the American Board of barriers which include a general lack of awareness
Special Care Dentistry and training programmes have and a lack of positive attitudes towards oral health and
been offered in numerous universities. They also have governmental barriers include a lack of resources for
founded the Special Care Dentistry Association, which is oral health services. [10, 11] Barriers to physical access
an international organization of oral health professionals continue to exist in the form of lack of facilities like
who are dedicated to providing and promoting oral ramps for wheelchairs, suitable parking, accessible
health for patients with special oral health care needs. toilets, hoists or stairlifts.[12] Barriers in communication
[6, 7] The Australian society for Special Care in Dentistry
may be encountered in patients with hearing and/or
(ASSCID) has been added as an affiliate professional visual impairment, neurological deficits, psychiatric or
organization of the Australian Dental Association. cognitive difficulties.[13] Patients with a reduced mental
Universities in Australia and New Zealand provide capacity or inability to communicate their decision can
postgraduate courses in Special Needs Dentistry and also present a challenge while obtaining consent for
Hospital Dentistry. dental procedures.[14] Dentists are required to work in
new ways using extended teams and taking responsibility
According to the 2001 census, 21 million people for educating the team into incorporating a holistic
in India have some form of disability constituting 2% approach to oral health care for each individual with a
of the world population and 75% of these people are disability.[5] Certain conditions that might predispose
concentrated in the rural areas. A formal organization patients to complications or emergency situations
for treating oral problems of these patients has still not (epilepsy, allergies, bleeding disorders, etc) in the dental
been organized. Collaborative efforts of AIIMS (All chair. Ensuring that the dental team knows how to
India Institute of Medical Sciences) and WHO have manage such situations can be life-saving.[15]
recommended actions to be taken by governmental and
non-governmental sectors in this issue. SCD as a part Value of education in special care dentistry
of a postgraduate curriculum is a necessity in today’s
scenario.[8] The lack of dental service available for disabled
people is partly because of the reluctance among
Barriers and issues in treating special care professional to treat them and most practitioners receive
dentistry patients minimal education to prepare them to work with such
patients. Having positive attitudes, positive experiences
The special needs patients are one of the neediest and positive social contact has been shown to improve
and most underserved populations in the current scenario interest in serving these populations.[16] Dental
in India and other countries. The physical, mental and professional who are trained and willing to care for
medical disabilities make it difficult for the patients to disabled people are needed. Clinical contact with older
visit a dental office and they are also limited in their and disabled people, positive clinical experiences are
ability to afford therapeutic and preventive treatment. essential for students to overcome anxieties and develop
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 119

sound management skills.[17] A survey showed that diagnostic and medical disorders affecting the mouth and
dental practitioners with no contact or experience with jaws. Clinicians manage oral mucosal disease, salivary
treating special needs patients were less likely to care gland disorders, facial pain syndromes and also provide
for such patients whereas practitioners who had hands- dental care for patients with complicating medical
on educational experiences were less likely to consider disease.” The newest edition of Burket’s Oral Medicine
disability as obstacles to oral care and were more likely (2015), as “a specialized discipline within dentistry
to desire further education in caring for these patients.[18- that focuses on provision of dental care for medically
20] Reports also say that practitioners feel the pressures complex patients, diagnosis and management of medical
of time and lack of reimbursements creates disincentives disorders involving the mouth, jaws and salivary glands.
to treat these patients. Practitioners may abstain from [23] The American academy of Oral Medicine has defined

treating these patients if they felt that these issues have Oral Medicine as the discipline of dentistry concerned
not been resolved.[21] with the oral health care of medically compromised
patients and the diagnosis and non-surgical management
Providing necessary education and training for of medically related disorders and conditions affecting
practitioners and students implies the creation of an the maxillofacial region”.[24]
academic and clinical discipline to provide teaching,
training and a career pathway. Development of a discipline Hundreds of medical diseases impact the oral cavity
may aid in the development of specialist services for and oral pathological conditions also have an impact
patients with complex dental needs. In addition to the on systemic health. Unfortunately in our country lack
UK, US, Canada, Australia and New Zealand, other of access to primary medical / dental care prevents
countries like Japan, the Netherlands, Spain, Argentina patients from seeking treatment until a negative event or
and Mexico are in the process of recognizing SCD as complication has occurred. So the best way is to create
a stand-alone speciality.[22]and a large proportion of awareness among patient and for dental professionals
these persons will require Special Care Dentistry at to have a clear understanding of the chronic conditions
some point in their lifetime. It is estimated that 90% that affect the oral and systemic health of the patient.
of people requiring Special Care Dentistry should be Since Oral Medicine is the intersection of medicine
able to access treatment in a local, primary care setting. and dentistry and a window to the general health of the
Provision of such primary care is only possible through patient, we may be the best suited among all specialities
the education and training of dentists. The literature to provide dental care for medically compromised
suggests that it is vital for the dental team to develop the patients.
necessary skills and gain experience treating people with
special needs in order to ensure access to the provision The American Academy of Oral Medicine has
of oral health care. Education in Special Care Dentistry described clearly defined minimum competencies that
worldwide might be improved by the development of are required of all individuals to successfully complete
a recognised academic and clinical discipline and by an Oral Medicine Training program. The scope of Oral
providing international curricula guidelines based on the Medicine was divided into three domains that represent
International Classification of Functioning, Disability required clinical expertise.
and Health (ICF, WHO In India, there is neither a 1. Diagnosis and Non surgical management of
recognized speciality nor a clear career pathway for oral mucosal and salivary gland disorders.
dentists to be trained in SCD.
2. Diagnosis and Non surgical Management
Oral medicine and the potential role of oral of temporomandibular disorders, orofacial pain and
physicians in special care dentistry orofacial neurosensory disorders.
Dr. Lester Burket, a pioneer in the field of Oral 3. Management of medically compromised
Medicine, considered by many to be the father of this patients.
discipline, was one of the first educators to promote the
concept of integration of medicine into dental education So, an Oral Medicine graduate must have a
and clinical practice. Burket’s textbook previously thorough knowledge of how systemic diseases affect
defined Oral Medicine as a “speciality within dentistry oral health and vice versa, and how management may
that focuses on the diagnosis and management of complex
 120 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

require modifications of treatment when compared to References

healthy patients. They must assess wound healing, risk
1. Fiske DJ. Special care dentistry. Br Dent J. 2006
of infection, bleeding risk, medication/drug interactions
Jan 28;200(2):61–61.
and behavioural issues. This comprehensive evaluation
should be accompanied by diagnostic tests and expert 2. Oral Health and Dental Care of People with
medical consultations when indicated. The clinician will Disabilities [Internet]. FDI World Dental
then apply this knowledge to implement modifications Federation. 2017 [cited 2019 Mar 6]. Available
that are necessary in delivery of dental treatment.[25-26] from: https://www.fdiworlddental.org/resources/
policy-statements-and-resolutions/oral-health-and-
A survey conducted on the Oral Medicine curriculum dental-care-of-people-with-disabilities
and training was presented in the World Workshop of 3. Gallagher J, Scambler S. Disability and Oral
Oral Medicine in 2010 which explored the Oral Medicine Health. In: Sittiprapaporn W, editor. Learning
post graduate training and curricula in 22 countries. Oral Disabilities [Internet]. InTech; 2012 [cited 2019
Medicine was not a recognized speciality in 8 of these Mar 6]. Available from: http://www.intechopen.
countries and in 9 countries oral medicine is combined com/books/learning-disabilities/disability-and-
with another distinct field of study like Oral Pathology, oral-health
Oral Radiology or SCD. There was a significant
4. Waldman HB, Perlman SP, Valle LML dei. A review
variability of responses regarding the integration of
of the oral health of individuais with disabilities in
oral medicine with special care dentistry with most
Puerto Rico and among U.S. Hispanics. Spec Care
agreement from participants from India, Israel, Italy,
Dentist. 2007;27(1):26–30.
Spain, Brazil, Canada, USA, UK and Thailand.[27]Oral
Medicine and Radiology as a specialty was introduced in 5. Dougall A, Fiske J. Access to special care dentistry,
India in the year 1971 at the Government Dental College, part 4. Education. Br Dent J. 2008 Aug;205(3):119–
Bangalore with huge improvements in the practice in the 30.
past 46 years. Several recent reviews have discussed the 6. Ettinger DRL, Frenkel DH. A different perspective
nature and extent of training Oral Medicine graduates on care of the special needs patient: the UK Model.
and the need to further enhance their curricula. [28] As Spec Care Dentist. 2004;24(1):5–6.
there is a scarcity of specialists who deal with the active 7. Schwenk DM, Rieken SE. Survey of Special
management of dental issues in medically compromised Patient Care Programs at U.S. and Canadian Dental
patients and patients with special needs, this could be the Schools. J Dent Educ. 2007;71(9):7.
right step to include Special Care Dentistry as part of the 8. Balasubramanian R. 46 Education and Training
Oral Medicine curriculum. in Special Care Dentistry- A Review. Medico Res
Chron. 2014;7.
Conclusion
9. Steinberg BJ. Issues and Challenges in Special
Why should Oral Medicine accept a new speciality Care Dentistry. :2.
as its own? As the only speciality at the crossroads of
10. Scully C, Dios PD, Kumar N. Special Care in
Medicine and Dentistry, we are already positioned to
Dentistry E-Book: Handbook of Oral Healthcare.
diagnose and treat oral/systemic conditions. Having
Elsevier Health Sciences; 2006. 515 p.
a unified speciality could be a referral point for the
medical fraternity and improve communication. In 11. Gallagher JE, Fiske J. Special Care Dentistry:
addition, training in Special Care Dentistry could help a professional challenge. Br Dent J. 2007
bring out robust professionals who are competent in May;202(10):619–29.
handling patients with disability and provide graduates 12. Dougall A, Fiske J. Access to special care dentistry,
with better career opportunities. part 1. Access. Br Dent J. 2008 Jun;204(11):605–
16.
Ethical Clearance: Not required
13. Dougall A, Fiske J. Access to special care
Conflicts of Interest: None dentistry, part 2. Communication. Br Dent J. 2008
Jul;205(1):11–21.
Source of Funding: Self 14. Dougall A, Fiske J. Access to special care dentistry,
part 3. Consent and capacity. Br Dent J. 2008
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 121

Jul;205(2):71–81. Dougall A. The value of education in special care

15. Dougall A, Fiske J. Access to special care dentistry, dentistry as a means of reducing inequalities in oral
part 5. Safety. Br Dent J. 2008 Aug;205(4):177–90. health: Value of education in special care dentistry.
Eur J Dent Educ. 2012 Nov;16(4):195–201.
16. Wolff AJ, Waldman HB, Milano M, Perlman SP.
Dental students’ experiences with and attitudes 23. Glick M. Burket’s Oral Medicine, 12e. PMPH-
toward people with mental retardation. J Am Dent USA; 2015. 732 p.
Assoc. 2004 Mar 1;135(3):353–7. 24. The American Academy of Oral Medicine
17. Baumeister SE, Davidson PL, Carreon DC, [Internet]. [cited 2019 Mar 6]. Available from:
Nakazono TT, Gutierrez JJ, Andersen RM. What https://www.aaom.com/
influences dental students to serve special care 25. Whitney EM, Stoopler E, Brennan MT, DeRossi
patients? Spec Care Dentist. 2007 Jan;27(1):15–22. SS, Treister NS. Competencies for the new
18. Casamassimo PS, Seale NS, Ruehs K. General postdoctoral Oral Medicine graduate in the United
dentists’ perceptions of educational and treatment States. Oral Surg Oral Med Oral Pathol Oral Radiol.
issues affecting access to care for children with 2015 Sep;120(3):324–8.
special health care needs. J Dent Educ. 2004 Jan 26. Rogers H, Sollecito T, Felix D, Yepes J, Williams
1;68(1):23–8. M, D’Ambrosio J, et al. An international survey
19. Dao LP. General Dentists and Special Needs in postgraduate training in Oral Medicine:
Patients: Does Dental Education Matter? J Dent Postgraduate training in Oral Medicine. Oral Dis.
Educ. 2005;69(10):9. 2011 Apr;17:95–8.
20. Waldman HB, Perlman SP. Preparing Dental 27. Spielman A. The future of oral medicine. Oral Dis.
Graduates to Provide Care to Individuals with 2018 Mar;24(1–2):285–8.
Special Needs. J Dent Educ. 2005;69(2):6. 28. Joshi RK, Nagesh KS. Challenges and Areas for
21. Waldman HB. A Special Care Dentistry Specialty: Future Research in Oral Medicine and Radiology.
Sounds Good, But . . . J Dent Educ. 2006;70(10):4. Journal of Dental and Orofacial Research.
2017;13(1):43-8.
22. Faulks D, Freedman L, Thompson S, Sagheri D,
 122 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Lifestyle Diseases among Girl Child in Urban India

Puja Gupta1, Papia Raj2

1Research Scholar, 2Assistant Professor, Indian Institute of Technology Patna

Abstract
The paper will focus on the problems due to lifestyle in the health status of girl child in urban India. To
access lifestyle changes among the girl child, different lifestyle diseases and their impact on health will be
emphasized. Lifestyle is an individually constructed behaviour that determines the health and well-being
of an individual. Health of the girl child is determined by a wide range of factors like family background,
their socialization process, social class, peer group influence and their like. Girl child in urban India is more
vulnerable to lifestyle diseases owing to lack of physical activities and improper food habits resulting due
to transformation in consumption pattern. As a result, they are susceptible to obesity which leads to health
problems in the long run. Besides obesity, lifestyle also develops the risk of other diseases like type-2
diabetics, cardiovascular disease, cancer, etc. In recent years, these diseases have developed a severe public
health concern not only among adults but also for children. This study is based on an extensive literature
review to identify the evolving problems and significant health risks associated with such diseases. It is
observed that the role of media such as television, mobile phone, and access to a computer also play a
prominent role in the lifestyle of the girl child. Therefore, this paper also delineates the effect of digital
accessories that has changed the preferences and choices of the girl child in multiple ways.

Keywords: Lifestyle diseases, Girlchild, Urban India, Consumption pattern, Public Health

Introduction Girls are particularly more vulnerable to NCDs as in

many developing countries they are discriminated in
In the contemporary society, fast production and
terms of their marriageability which in some societies
consumption are some of the critical areas of life that
represents the route for economic and social status. The
has given rise to into unplanned urbanization and
vulnerability of girl child is also observed in physical
globalization particularly in developing countries9.
mobility which is often associated with diabetics,
Not surprisingly, this principle of ever advancing
obesity, cardiovascular disease and certain types of
social acceleration in developing countries has led to
cancer1.
the emergence of non-communicable diseases (NCDs)
like cardiovascular disease, cancer, chronic respiratory Various Social Determinants of Health (SDOH)
disease, and diabetics. It is estimated that globally 41 like gender, lifestyle, standard of living, social norms
million deaths each year are the result of NCDs where and attitude, geographical location, and culture impact
85% of these premature deaths occur in low and middle- health and well-being of the girl child4, 32, 13. SDOH is
income countries2. In a country like India, the incidence the condition in which people are born, grow, live, work,
of the NCDs has developed stern public health concern and age and the circumstances that are shaped by the
not only in the health of adults but also among children25. distribution of money and resources at global, national
and local level. SDOH are responsible for health
Corresponding Author: disparities where unfair differences in health status
Ms. Puja Gupta, are seen within and between countries33. Interestingly,
Public Health Research and Documentation Laboratory, in the health of girl child, the SDOH like lifestyle,
Indian Institute of Technology Patna, Bihar 801106, gender, and culture play a prominent role in bringing
India, Email: [email protected] Contact No: 0612- health disparity34. Lifestyle is a crucial SDOH that
3028078 shape the choices and preferences of the girl child16.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 123

The formative years of the girl child stand fundamental of their bodies8. Moreover, lifestyle pattern of children
in their lifespan as, during this period of the life cycle, particularly girl child cannot be characterised by a
lifestyles are formed and hence becomes established single entity as it is determined by the range of factors
where girls become more independent and make their like family background, social class, cultural milieu,
own choices3,2. Thus, the objective of this paper is to and religious affiliation7. It is in fact shaped during
understand the growing prevalence of lifestyle diseases their childhood that makes a lasting effect in their adult
among girl child resulting due to less physical activity, lifestyle and later life 6.
sedentary lifestyle, and dietary practices.
Health, as perceived from the social model, is
Methodology influenced by various factors like political, economic,
social, psychological, cultural, and environmental 5.
This study is based on secondary data which WHO (1998, p.1) defines health as a “state of complete
includes published academic of literature. Therefore, physical, mental, spiritual and social well-being and
an extensive literature review was conducted for the not merely the absence of disease or infirmity.” As for
same. The age group of girl child was chosen between the health of girl child is concerned adherence to basic
8-18 years based on literature, the problem concerning lifestyle behaviour as a result of imposition by the adult
lifestyle disease among girl was found within the member of the society becomes a part of imitation in
specified age-group4,3,22. The literature search was done their early life21. Under such conditions identifying the
on an available public domain such as Google Scholar, risk of ill health problems can serve as a useful measure
Jstor. The keywords used for the search included but not to stop the preventable lifestyle-related health problems
limited to lifestyle and urban children, gender and Social among girls and for future generations1. In most of the
Determinant of Health, technological use and impact situation self-reflection in behaviour patterns among
on children health. Journals were chosen concerning the girl child in adopting healthy lifestyle becomes
the health of girl Journal of Child Health Care, Indian inherently blurred in the absence of adult control. As a
Pediatrics, Asia-Pacific Journal of Public Health, result of which they violate basic principles of a healthy
Health Promotion International, etc. lifestyle in later life21. Moreover, failure to act on the
Children Lifestyle and Health problems of NCD will undermine developmental gains
that also include progress by recognising the importance
WHO (2019) defines a child to be any person within of girl child in the contribution to society1.
the age of 19 years or younger. However, a child is also
defined to be any human being below 18 years of age Delineating causes of lifestyle diseases among the
unless s/he attends a majority under the prescribed law35. girl child
Apart from this, childhood is a social construction and NCDs are generated with increased indulgence in a
not merely a biological fact. It is not only determined social and physical environment designed to influence
by culture but also conceived according to social class, the way we work, produce, process, and consume9.
ethnicity, and gender7. The sociological understanding This advanced level of development and change in
of childhood perceives a child as a social actor who structures can be perceived in the consumption patterns
reflexively constructs their environment18. The social and physical inactivities that have ultimately led to
character of childhood is recognized as an essential epidemiological transition30. According to WHO (1996),
factor in shaping experiences of the children15. the epidemiological transition is the condition where
Lifestyle, on the other hand, is defined as a set of a general shift from acute infectious and deficiency
mediating structure that seeks to reflect upon activities, disease to chronic NCD become widely visible. India is
attitudes, social values, and an array of behavioural in the midst of the epidemiological transition due to the
patterns depending upon age, education, economic and emerging conditions of NCDs23. Given this background,
social factor, among other36. It also represents the steady identifying the factors responsible for rising risk of NCDs
form of personal behaviour where independent choice becomes essential. Hence, it is of particular significance
provides a way to solve social system antagonisms21. to investigate causes of NCDs on many counts.
Lifestyle in the contemporary society is considered to be First, in addition to lifestyle as a SDOH, technology
integrated into the bodily regimens where people have has an important role to play in health of a girl child4.
become more responsible for both health and design
 124 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

At one hand technology has been praised for reinforcing NCDs among the girl child24.
educational advancement that has enhanced learning
while on the other, it has induced anomie and anti-social Discussion and Conclusion
behaviour among girls14. Prolonged television viewing The UNCRC (1989) recognises the right of every
along with snacking behaviour is allied with the risk for child to self-determination, dignity, respect, non-
development of overweight among the girl child10. Here interference, and the right to make an informed decision.
the risk is presumed in a way where society actively tries UNICEF (2003) claimed that ‘World Fit for Children’
to break away from the past to that of a modern system will only be accomplished with full participation of
of lifestyle12. Lifestyle choices are also shaped by the children and young people. Children’s participation in
conditions where girls are not provided with a safe research should advocate in understanding their needs
environment due to lack of opportunity17. This brings us to determine health literacy capacities across diverse
to analyze the role of gender which is an essential SDOH communities by adopting a child-centred approach in
and their impact on health of the girl child. Cultural research. Ironically, the active involvement of children
differences in terms of gender forbid girls to engage in in the study is not acknowledged in academic discourse
outdoor play activity as compared to boys. Due to this, 27
.
they invest their time in watching television or computer
which also develops the risk of NCDs among the girl In addition to this, the development of the
child4. curriculum should be such that it resonates with the
experiences of children in terms of both media and
Second, advertisements commercialize living health37. SDOH like gender and lifestyle should also be
standards of the girl child in such a way that the images addressed by focusing on the gender-responsive health
that are sold through advertisements become the system to provide adequate attention to gender needs
symbols of their childhood14. Their childhood is in fact and priorities1. In the Indian context, awareness among
trapped in ‘steel-hard’ cage where advertisement media the parents in making right choices in food and physical
are also responsible for reinforcing hegemonic control activity should be internalized as they play an active
over the mind of a girl child9. However, in India, the role in the socialization process. Their role in addressing
pervasive influence of advertisements mainly through purchasing power and choices relating to food should
audio and visual aids has influenced the dietary pattern also be discussed to minimise the health consequences26.
of girls20. This is for the fact that in India advertisement
promotes an unhealthy diet including food that is rich Moreover, in India understanding the problems
in fat, sodium or added sugar16,29. Such kind of shift in of lifestyle diseases among the girl child is a national
food pattern develops the problem of obesity which is concern. It is because problems associated with the
not just a physical problem but also a social problem like NCD are emerging at a time when undernutrition is still
eating disorder and obsession with body shape26. a significant public health concern13.

Third, urban settings are mostly associated with Besides, not many studies have specifically provided
lower levels of physical activity as compared to rural insight into the health of a girl child. Furthermore, studies
settings1. Limited space in the cities does not provide an related to the problem of NCDs in India correlates with
adequate and safe environment due to which the girls are affluence while it is also prevalent among children
sequestered in their home thereby focusing on the use of belonging to the middle-income group. Therefore, to
television or computer28. SDOH like gender also plays elude the risk of NCDs, empowerment and equal access
a significant role in bringing health differences among to knowledge and resources should be emphasized
the girl child where interests on sports are emphasized through interventional programme. Such programme can
among the boys as compared to the girls28. Moreover, assist policymakers in reducing the growing problems of
despite the involvement of girl child in activities like risks associated with lifestyle among girl child.
walking and cycling, the overprotective nature of the
parents often restrict them from such physical activities19. Ethical Clearance- Not required as, it is a review
Therefore, the above factors show the susceptibility of article.
girl child in urban areas. Under such circumstances, an Source of Funding- Self.
interactive approach through intensive and repetitive
intervention can serve as an effective pillar in preventing Conflict of Interest– Nil
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 125

References is impacting child and youth identity. Media,

Culture & Society. 2011 Apr;33(3):347-62.
1. Alliance NC. Non-communicable diseases: a
priority for women’s health and development. 15. James A, James AL. Childhood: Toward a theory of
Geneva: NCD Alliance. 2011. continuity and change. The Annals of the American
Academy of Political and Social Science. 2001
2. Al-Hazzaa HM, Abahussain NA, Al-Sobayel HI,
May;575(1):25-37.
Qahwaji DM, Musaiger AO. Physical activity,
sedentary behaviors and dietary habits among Saudi 16. Kaushik JS, Narang M, Parakh A. Fast food
adolescents relative to age, gender and region. consumption in children. Indian pediatrics. 2011
International Journal of Behavioral Nutrition and Feb 1;48(2):97-101.
Physical Activity. 2011 Dec;8(1):140. 17. Lobstein T, Baur L, Uauy R. Obesity in children
3. Aranceta J, Perez-Rodrigo C, Ribas L, Serra- and young people: a crisis in public health. Obesity
Majem LL. Sociodemographic and lifestyle reviews. 2004 May;5:4-85.
determinants of food patterns in Spanish children 18. Matthews SH. A window on the ‘new’sociology of
and adolescents: the enKid study. European Journal childhood. Sociology Compass. 2007 Sep;1(1):322-
of Clinical Nutrition. 2003 Aug 28;57(S1):S40. 34.
4. Bener A, Al-Mahdi HS, Vachhani PJ, Al-Nufal 19. Metos J, Gren L, Brusseau T, Moric E, O’Toole
M, Ali AI. Do excessive internet use, television K, Mokhtari T, Buys S, Frost C. Adolescent
viewing and poor lifestyle habits affect low vision girls’ reactions to nutrition and physical activity
in school children?. Journal of child health care. assessment tools and insight into lifestyle habits.
2010 Dec;14(4):375-85. Health Education Journal. 2018 Feb;77(1):85-95.
5. Warwick-Booth L, Cross R, Lowcock D. 20. Misra A, Singhal N, Sivakumar B, Bhagat N,
Contemporary health studies: An introduction. Jaiswal A, Khurana L. Nutrition transition in
Polity; 2012 Jul 16. India: Secular trends in dietary intake and their
6. Carlsen KH. Lifestyle and lung health in children relationship to diet‐related non‐communicable
and adolescents: Children’s way of life and their diseases. Journal of diabetes. 2011 Dec;3(4):278-
respiratory health. 92.
7. Clarke A. The Sociology of Health Care. New 21. Pakholok O. The idea of healthy lifestyle and its
York, United States of America: Routledge; 2010. transformation into health-oriented lifestyle in
contemporary society. SAGE Open. 2013 Aug
8. Cockerham WC. Health lifestyle theory and the
9;3(3):2158244013500281.
convergence of agency and structure. Journal of
health and social behavior. 2005 Mar;46(1):51-67. 22. Richter M, Moor I, van Lenthe FJ. Explaining
socioeconomic differences in adolescent self-rated
9. Elliott A. Contemporary social theory: An
health: the contribution of material, psychosocial
introduction. Routledge; 2009 Jan 13.
and behavioural factors. J Epidemiol Community
10. Francis LA, Lee Y, Birch LL. Parental weight Health. 2012 Aug 1;66(8):691-7.
status and girls’ television viewing, snacking,
23. Sengupta A, Syamala TS. The changing face
and body mass indexes. Obesity research. 2003
of malnutrition in India. Journal of Health
Jan;11(1):143-51.
Management. 2012 Dec;14(4):451-65.
11. Galal OM, Hulett J. Obesity among schoolchildren
24. Singhal N, Misra A, Shah P, Gulati S. Effects of
in developing countries. Food and nutrition bulletin.
controlled school-based multi-component model
2005 Jun;26(2_suppl2):S261-6.
of nutrition and lifestyle interventions on behavior
12. Giddens A. Runaway world: How globalization is modification, anthropometry and metabolic risk
reshaping our lives. Taylor & Francis; 2003. profile of urban Asian Indian adolescents in North
13. Ghosh A. Rural–urban comparison in prevalence India. European journal of clinical nutrition. 2010
of overweight and obesity among children and Apr;64(4):364.
adolescents of Asian Indian origin. Asia Pacific 25. Singh AK, Maheshwari A, Sharma N, Anand K.
Journal of Public Health. 2011 Nov;23(6):928-35. Lifestyle associated risk factors in adolescents. The
14. Hill JA. Endangered childhoods: How consumerism Indian Journal of Pediatrics. 2006 Oct 1;73(10):901-
 126 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

6. global survey.
26. Singh R, Nayak JK. Adolescents’ health education 32. Singh AP, Misra G. Adolescent lifestyle in India:
and social media: an exploratory study in India. Prevalence of risk and promotive factors of health.
Journal of Health Management. 2015 Mar;17(1):63- Psychology and Developing Societies. 2012
74. Sep;24(2):145-60.
27. Velardo S, Drummond M. Emphasizing the child 33. Wilkinson RG, Marmot M, editors. Social
in child health literacy research. Journal of Child determinants of health: the solid facts. World
Health Care. 2017 Mar;21(1):5-13. Health Organization; 2003.
28. Vilhjalmsson R, Kristjansdottir G. Gender 34. Marmot M, Friel S, Bell R, Houweling TA, Taylor
differences in physical activity in older children S, Commission on Social Determinants of Health.
and adolescents: the central role of organized sport. Closing the gap in a generation: health equity
Social science & medicine. 2003 Jan 1;56(2):363- through action on the social determinants of health.
74. The lancet. 2008 Nov 8;372(9650):1661-9.
29. Wehling Weepie AK, McCarthy AM. A healthy 35. Assembly UG. Convention on the Rights of the
lifestyle program: promoting child health in Child. United Nations, Treaty Series. 1989 Nov
schools. The Journal of School Nursing. 2002 20;1577(3).
Dec;18(6):322-8. 36. Smith BJ, Tang KC, Nutbeam D. WHO health
30. Popkin BM. The nutrition transition in the promotion glossary: new terms. Health promotion
developing world. Development policy review. international. 2006 Dec 1;21(4):340-5.
2003 Sep;21(5‐6):581-97. 37. Higgins JW, Begoray D. Exploring the Borderlands
31. World Health Organization. Assessing national between Media and Health: Conceptualizing”
capacity for the prevention and control of Critical Media Health Literacy”. Journal of Media
noncommunicable diseases: report of the 2017 Literacy Education. 2012;4(2):136-48.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 127

Effect of Core Training with and without Yogic Practices on

Elasticity among College Female Athletes

R. Meera1, R.Mohanakrishnan 2, T. Arun Prasanna3

1Research Scholar, Dept. of Physical Education And Sports Sciences, Srmist, Kattankulathur,
2
Hod, Dept.of Physical Education And Sports Sciences, Srmist, Kattankulathur, 3Research Scholar, Dept. Of
Physical Education And Sports Sciences, Srmist, Kattankulathur

Abstract
The present study evaluates the impact of core strength training with and without yogic practices on elasticity
among the college female athletes. To attain the aim of the study forty five (N=45) female students were
selected randomly as subjects from Chennai, Tamilnadu, India aged between 17 to 25 years at random. The
athletes were separated into groups of three with 15 students each named as experimental group I with core
strength training , experimental group II with core strength training with yogic practices and group - III
with controlled training. Prior to and after the twelve weeks of experimentation, the subjects were tested.
The core strength training and the yogic practices were selected as training protocol. The core strength
training given based on stress given in each exercise and sets and the load administered between 5 and 10
repetitions in a set with the time lapse of 15 to 10 seconds for a set. The training protocol followed by proper
warming up and cooling down regime. The yogic practice was given on morning time with proper prayer
and warming up practice. The load of the yogic practice increased by the number of yogic practices by 2
to 8 repetitions with 2 to 5 sets. The obtained data from the experimental and control group initial and final
readings underwent statistical analysis along with analysis of covariance (ANCOVA) with the application of
Scheffe’s post hoc test to examine the groups’ difference and testing condition. The level of confidence had a
fixation of 0.05 confidence level. The group that acted as the experimental group had improved significantly
on flexibility in comparison with control group.

Keywords: Core strength training, Yogic practice, Female Athletes, Flexibility.

Introduction A wide practice of core strength training is

undergone by professionals. It aims to develop core
The spine, hips, pelvis, lower limb at the proximal
stability and improve core muscular strength leading
level and structures in the abdomen which forms the
to the improvement of the performance of the athletes.
musculoskeletal core of the body are responsible for
Core strength training is considered as an element of
stabilizing spine and pelvis. During the sports activities
strength and conditioning by the professionals of health
of a person, they help in the energy transformation
and fitness as it enhances the performance of the athletes
between the large and small parts of the body.1 Thoracic
and prevents injuries. 3 But few studies failed to show the
lumbar fascia, abdominals, hip girdle musculature, para
significance of changes in the lower extremity stability
spinals, hip joints, diaphragm, pelvic floor and spine
or performance. However, further studies are needed
have a central location as core muscles. They perform the
to transform core strength training to performance.
required stabilising functions of the body for the distal
Scientific studies that are limited were done to evaluate
segments to do their functions specifically. Also they
the effect of core strength training on the stability of
provide proximal stability of the limbs for their distal
lower extremity and the performance of the athletes. 4
mobilization and function. Along with these functions,
the core activity is involved with the oactivities that are The practice of Yogasana includes stretching,
limited, for example agility, kicking, throwing etc., 2 moving and holding the body of an individual into
various positions comfortably. This improves the muscle
 128 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

flexibility, where the positions are believed by many ends are joined each other basically decides the type of
practitioners. It helps in the maintenance of the balance movements possible in the joint. Greater mobility is in
of varied internal glands and organs of the body. Hence, ball and socket joint. The elasticity of ligaments can be
the study examines the effect of yogasana exercise that increased up to some extent by training, but length of the
may influence the significant changes in the flexibility ligaments can’t be change by training.
on experimental group.
There are very few studies, which are measuring
Yoga is considered as the discipline of psycho- effect of core stability training with and without yogic
somatic-spiritual being that helps in the unity and practices on flexibility in female athletes. Hence there
peace of our mind, body and soul. It also helps in the is need to analyse the influence of core stability training
unity of consciousness of an individual eventually with with and without yogic practices on flexibility among
the universe.5 It allows a person to synchronize with female athletes.
breathing through meditation and relaxation with a body
technique. Yoga is one of the most effective methods, by Statement of the problem
which the perfection of the latent potentialities, partially The research aims to assess the impact of core
expressed in man is attained. Perfection is not an addition strength training with and without yogic practices on
– addition of capacities or it is the manifestation of those elasticity among college female athletes.
potentialities which are inherent in man and which
lie idol until and efforts is made to bring them to the Methodology
surface. Jnana, Bhakti, Karma and Raja are the several
means to attain the perfection of personality.6 Flexibility To attain the aim of the study forty five (N=45)
can also be called the capacity for joint movements female athletes were selected randomly as subjects from
fluidly through its complete motion. It is the capability Chennai city, Tamilnadu, India aged between 17 and 25
of a person to move a part or body parts with a variety years at random. The athletes were divided into groups
of purposeful movements at the speed required. It helps of three with 15 each named as selected experimental
in joint movements with a normal variety of motion group I with core strength training, experimental group
devoid of undue stress to the muscular tendinous unit. II with core strength training with yogic practices and
7 Flexibility has important interrelationship with other group - III controlled . The athletes were tested before
performance factors. The traction of anteflexion, skin and after the twelve weeks of experimentation. The core
among the two fixed points in the midline of the back strength training and the yogic practices were selected
was tested for the ante flexibility of the lumbar spine. as training protocol. The core strength training given
The mark in the beginning was positioned on the process based on stress given in each exercise and sets and the
of spine LV, set up by the` intersection of the midline in load administered between 5 and 10 repetitions in a set
the dorsal region with the connecting line of both lateral with the time lapse of 15 to 10 seconds for a set. The
lumbar fossae. training protocol followed by proper warming up and
cooling down regime. The yogic practice was given
Active flexibility is also of two types – static and on morning time with proper prayer and warming up
dynamic. Static flexibility is required for movement done practice. The load of the yogic practice increased by
while individual is in the static state i.e. standing, sitting the number of yogic practices by 2 to 8 repetitions with
or lying. Dynamic flexibility is required for executing 2 to 5 sets. The core training protocol are Crunches,
movement with greater range when individual is Decline Crunch, Cable Crunch, Oblique Crunches,
moving. Active flexibility is always less than the passive Jack knife Sit-Up, Barbell Side Bend, Leg lift, Leg lift
flexibility. 8 The dynamic flexibility is always less than - Hang Position , Oblique Leg lift and yogic practices
static flexibility and is heavily dependent on the motor protocol are Suryanamaskar. Tadasana, Trikonasana,
coordination. The terms general & specific flexibility are Paschimottanasana, Chakrasana, Bhujangasana, Nadi
also commonly used to denote the levels of flexibility of Sodhana, Bhastrika and Kapalapathi. The criterion
all the important joints of the body specifically shoulder, variables measured by using sit and reach based test.
hip & trunk whereas special flexibility is the ability to The obtained data from the experimental and control
do movements of a sport with greater range. As stated group initial and final readings underwent statistical
earlier flexibility is largely depend upon anatomical analysis with ANCOVA and Scheffe’s post hoc test to
structure of the joint. The manner in which the bone examine the groups difference and testing condition.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 129

The confidence level is fixed at 0.05. The statistical analysis computed with IBM-SPSS – v21 software.

Results and Discussions

Table – I: The descriptive analysis of experimental and control group on flexibility

Core Strength Training Core Strength Training with Yogic

Test Control Group
group practice group

Mean 21.20 22.30 22.35

Pre Test
SD 0.86 0.58 1.45

Mean 25.45 28.56 22.56

Post Test
SD 0.86 1.25 1.02

Adjusted Post Test Mean 25.78 28.89 23.45

Magnitude of Improvement 17.76% 21.66% 4.69%

TABLE – II: ancova on flexibility among groups

Test Sum of Squares Df Mean Square F ‘P’ Value

8.01 2 4.00
Pre Test 3.07 0.065
54.62 42 1.30

135.25 2 67.62
Post Test 44.48* 0.000
64.20 42 1.52

136.89 2 68.44
Adjusted Post Test 44.15* 0.000
63.58 41 1.55

*Significant at 0.05 level of confidence

TABLE-III: Scheffe’s post hoc test of paired mean difference on flexibility

Core Strength Core Strength Training with

Control Group Mean Difference ‘P’ Value
Training group Yogic practice group

25.78 28.89 - 3.11* 0.000

25.78 - 23.45 2.33* 0.000

- 28.89 23.45 3.44* 0.000

*Significant at 0.05 level of confidence

The results in table I-III on flexibility were similar that the adjusted post test paired mean differences on
before the training programme. The post test found flexibility between core strength training and training
significant among the groups on the chosen criterion of core strength with yoga, core strength training and
variables. Further, the Scheffe’s post test showed control groups and core strength training with yoga
 130 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

training groups and control group found significant flexibility in obese males. Study done by Stanton,R et
with the P value 0.000. Hence, the results show that the al 1 observed the impact of Swiss ball based training for
flexibility in the training with core strength along with 6-week on running economy and core stability. in an
yoga training groups and core strength training groups athletic population. After giving core stability training
improved significantly. The control group have shown program in improving function mobility as above study.
insignificant on flexibility. The data is represented Core stability extensively benefits the sport performance
graphically in Figure I and II. with a foundation for extensive force production in the
upper and lower level of extremity.

Conclusions
The conclusion based on the result and discussions
that the flexibility has improved both the experimental
groups such as core strength with yogic practice group
and core strength training group, in comparison with
the control group. Further, the core strength with yogic
practice group shows better improvement on flexibility
when compare with isolated core strength training group
on flexibility.
Figure I: The graphical presentation of data of descriptive
statistics on flexibility Ethical Clearance- Nil

Source of Funding- Self

Conflict of Interest- Nil

References
1. Khan K, Brunker K. Clinical Sports Medicine.
3rd edition. McGraw Hill Medical Publication
2009:158-73.
2. Stanton R, Reaburn PR, Humphries B. The effects
Figure II: The graphical presentation of magnitude of
of short-term swiss ball training on core stability
improvement from the initial to final means on flexibility
and running economy. J Strength Cond Res.
Discussion on Findings 2004;18(3):522–8.
Most of the previous research confirmed the finding 3. Scibek JS, Guskiewicz KM, Prentice WE, Mays
of the present study. It is apparent that core strength S, Davis JM. The effects of core stabilization
training and yogic practices is very specific to the training on functional performance in swimming.
flexibility. No well established was observed on the Unpublished master’s thesis, University of North
independent effects of aerobic training on flexibility. Two Carolina, Chapel Hill, North Carolina, USA. 2001.
previous studies showed no improvement on flexibility 4. Cosio-Lima LM, Reynolds KL, Winter C, Paolone
through the aerobic training. 9 Without the inclusion of V, Jones MT. Effects of physioball and conventional
the stretching based exercises in the training schedule floor exercises on early phase adaptations in back
there was no development in the flexibility with land- or and abdominal core stability and balance in women.
water-related aerobic training. The present study which J Strength Cond Res. 2003;17(4):721–5.
involves the yogasana exercises improved the flexion 5. Madanmohan D. Introducing Yoga to Medical
and extension of the hip.10 The reason is the increase Students-The JIPMER Experience: ACYTER. Int
of the strength of muscle and collagen in the region of J Educ Res Technol. 2008: 605-6.
lower limbs. 11 However, this research also supports the
6. Putnam CA. Sequential motions of body segments
present study to derive the better training programme. In
in striking and throwing skills. J Biomech. 1993;
our study, we found that 12 weeks of yogasana training
26: 125-35.
at medium intensity significantly improves lumbar
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 131

7. Zattara M, Bouisset S. Posturo-kinetic organization study. Med Sci Sports Exerc 1985; 17: 482–487.
during the early phase of voluntary limb movement. 10. Taunton J, Rhodes E, Wolski L. Effect of land-
J Neurol Neurosurg Psychiatry 1988; 51: 956;p-65. based and water-based fitness programs on the
8. Baechle TR, Earle RW, Wathen D. Resistance cardiovascular fitness, strength and flexibility of
training. In Baechle TR, Earle RW. Essentials women aged 65–75 years. J Gerontol 1996; 42:
of strength training and conditioning. 2nd ed. 204–210.
Champaign (IL): Human Kinetics, 2000: 395-425. 11. Michna H. Morphometric analysis of loading-
9. Marcinik E, Hodgdon J, Mittleman K, O’Brien induced changes in collagen- fibril populations in
J. Aerobic/calisthenic and aerobic/ circuit weight young tendons. Cell Tiss Res 1984; 236: 465–470.
training programs for Navy men: a comparative
 132 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A Study on Impact of Environmental Pollution on Health in

Referance to Tuticorin Industrial Town, Tamil Nadu

R.V.Suganya1, R.lakshmi2
1Assistant Professor, 2Associate Professor, Department of Commerce, School of Management Studies & Commerce,
VELS University, Chennai

Abstract
The paper highlights impact of environmental pollution on Health. The present study has been taken up in
Tuticorin industrial town area. Major industries numbering 12 established in the district. They are engaged
in the production of cotton, staple yarn, caustic soda, PVC Resin, fertilizers, soda ash, carbon-di-oxide gas
in liquid etc., The important major industries are sterlite, SPIC, Tuticorin Alkali Chemicals, Dharangadhra
chemicals work, Madura coats, Kilburn chemicals industries. The public sector undertakings are the
Thermal power unit (620mm), Heavy water plant, and port trust. The district contributes 70% of the total salt
production of Tamil Nadu and meets 30% of salt requirement of our country. Aside from deficiencies in the
life support system, men is subjected to a variety of environmental Hazards. Some of these are natural, but
increasingly environmental hazards result from man’s activities and numbers. Sometimes manmade hazards
are direct in their impact on other man. But they may be indirect in their influence, acting through other
biological systems or overburdening the capacity of natural systems for renewal, dispersion, or assimilation.
The following factors can be used in categorizing environmental hazards. (1) Biological (2) Chemical (3)
Physical (4) Psychological and (5) Sociological. Hence more than 12 major industries have established in
and around Tuticorin. This becomes one of the source of air pollution, water pollution, Noice pollution,
in this area. Air pollution may be broadly defined as the presence of one or more contaminants like dust,
smoke, must and odour. The atmosphere which are injurious to human beings, plants and animals which
unreasonably interfere with the comfortable enjoyment of life or property. Air pollution seriously damages
human beings.

Keywords: Environmental pollution, Health Problems in India, Impact on Pollution.

Introduction loss on the global biosphere and human welfare have

Environmental sociology in the study of the been mounting in recent years. Loss and modification
reciprocal interaction between the physical environment, of ecosystems and habitats are occurring at an alarming
social organization, and social behaviour. Within this rate, although it is much difficult to quantity or estimate
approach, environment encompasses all physical and on a global scale. The continuing loss of the biological
material bases of life in a scale ranging from the most wealth may leave us with a smaller and less ‘varied’
micro level to the biosphere. An important development stock of global biological resources. The result may leave
of this sub discipline was the shift from a sociology of the human livelihood and the future of the biosphere at
Environment to an Environmental sociology while the risk. Development efforts along with modern warfare
farmer refers to the study of environmental issue through have created an uneasy and irreparable environmental
the lands of traditional sociology, the later encompasses consequences, the world over2. Human life and health
the societal environmental relations1. are at great jeopardy and the burden of diseases and ill
health raise questions on the development efforts in the
A major challenge for the 21st Century is not the pursuit of global prosperity and wealth.
creation of wealth, but the management of health.
Concern over the rapid depletion and degradation of the The environmental pollution and degradation may
World’s biological resources and the implications of this rise in step with such a rise in output, the result leading to
an appalling environmental pollution and damage. Tens
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 133

of millions more people may become sick or die each The physical environment has a major influence on
year from environmental causes. Water shortages may human health not only through temperature, precipitation
become intolerable and tropical forests and other natural and composition of air and water but also through its
habitats may decline to a fraction of their current size. interaction with the type and distribution of the flora
The earth’s ‘sources’ are limited and so is the absorptive and fauna (the biological environment). The biological
capacity of its ‘sinks’. Whether these limitations will environment is a major influence on the food supply and
hinder the growth of human activity will depend on the on the reservoirs and transmission mechanisms of, many
scope for substitution, technical progress and structural diseases. The following gives the simplified illustration
change3. of these relationships.

Environmental Health in India The scale and nature of human activities including
agricultural, industrial, and energy production, the use
Environmental health can be defined as “the aspect and management of water and wastes, urbanization, the
of public health that is with all external conditions distribution of income and assets within and between
such as all forms life, substances, forces, problems and countries, the quality of health and other public services
challenges and any other condition in the surroundings and the extent of protection of the living, working, and
of man that that may extent an influence on man’s natural environment.
health and well-being”. Disease in this sense represents
maladjustment of the human being to his environment. Environmental hazards to health fall into two broad
This rapid industrial growth has made water pollution, air categories. On the one side is the lack of accessibility
pollution, and hazardous wastes pressing environmental to basic environmental resources like sanitation, water,
problems in many areas of the developing world. fresh air, shelter and the like. On the other side is the
Industrial emission’s combine with vehicle exhausts to exposure to hazardous environment. These hazards
cause air pollution, while concentrations of heavy metals include biological agents viz., micro-organisms such
and ammonia loads are often high enough to cause major as bacteria and viruses and parasites which contribute
fish kills down- River from industrial areas. The lack of to the global burden of infectious disease, chemical
hazardous waste facilities compounds the problem with pollutants, ultra violet radiation and the like which cause
industrial wastes4. birth defects and damage the body immunity system and
which render people susceptible’ to a variety of health
risks5.
Table: 1: Statement Showing That General Environmental Problems

S.N Environmental Problem Effect on Health

Water pollution and water More than 2 million deaths and billions of illnesses a year attributable to pollution,
1
scarcity poor household hygiene and added health risks caused by water scarcity.

Many acute and chronic health impacts excessive matter levels arc responsible for
2 Air pollution 300, 00 - 70, 0,000 premature deaths annually and for half of childhood chronic
diseases; women and children in poor rural areas affected by smoky indoor air.

Possible shifts in vector-borne diseases; risks climatic natural: diseases attributable

3 Atmospheric disasters to ozone changes depletion (perhaps 300,000 additional cases of skin cancer a year
worldwide; 1.7 (million cases of cataracts).

Source: Report of Indian public health organization

Among the environmentally-based diseases water, both bacteria and virus.

food and oil borne diseases affect a majority of the world
population. Diarrohea, Cholera and Hepahtis A and E According to a study, Diarrohea deaths were around
have the clearest link to the environment and spread by 2.5 million in 1996. Around 4 billion cases of diarrohea
 134 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

cause widespread debilitations each year. The nuclear analyses the extent to which urban people have
development and use, the world over is a major threat to knowledge of environment and awareness. It analyses
human health today. The radiation hazard arising from their behaviour on environmental conservation and
Extra Low Frequency (ELF) magnetic fields of between preservation. It outlines the respondents’ awareness of
one and one hundred hertz (HZ) as well as the very various environmental hygiene and sanitation issues and
High frequency fields of 147 MHZ, which can alter the measures.
outflow of calcium ions from the brain tissue of children,
in particular with steadily weakening resistance causes It is generally an exploratory framework of
tumour formation in the human body. Health is a identifying the awareness of among urban people about
fundamental resource to individual and community and environmental issues along with their action oriented
is a pre-requisite for their social, spiritual and physical activities to preserve and conserve rural environment
well-being, the protection and preservation of which is in particular. Thus, this study is partlyexploratory in
dependent on the ecological status of the environment nature. Thus it constitutes the analytical aspect of the
and sustainable development. study. Hence, this study is partly exploratory in nature
and partly analytical in nature.
Objectives
Limitations
The following objectives are framed for the purpose
of the present study: The findings of this study are applicable on to
selected areas only mid it is not applicable to the entire
 To study the socio-economic life of the areas of Tuticorin. This study covers only environment
respondents in Tuticorin town. related aspects and studying of all aspects of hygiene
and sanitation is not possible at the level of an individual
 To analyse the problems of environment in the researcher due to constraints imposed by money, time,
study area. energy and efforts.
 To find out the defects and problems in the
existing environment hygiene and discomfort at their
Results and Discussion
life. The actual process of research findings, data
analysis, data interpretation and logical arguments are
Methodology discussed. This chapter starts with the socioeconomic
This study attempts to examine the respondents’ background of the households followed by information
behaviour on environmental hygiene and sanitation seeking behaviour, information use pattern, information
practices by making an experiment in Tuticorin town, sharing behaviour, and data search behaviour and so on
Tamil Nadu. This study deals with environmental for statistical analysis. All tabular data and statistical
hygiene issues relating to environmental pollution analysis are presented in this chapter.
and its impact on land, water, health etc., this study

Table: 2: Sex wise distribution of the respondents

S. No. Sex No. of Respondents Per cent

1 MALE 301 75.25

2 FEMALE 99 24.75

Total 100 100

Source: primary data

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 135

The above table shows that the majority 301 (75.25 %) of the respondents were male, the remaining 99 (24.75%)
of them were female. It inference that the majority of the male were ready to replay for the problem of environmental
pollution.

Table: 3: Impact of Environmental Pollution

S. N Name of the Disease No. of Respondents Per cent

1 Skin diseases 371 93.00

2 Eye irritation 380 95.00

3 Asthuma 153 38.00

4 Deftness 298 75.00

5 Allergy 312 78.00

6 Unhygienic conditions 390 98.00

7 Respiratory problems 393 98.00

8 Cancer 09 2.00

9 Hypertension 91 23.00

Source: primary data

The above table prove the impact of environmental by water or air over long distances. They disturbed
pollution an account of establishment of hazard industry the function of the endocrine system, resulting in
such as Kilburn chemical industries, Sterlite Copper reproductive, developmental, and behavioral problems.
Plant, Thermal power plant, Spic Industries, Heavy Water The endocrine disrupters reduced the fertility and
Plant and Madura Coats, in this regard they replayed that increased the occurrence of still births, birth defects,
an account of the establishment of the above hazardous and hormonally dependent Cancers such as breast,
industries, the majority 371 of the respondents faced the testicular, and prostate cancers. The effects on the
problems of skin diseases, 380 of them were facing the developing nervous system can include impaired
problem of eye irritation, 153, of the faced the problem mental and psychomotor development, as well as
of Asthuma 298 of them were facing the problem of cognitive impairment and behavior abnormalities and
deftness 312 of them facing the problem of allergy, 390 pharmaceuticals such as antibiotics and synthetic sex
of the facing the problems of unhygienic conditions, 393 hormones from contraceptives. The GOs and NGOs
of the facing problem of respiratory problem, 9 of the should take effective steps to clean and green the streets,
were facing the problem of cancer and 91 of them were schools, public safety, etc. Even though it’s obvious that
facing the problem of hypertension. society stands to benefit from such things, people have
always struggled to find some sensible, acceptable way
The inference drawn from above discussion is that
to pay for them. This perennial wrangle. Far on the right,
the majority of the respondents facing the problem likes
they tell us that self-interested private ownership is the
in diseases, eye irritation, deftness, allergy, unhygienic
fairest and most efficient way to assign resources6.
condition respiratory problems and diarriah.
The developing countries like India should
Conclusion be instrumental in raising societal concerns about
Industrial disposals and other chemical contaminates environmental problems. The scientists should
that enter waterways through agricultural runoff, storm contribute in ways to increasing scientific input in
water drains, and industrial discharges may persist in public policy. The governmental agencies, as members
the environment for long periods and be transported of organized scientific bodies such as the National
 136 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Academy of Sciences, and as researchers in universities 2. Hansluwka, H.E. Measuring the health of
and environmental nongovernmental organizations or, populations, indicators and interpretations. Social
conversely, in industries. There are some debates about Science and Medicine, (1985), VOL. 20 (12), Pp.
whether too much or too little science is reflected in actual 1207- 1224.
policy making, few will deny that significant human and 3. Kaplay and Patode .H.S. Groundwater pollution
institutional resources are expended in an effort to make due to industrial effluent at Tuppa, New Nanded,
scientific analyses responsive to policy needs. Therefore, Maharashtra, India. Environmental-Geology,
an appropriate forum like scientists, academicians, (2004), VOL. 46(6/7), Pp.871-882.
policy makers and panchayat raj institutions should take
4. Mitsch, William J. Ecological Engineering.
effective step to protect environment in all aspects7.
Environmental Science and Technology, (1993),
Ethical Clearance: Completed (Annamalai VOL. 27(3), Pp. 438-445.
University, Vels University) 5. Mohanraj. R and Azeez. P.A. Urban development
and particulate air pollution in Coimbatore city,
Source of Funding: Self India. International Journal of Environmental
Conflict of Interest : NIL studies, (2005), Vol.62. (1), P.10.
6. Randall. C.W. The Environmental, Economic and
References Societal Consequences of Inadequate Nitrogen
Pollution Controls. Water Science and Technology,
1. Alka and Tangri. Studies on Some Industrial
(2004), VOL.49 (5/6), Pp.23-33.
Effluents Causing Water Pollution in River Pandu
at Kanpur. International Journal of Chemical 7. Umamaheswari.S. Water quality assessment of
Sciences, (2005), VOL. 3(2), Pp.342 – 346. River Thamirabarani at Ambasamudram. Journal
of Ecotoxicology and Environmental Monitoring,
(2004), VOL. 14(4), Pp. 273-276.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 137

Seasonal variation and malaria in endemic Mangalore city in

South India

Rakshita Maskeri1, Animesh Jain2, Sheetal Ullal3, Suchitra Shenoy4, Damodar Shenoy5, Sharada Rai6
1Tutor,Department of Pharmacology, 2Professor and Head, Department of Community Medicine, 3Associate
Professor, Department of Pharmacology, 4Associate Professor, Department of Microbiology, 5Professor and Head,
Department of Emergency Medicine,6Professor and Head , Department of Pathology, Kasturba Medical College,
Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India

Abstract
Background: In the year 2017 India has contributed to 4% of global malaria cases and Mangalore is
endemic to malaria. Malaria transmission also depends on the season of the year, i.e. the wet or dry season.
Regardless of huge endemicity and massive health burden, at present limited data has been documented on
malaria prevalence and factors contributing to prevalence of malaria and its association with seasonal factors
in Mangalore region.

Objective: To study the seasonal variations in malaria burden and species prevalence in Mangalore.

Settings and Design: This is a cross-sectional study conducted at District hospital

Methods and Material: Patients with microscopically confirmed malaria attending the District hospital
were included in the study. Demographic details were collected from participants.

Statistical analysis used: Descriptive statistics

Results: In this region malaria is present all around the year and Plasmodium vivax is more predominant
than Plasmodium falciparum. The number of cases peaks during the rainy season suggesting that high rains
provide an ideal environment for malaria transmission.

Conclusions: A complex relationship exists between rainfall, temperature, occupation and malaria.
Implementing malaria elimination interventions such as preventing water clogging, cleaning the water
bodies and increasing awareness for use of prevention practices might help in reducing malaria burden in
Mangalore.

Keywords: Malaria, Infectious disease, Public Health, Mangalore, India

Introduction Though most of the malaria burden is in the African

countries, a considerable number of cases are reported
According to the WHO there were 219 million cases
from South-East Asia, where, India accounts for the
and 4,35,000 deaths due to malaria worldwide in 2017.
highest malaria burden of around 70%.1

Corresponding Author: The National Malaria Control Program launched

Dr. Animesh Jain in 1953 resulted in a decrease of malaria cases to
Address- Professor and Head, lower than 50,000 in mid-sixties. However, after its
Department of Community Medicine, near eradication malaria staged a dramatic comeback
Kasturba Medical College, with nearly 2 million recorded cases every year since
Light house hill road, Mangalore, Karnataka, India 1995 and a clear change in malaria epidemiology: an
Mobile number: +91 9845032334 increase in insecticide resistance, rise in proportions
E-mail address: [email protected] of Plasmodium falciparum malaria and rise in urban
 138 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

malaria2. Between 2010 to 2014, annually there have Males outnumbered females presenting to the hospital.
been 7–16 lakh confirmed cases of malaria and 400-
1,000 deaths.3 In the year 2017 India has contributed to Table 1: Demographic details of Participants
4% of the global malaria cases.1
Mean age (± SD) 32 (±12) years
Malaria was unknown in the coastal city of Mangalore
till 1990 but as a consequence of industrialization and Males 1038
urban development it has become endemic in the recent
times.4 Females 57

Despite the endemicity and health burden, limited Occupation

data has been documented on malaria prevalence,
contributing factors and its association with seasonal Construction workers 411
variations in Mangalore region.
Labourers 154
Objective: The purpose of this study was to evaluate
the seasonal variations in malaria burden and species Hotel workers 145
prevalence in Mangalore.
Others* 385
Materials and Method
*Others included security guards, police personnel,
Study area: Mangalore is located 12.91°N, 74.85°E bus drivers and conductors, businessmen, fishermen,
on the shores of Arabian Sea in Dakshina Kannada students, homemakers, retired people
district, Karnataka, South India. Mangalore city has
hot and humid tropical climate with two seasons, rainy
and summer. The climate of the city makes it a perfect
place for breeding of Anopheles species and malaria
transmission, thus making the city highly endemic to
malaria.

Study Setting: Wenlock District hospital, a tertiary

care centre

Study design: A cross-sectional study was carried

out among patients attending the malaria clinic. Giemsa-
Figure 1 - Summary of total number of smear positive malaria
stained thick and thin blood smear examination was
cases and the average temperature every month (2017)
done and confirmed cases of malaria were recruited in
the study. Demographic details were collected from the Figure 1 shows the total number of microscopically
participants. positive cases of malaria every month and average
temperature in the year 2017.5 This shows that highest
Study duration: The study was carried out for a number of cases were recorded during the peak rainy
period of one year from January 2017 to December 2017. season during July and August. The highest recorded
temperature during the year is in April and May at around
Ethical considerations: The study was started 33 °C while later the temperature gradually reduces to
after getting permission from the Institutional Ethics 26 °C in December. During the dry season, though the
Committee, Kasturba Medical College, Mangalore, cases reduced, it was still substantial in number.
India. Written informed consent was taken from all the
participants.

Results
Data was collected from 1095 consecutive patients
with confirmed malaria. Table 1 depicts the demographic
details of the participants. The mean age was 32 years.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 139

and around the construction sites. These sites have

stagnant water used for curing concrete and construction
related activities making it an ideal breeding site for the
Anopheles species. Lack of prevention methods like bed
net use and mosquito sprays is putting these workers at a
higher risk of malaria. Additionally, limited prevention
practices against malaria is one the major factor for
the high number of malaria cases as found by these
studies10,11.
Figure 2-Month-wise distribution of P.vivax, P.falciparum and
mixed infection cases
Climatic conditions such as rainfall, temperature
and humidity affect mosquito survival and malaria
Figure 2 depicts the number of cases of P.vivax,
transmission rates. In various places the transmission
P.falciparum and mixed infection during every month.
is seasonal and usually peaks during and after the rainy
P.vivax was found in highest number followed by
season. The present study shows that there is a strong
P.falciparum and mixed infection.
relationship between rainfall and malaria. Mangalore
during the monsoon season from May to October
Discussion
receives an annual average of 3479 mm rainfall12.
Malaria is a grave health problem in certain parts The number of cases peaked between June to August
of India and Mangalore city is known to be endemic suggesting that high rains provide an ideal environment
to malaria. In the present study the ratio of P.vivax, for malaria transmission. There was a decline in cases
P.falciparum and mixed infections was 81%, 16 % during the dry seasons. In the month of July even though
and 3% respectively. The results found in our study the temperature was 32 °C the highest number of cases,
are similar to results published in the study conducted 10 times more than number of cases during February
by Dayanand KK et al6.The data recorded by District was recorded, as in drier months when the weather is hot
Vector Borne Disease Control Programme (DVBDCP) the breeding sites of the mosquitoes are dried, and the
office of Dakshina Kannada has shown 80% of malaria number of cases reaches low.
cases were by caused by P.vivax and 20% cases were by
caused by P.falciparum which is compatible with results Both, Plasmodium parasite and
found in our study.4,7 Anopheles mosquitoes are known to be temperature
sensitive. The optimal temperature for most of the
The total of malaria cases in the year 2013 in Anopheles species is in the range of 20°C to 30°C.13
Mangalore was 4714 which drastically increased to
11021 in 2015 and 11037 in 2016 which has now Mangalore has the optimum temperature throughout
reduced to 8075 in the year 2017 and to 6110 in the year the year. Hence malaria is present in the city throughout
2018.4Thus the decrease in number of cases suggests the year. P.vivax predominates as the causative agent
the success NVBDCP’s strategies to reduce the cases. in urban malaria. In Mangalore too, the highest burden
The framework for malaria elimination in India (2016– of malaria is caused by P.vivax. Both P.vivax and
2030) launched by the government of India in 2016 also P.falciparum are present all around the year. P.vivax is in
aims to control and eradicate malaria.8In the year 2018 higher ratio of about 80% throughout the year compared
the number of cases has reduced, and the deaths has to P.falciparum. In comparison, in other parts of the
drastically reduced to only 85.3 country like in Orissa P.falciparum is more predominant
than P.vivax; in Tamil Nadu it is again P.vivax and in
In various other endemic regions in the world the west it is mixed species infections which are more
including Africa, malaria usually affects younger age prevalent.
groups mainly children.9In Mangalore the majority
of the cases with malaria are adults. It is similar with P.vivax has the potential to act as a hypnozoite
other cities in India and South East Asia. A high number reservoir and cause multiple relapses leading to an
of study participants were construction workers and increased burden. P.vivax which was earlier considered
labourers leading to skewing of the gender ratio towards to be a benign form of malaria is now being found to be
males. Majority of the construction workers stay in not so benign thus making it an issue of concern.
 140 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Conclusion: In summary high transmission is found after getting permission from the Institutional Ethics
in Mangalore area. The results depicted here show a Committee, Kasturba Medcial College, Mangalore,
complex relationship between rainfall, temperature, India (IEC KMC MLR 06-15/126). Written informed
occupation and malaria cases. The results of this study consent was taken from all the participants.
will be useful for malaria elimination control program of
India. Implementing malaria elimination interventions References
such as preventing water clogging, cleaning the water 1. WHO. World malaria report 2018. World Health
bodies etc and increasing awareness for use of prevention Organization. https://www.who.int/malaria/
practices might help in reducing malaria burden in publications/world-malaria-report-2018/en/.
Mangalore. Accessed June 13 2019
Recommendation Malaria is a huge health burden 2. Mohan VR, Naumova EN. Temporal changes in
in Mangalore. It has been found that the number of land cover types and the incidence of malaria in
cases generally peaks with the rainy season. Thus, Mangalore, India. Int J Biomed Res.2014; 5(8):494-
awareness and malaria preventive measures have to 498.
be concentrated mainly before and during the rainy 3. Malaria situation. National Vector Borne
season during which the number of cases are higher. Disease Control Programme. Available
We also found that the construction workers are mainly at https://nvbdcp.gov.in/WriteReadData/
affected by malaria. Hence the results may help in l892s/33071492161551875364.pdf. Accessed June
targeting a seasonally focused malaria interventions to 15 2019
specific target population like construction workers. 4. Malaria in Mangalore. Malaria site. http://www.
Further strategies have to be developed to create public malariasite.com/malaria-Mangalore/. Accessed
awareness mainly among the construction workers and July 4 2019
implement protective measures to reduce the risk of
5. Timeanddate.com. Past Weather in
transmission.
Mangalore, Karnataka, India https://www.
Limitation of the study There are a few limitations timeanddate.com/weather/india/mangalore/
in our study. Firstly, since it is a hospital based study historic?month=6&year=2017. Accessed June 4
it doesn’t depict the exact picture of overall cases of 2019
malaria in Mangalore. Secondly, the study period is one 6. Dayanand KK, Punnath K, Chandrashekar V,
year which is a little short to study the prevalence trends. Achur RN, Kakkilaya SB, Ghosh SK, et al.
Thirdly, doing a community based study would give Malaria prevalence in Mangalore city area in the
clearer insight of seasonal variation. southwestern coastal region of India. Malar J. 2017;
16:492.
Relevance of the study In Mangalore, malaria is
highly endemic and a huge health burden to the society. 7. Shivakumar Rajesh B, Kumar A, Achari M, Deepa
Despite this, very limited data has been documented S, Vyas N. Malarial trend in Dakshina Kannada,
regarding the malaria cases, contributing factors and Karnataka: an epidemiological assessment from
its association with seasonal variations in Mangalore 2004 to 2013. Indian J Health Sci Biomed Res
region. This study depicts that in Mangalore a complex (KLEU).2015(8):91–94.
relationship exists between rainfall, temperature, 8. World Health Organization, Country Office for
occupation and malaria and further adds to the scientific India. National framework for malaria elimination
evidence. in India 2016-2030. India:WHO, 2016 Available
at http://www.who.int/iris/handle/10665/246096.
Conflict of Interest: NIL Accessed June 13 2019
Source of Funding: This study is a part of project 9. Maitland K. Severe malaria in African children—
funded by Women Scientist Scheme- A, Department the need for continuing investment. N Engl J Med.
of Science and Technology (Government of India) file 2016;375:2416–7
number SR/WOS-A/LS-523/2016 10. Maskeri R, Jain A, Ullal S, Shenoy D, Shenoy S,
Rai S. Knowledge, attitude and practices (KAP)
Ethical Considerations: The study was started regarding malaria and its prevention among patients
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 141

with suspected malaria in Mangalore. Indian J 12. ClimaTemps.com.Rainfall/Precipitation in

Public Health Res Dev. 2018 Sep 1;9(9):271-276 Mangalore, Karnataka, India. http://www.
11. Shivalli S, Pai S, Akshaya KM, D’Souza N. mangalore.climatemps.com/. Accessed June 4
Construction site workers malaria knowledge and 2019
treatment-seeking pattern in a highly endemic 13. Centre for Disease control and Prevention. Malaria.
urban area of India. Malar J. 2016; 15:168 https://www.cdc.gov/malaria/about/biology/index.
html. . Accessed June 4 2019
 142 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A Study to Assess the Level of Burden and Coping Strategies

among Caregivers of Patient with Affective Disorders at
Selected Hospitals of Sangli, Miraj, Kupwad Corporation Area

Ramesh Giramalla Honamore1, Narayan K Ghorpade2

1
M.SC Nursing at BharatiVidyapeeth (Deemed to be University), College of Nursing, Sangli,
2Assistant Professor, B.V.D.U.College of Nursing,Sangli

Abstract
Introduction Interactions with caregivers of patients with severe mental illness like schizophrenia and
bipolar affective disorder have revealed negative feelings about the disability status of their relative and
burden related to caring for their relative with mental illness. Many caregivers have expressed that the
patient‘s disability status affects the family pattern, roles of family members, prosperity of the family and
relationship among the family members. Patient outcome and compliance with treatment are also dependent
on optimal care giving and addressing family‘s needs. Unfortunately these needs are not routinely considered,
addressed or met. Addressing the burden perceived by caregiver and improving their coping can assist with
good clinical care of patients with severe mental illness and hence these study to assess the burden perceived
by caregiver and their coping.1 Objectives: To assess the levels of Burden among care givers of patients
with affective disorders and To assess the coping strategies among the caregivers of patients with affective
disorders. Materials and Method: The researcher used quantitative research approach to assess burden and
coping strategies. The research design was descriptive research design. The tool reliability coefficient ‘r’ of
the scale was 0.7, hence it was found reliable. Total 120 samples were selected by non Probability convenient
sampling technique. Total two scale namely Zarit burden interview and Rating scale for assessing coping
strategies to collect data. The conceptual framework adopted is Sr.Calista Roy’s adaptation model (1984) the
main concept of this conceptual framework is human being, stimuli, adaptation models and nursing. Results
and Conclusion: In this study found the level burden among the care givers of affective disorders patients
have experienced 60(50%)were had moderate to severe level of burden,29(24.17%) were had severe burden,
13(10.83) were had no or little burden and 18(15%) were had mild to moderate burden and levels of coping
strategies among care givers, 19(15.83%) were had moderately adequate coping strategies, 93(77.50%)
were had adequate coping strategies and 08(6.67%) were had inadequate coping strategies.

Key words: Care giver, Burden, Coping strategies,

Background of Study disorders are commonly known as affective disorders.

Broadly speaking, the emotions can be described as
In 1896, Kraeplin according ‘manic-depressive
two main types Affect which is a short-lived emotional
psychoses’ as a circumscribed illness entity. Ever since,
response to an idea or an event, and Mood, which is
frenzied depressive mental disease, or the present term
a sustained and pervasive emotional response which
used nosologically as ‘bipolar’ mood disorder, has
colors the whole psychic life1.Caregivers of patients
been studied within the Indian perspective. The mood
of schizophrenic disorder and bipolar major affective
disorder (BAD) expertise appreciable burden whereas
Corresponding Author:
caring their patients. They develop totally different
Mr. Narayan K Ghorpade,
cope methods to cope with this burden. Care giving
Assistant Professor, B.V.D.U.College of
is a chronic stressor and different coping methods
Nursing,Sangli.Email.ID:[email protected]
are used to handle such a situation. The present study
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 143

attempts to assess coping in caregivers of Chronic research design. The tool reliability coefficient ‘r’ of
Schizophrenia and Bipolar Affective Disorder and make the scale was 0.7, hence it was found reliable. Total 120
a comparison between them. The study also tries to samples were selected by non Probability convenient
assess the relationship between the burdens experienced sampling technique. Total two scale used namely Zarit
by the caregivers of both these groups of patients with burden interview and Rating scale for assessing coping
the coping strategies adopted by them. It was a hospital strategies to collect data. The conceptual framework
based cross sectional and comparative study, conducted adopted is Sr.Calista Roy’s adaptation model(1984) the
in the Department of Psychiatry, Assam Medical College main concept of this conceptual framework is human
and Hospital with a sample size of 30 primary caregivers being, stimuli, adaptation models and nursing.
of equal number of patients of Chronic Schizophrenia
and 30 Primary caregivers of equal number of Bipolar ASSUMPTION 1. The caregivers of affective
Affective Disorder patients. Appropriate statistical disorders patients may experience some level of burden
tests were used for analysis of obtained data setting and The caregivers of affective disorders patients may
significance threshold at p coping (90%) followed by use some coping strategies.
external attribution and magical thinking. Among the
caregivers of patients of BPAD the most commonly
Results
used coping strategies included help seeking (93.33%) SECTION I: Deals with analysis of data related to
followed by religious coping strategies and external assessment of the level of burden among care givers in
attribution. 2 Materials and Method: The researcher terms of frequency, percentage.
used quantitative research approach to assess burden and
coping strategies. The research design was descriptive

Table.No.1: Classification of respondents based on levels of burden among care givers of affective
disorders. N=120

Sr. No Level of Burden Score Frequency Percentage%

1 No or little burden 0-20 13 10.83%

2 Mild to moderate burden 21-40 18 15%

3 Moderate to severe burden 41-60 60 50%

4 Severe Burden 61-88 29 24.17%

The above table describes the levels of burden among care givers of affective disorders, 60(50%) were had moderate
to severe burden, 29(24.17%) were had severe burden, 13(10.83%) were had no or little burden and 18(15%) were
had mild to moderate burden.

SECTION II: Deals with analysis of data related to assessment thecoping strategies among care givers of
affective disorders patients in terms of frequency and percentage.

Table No.2: Classification of respondents based on coping strategies among care givers of affective
disorders.
N=120
Sr. No Strategies Score Frequency Percentage %

1 Inadequate coping strategies 01-24 08 6.67%

2 Moderately adequate coping strategies 25-50 19 15.83%

3 Adequate coping strategies 51-75 93 77.50%

 144 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

The above table describes the coping strategies samples regarding the level of of burden and coping
among care givers, 19(15.83%) were had moderately strategies among care givers of affective disorders. The
adequate coping strategies, 93(77.50%) were had data was collected by using the Zarit burden Interview
adequate coping strategies and 08(6.67%) were had and Rating scale for assessing coping strategies. The
inadequate coping strategies. study was conducted at selected hospitals, Sangli and
Miraj,kupwad corporation area. The data analysis
Discussion was done by descriptive and inferential statistics. The
The study was descriptive in nature and the population findings of the study are as follows; The study reveals
taken for the study was of a low socioeconomic status. that the care givers of affective disorders patients was
An Exploratory study to assess the level of burden and 60(50%) were had moderate to severe levels of burden,
coping strategies among caregivers of patients with 29(24.17%) were had severe burden, 13(10.83%) were
affective disorder at selected hospitals of sangli miraj had no or little burden and 18(15%) were had mild to
kupwad corporation area. The findings of the study moderate burden. The mean percentage score was 54.71
have been discussed with reference to objective and with mean and standard deviation of 48.15±2.75. The
assumption. coping strategies among care givers of affective disorder
using 19(15.83%) were had moderately adequate coping
Discussion regarding demographic variables: strategies, 93(77.50%) were using adequate coping
strategies and 08(6.67%) were using inadequate coping
• Majority of the caregivers, 30(25%) were strategies.
between 31-35 years. The majority of care givers were
70(58.30%) were females. With regard to religion, Conflict of Interest: - Column is Nil
80(66.7%) were Hindus. Majority 69(57.5%) were
graduates. With regard to monthly income, 50(41.66%) Sources of Funding: - Self
were had Rs. 10000 -15000 income per month. In Ethical Consideration: - Permission was obtained
relation to the type of family, 80(66.70%) were from from the research ethical committee of the Bharati
joint family. With regard to duration of care giving, Vidyapeeth (Deemed to be) University College of
majority 40(33.33%) were giving for 1 to 3 years, In Nursing, Sangli and permission taken for data collection
relation to the care givers relationship, 30(25%) were from Hospital authority of sangli Miraj, Kupwad
fathers, 30(25%) were son. Corporation area. Informed consent was obtained from
Objective 1.To assesses the levels of Burden individual(Samples)who are selected for the study.
among care givers of patients with affective disorders. Ethical clearance was done by head of committee
members Dr shripriya and Dr. Nilima Bhore.
The study reveals that the majority caregivers of
affective disorders patient 60(50%) were had moderate References
to severe burden, 29(24.17%) were had severe burden, 1. Prasad G. Rao, An overview of Indian research in
13(10.83%) were had no or little burden and 18(15%) bipolar mood disorder. Indian J Psychiatry. 2010
were had mild to moderate burden. Jan; 52(Suppl1): S173–S177.
Objective 2.To assesses the coping strategies 2. Dr. Kavery Bora, Dr. Abhilekh Das. Coping In
among the caregivers of patients with affective Caregivers of Chronic Schizophrenia and Bipolar
disorders. Affective Disorder – A Comparative Study. IOSR
Journal of Dental and Medical Sciences. 2017;16
The coping strategies among care givers, 19(15.83%) (11):58-64.
were had moderately adequate coping strategies,
3. Rabah Kamal. What are the current costs and
93(77.50%) were had adequate coping strategies and
outcomes related to mental health and substance
08(6.67%) had inadequate coping strategies.
abuse. 2017. https://www.healthsystemtracker.org/
chart-collection/current-costs-outcomes-related-
Conclusion
mental-health-substance-abuse-disorders/
This chapter deals with the conclusion, implication, 4. Phyllis M. Eaton, Bertha L. Davis, Pamela
recommendation and data collected from 120 individual V. Hammond, Esther H. Condon, and Zina T.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 145

McGee. Coping Strategies of Family Members 15. Perlick DA, Rosenheck RA, Miklowitz
of Hospitalized Psychiatric Patients. Nursing DJ, Chessick C, Wolff N, Kaczynski R, Ostacher
Research and Practice. 2011; Article ID 392705, 12 M, Patel J, Desai R; STEP-BD Family Experience
pages. Collaborative Study Group. Prevalence and
5. Murthy R S. Caregiving and caregivers: Challenges correlates of burden among caregivers of patients
and opportunities in India. Indian Journal of Social with bipolar disorder enrolled in the Systematic
Pyshciatry. 2016;32:10-18. Treatment Enhancement Program for Bipolar
Disorder. Bipolar Disord. 2007 May;9(3):262-73.
6. Bazondlile D. Marimbe, Frances Cowan, Lazarus
Kajawu, Florence Muchirahondo, and Crick Lund. 16. K. K. Ganguly ,R. K. Chadda &T. B. Singh.
Perceived burden of care and reported coping Caregiver Burden and Coping in Schizophrenia
strategies and needs for family caregivers of people and Bipolar Disorder: A Qualitative Study.
with mental disorders in Zimbabwe.Afr J Disabil. american Journal of Psychiatric Rehabilitation.
2016; 5(1): 209. 2010; 13(2).19-21.
7. S. Vasudeva, Chandra K. Sekhar, and Prasad G. Rao. 17. Chadda R K, Singh TB, Ganguly K K. Caregiver
Caregivers Burden of Patients with Schizophrenia burden and coping: a prospective study of
and Bipolar Disorder: A Sectional Study. Indian J relationship between burden and coping in
Psychol Med. 2013 Oct-Dec; 35(4): 352–357. caregivers of patients with schizophrenia and
bipolar affective disorder. Soc Psychiatry Psychiatr
8. Deborah A. Perlick, Robert A. Rosenheck, David
Epidemiol. 2007 Nov;42(11):923-30. Epub 2007
J. Miklowitz, Richard Kaczynski, et al Caregiver
Aug 13.
Burden and Health in Bipolar Disorder. J Nerv
Ment Dis. 2008 Jun; 196(6): 484–491. 18. Setsuko Hanzawa, et all. Study was conducted to
assess the Caregivers burden and coping strategies
9. Ganguly, K.K and Chadda, R.K. A Study of
for patients with schizophrenia. Psychiatry and
Socio Cultural Perspectives of Care Givers in
Clinical Neurosciences:2015;64(4):377-86.
Burden Coping Behaviour in Bipolar Disorder and
Schizophrenia Cases .the international Journal of 19. Sandeep Grover, Subho Chakrabarti, Munish
Psychosocial Rehabilitation. 2009;13(2):93-103. Aggarwal, et all. Comparative study of the
experience of caregiving in bipolar affective
10. Sandeep Grover, Pradyumna, Subho Chakrabarti.
disorder and schizophrenia. International journal of
Coping among the caregivers of patients with
social psychiatry. 2016;14(2)45-56.
schizophrenia. Industrial psycihiatry. 2015;24:5-
11. 20. Rita Bauer,Hermann Spiessl, and Marina J
Helmbrecht. Burden, reward, and coping of adult
11. Bazondlile D. Marimbe, Frances Cowan, Lazarus
offspring of patients with depression and bipolar
Kajawu, Florence Muchirahondo, and Crick Lund.
disorder. Int J Bipolar Disord. 2015; 3: 2.
Perceived burden of care and reported coping
strategies and needs for family caregivers of people 21. Chakrabarti S, Gill S. Coping and its correlates
with mental disorders in Zimbabwe. Afr J Disabil. among caregivers of patients with bipolar disorder:
2016; 5(1): 209. a preliminary study. Bipolar Disord. 2002
Feb;4(1):50-60.
12. Shiv Gautam, Madhu Nijhawan. Burden on families
of schizophrenic and chronic lung disease patients. 22. Akbari m, Alavi M, Irajpur A, Maghsoudi.
Indian Journal of Psychiatry. Indian J Psychiatry. Cahllenges of family caregivers of patients with
1984 Apr-Jun; 26(2): 156–159. mental disorder in iran: A narrative review. Iranian
J Nursing Midwifery research. 2018;23:329-37.
13. Masunga K. Iseselo, Lusajo Kajula, and Khadija
I. Yahya-Malima. The psychosocial problems of 23. Binil V and, Dr.Christopher Sudhakar and Sangeetha
families caring for relatives with mental illnesses Priyadarshini. A correlative study of burden
and their coping strategies: a qualitative urban and coping strategies among the Caregivers’ of
based study in Dares Salaam, Tanzania. BMC patients with affective disorder. Manipal academy
Psychiatry. 2016; 16: 146. of education. 2009;6:43. http://eprints.manipal.
edu/id/eprint/1607
14. Basavanthappa B T . Textbook of Nursing Theories.
2014;2ndedition, jaypee publications. 98-100. 24. Ong H C, Ibrahim N, Wahab S. Psychological
 146 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

distress, perceived stigma, and coping among bipolar affective disorder. Soc Psychiatry Psychiatr
caregivers of patients with schizophrenia. Psychol Epidemiol. 2007 Nov;42(11):923-30.
Res Behav Manag. 2016; Aug 16;9:211-8. 28. Steele A, Maruyama N, Galynker I. Psychiatric
25. Zendjidjian X, Richieri R, Adida M, Limousin symptoms in caregivers of patients with bipolar
S, Gaubert N, Parola N, Lançon C, Boyer L. disorder: a review. J Affect Disord. 2010 Feb;121(1-
Quality of life among caregivers of individuals 2):10-21.
with affective disorders. J Affect Disord. 2012 29. Sujata Chodankar Walke, Varalakshmi
Feb;136(3):660-5. Chandrasekaran,1 and Shreemathi S. Mayya.
26. Chadda RK, Singh T B, Ganguly K K. Caregiver Caregiver Burden among Caregivers of Mentally
burden and coping: a prospective study of Ill Individuals and Their Coping Mechanisms. J
relationship between burden and coping in Neurosci Rural Pract. 2018; Apr-Jun; 9(2): 180–
caregivers of patients with schizophrenia and 185.
bipolar affective disorder. Soc Psychiatry Psychiatr 30. Aditya Gupta, R K Solanki, G D Koolwal, Sanjay
Epidemiol. 2007 Nov;42(11):923-30. Gehlot. Psychological well-being and burden
27. Chadda RK, Singh TB, Ganguly KK. Caregiver in caregivers of patients with schizophrenia.
burden and coping: a prospective study of International Journal of Medical Science and Public
relationship between burden and coping in Health. 2015;4(1):23-28.
caregivers of patients with schizophrenia and
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 147

Cognitive Impairments and its Associated Risk Factors among

Patients with Diabetes Mellitus

Rasika Panse1, Ujwal Yeole2, Nikita Aher3

1Assistant Professor, 2Associate Professor and Principal, 3Student, Department of Physiotherapy
Tilak Maharashtra Vidyapeeth Pune

Abstract
Background: Diabetic patients are considered to be more prone to develop cognitive dysfunction and further
leading to dementia, hence systematic assessment and identification of risk factors plays a key role. Aim
and objectives: To study cognitive impairments and its associated risk factors among patients with diabetes
mellitus . Settings and Design: A hospital-based Multicentre cross-sectional study was conducted. Methods
and Material: In this study 245 individual medically diagnosed to have diabetes mellitus were recruited
according to inclusion and exclusion criteria. Demographic data included age gender and duration of diabetes
smoking, BMI, Family history of diabetes and Hypertension HbA1c was noted. Cognitive assessment was
done using Modified Mini Mental Scale (3MS). Data was collected and subjected to statistical analysis.
Results: The result shows about 22% had moderate cognitive impairment and associated risk factors can be
medications, age, glycaemic control, Hypertension, family history. There is no correlation of Cognition and
duration since diagnosed to be diabetic and BSL whereas weak linear relationships exist between cognition
and Age and HbA1c and strong linear relationship between cognition and BMI in Patients with diabetes.
Conclusions: Diabetic patients do exhibit Mild cognitive dysfunction with various associated risk factors.

Key-words: Diabetes, smoking, Duration of diabetes, Obesity, Hypertension, Cognitive impairment, HbA1c,
Modified mini Mental Scale.

Introduction Mellitus (NIDDM) or maturity onset diabetes caused

due to impaired insulin secretion or insulin resistance
Diabetes mellitus is autoimmune metabolic disorder, (1,2,3) Long term diabetes affects central nervous system,
caused by insulin deficiency, is complex in nature and
peripheral nervous system mainly manifest in the clinical
has various factors related to it, long-term complications
impact of diabetes.4
and co-morbidities can affect the cerebral cortex 1. Islets
of langerhans in Pancreas especially the beta (β) cells Type 2 diabetes is often associated with increased
secrete insulin. Defect in response of insulin causes risk of accelerated cognitive decline and almost two
diabetes mellitus. Type 1 Diabetes Mellitus also called times more susceptible to experience cognitive decline
as Insulin-Dependent Diabetes Mellitus (IDDM) or compared to those with normal glucose tolerance.
juvenile onset diabetes is caused by destruction of β cells Various researches have suggested that Type 2 diabetes
which leads to deficiency of insulin. Type 2 Diabetes affects cognitive domains like verbal memory, attention
Mellitus also called as Non-Insulin Dependent Diabetes and processing speed and executive functions when
performing task with change in environment and
challenges. Diabetes has also been consistently related
Corresponding Author:
with cognitive decrements such as reduced abstract
Dr Rasika Panse
reasoning, complex motor functioning and working
Assistant Professor Department of Physiotherapy Tilak
memory. 1
Maharashtra Vidyapeeth Pune
Phone numbers: 9689362993 Cognitive dysfunction affects memory, learning and
E-mail address : [email protected] attention. In mild cognitive impairment there is cognitive
 148 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

dysfunction without affecting the daily activity of life. was noted. Cognitive assessment was done using
Person with mild cognitive impairment can self manage Modified Mini Mental Scale (3MS). Data was collected
their daily routine. Conditions for cognitive dysfunction and subjected to statistical analysis.
are hyperglycemia, hypoglycaemia, insulin resistance
and insufficiency of insulin in patients with diabetes. Results
In young population due to immediate hypoglycemia, Demographic data for diabetic patients with mean
acute cognitive dysfunction can be observed. (5) age 73.22+7.9 , Mean duration since diagnosed to be
diabetic was 18+10.82, mean Cognition in diabetics
Subjects and Method was 75.59+1.6.Also mean BMI was 25.67 +5.351 with
Study setup and design: A Multicentered hospital Mean BSL and HbA1c as 190+54.13 and 7.118+0.958
based Cross-sectional study was conducted. respectively. Table 1 shows that Family history was
exhibited in 72.72%, Hypertension in 50%, Diabetic
Method: 398 participants had a diagnosis of type Male were 48% and Females were 52% and diabetic had
2 diabetes according to the World Health Organization addiction of Smoking in 68%.
1999 criteria, and 245 individuals were included in the
study. Study was conducted from July 2018 to January Table 2 shows that there is no correlation of
2019. 6 Both males and females were included. Subjects Cognition and duration since diagnosed to be diabetic
who willing five Informed Consent were included in , and BSL whereas weak linear relationships exist
study. An exclusion criterion was patient with Dementia, between cognition and Age and HbA1c and strong linear
Alzheimer’s disease and any psychological disorder relationship between cognition and BMI in Patients with
pregnancy. Demographic data included age gender diabetes.
and duration of diabetes, smoking, Family history of
diabetes, obesity and Hypertension, BMI, BSL, HBA1C

Table 1: Percentage of Family History Of Diabetes Cognitive dysfunction Gender Distribution,

Hypertension among Diabetics with Cognitive dysfunction.

Risk Factors Percentage

Family History of Diabetes 72.72%

Hypertension 50%

Gender Male 48%

Female 52%

Smoking 68%

Table 2: Correlation of Age Duration of Diabetes, BMI, BSL, HbA1c and Cognitive Dysfunction in
Patients with Diabetes.
Person correlation
Parameters Mean+SD
(r )
Age 73.22+7.9 0.0175
Duration since diagnosed to be
18+10.82 -0.03622
diabetic
BMI 25.67 +5.351 0.1337

BSL 190+54.13 -0.1996

HbA1c 7.118+0.958 0.0846

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 149

Discussion to prevent cognitive decline in older adults.(5)

Study showed that 22% had moderate cognitive E. van den Berg and others concluded in their
impairment (MCI). There is no correlation of Cognition study that obesity, hypertension, and dyslipidaemia
and duration since diagnosed to be diabetic whereas are features that have risk of cognitive dysfunction in
weak linear relationships exist between cognition and younger old. At the age up to 75, increased cholesterol
Age and HbA1c and strong linear relationship between levels and increased BMI are related with accelerated
cognition and BMI in Patients with diabetes. Risk factors cognitive decline up. (11)
of smoking family history of diabetes, Hypertension are
coexisting with patients with diabetes. In the general population, studies on other risk factors
for accelerated cognitive decline were hypertension
The prevalence in urban Kerala of Mild cognitive and obesity. Hypertension has been suggested to be an
impairment in patients with diabetes was 26.06%. This important factor of impaired cognition in diabetes. A
prevalence is reported from different areas of the world similar result is seen in this study that A higher HbA1c
varies widely between 3% and 42%. Previous researches level was largely unrelated to cognitive dysfunction. (11)
from India estimated prevalence between 15% and
33%(7) Omorogieva Ojo and others in their study concluded
that neurotransmitter acetylcholine functions for
A research showed that Deficits in memory is cognition and memory formation. Dysfunction in
correlated with decrease in gray matter density and insulin production and insulin resistance could lead
reduced glucose metabolism in the regions of orbital to a decrease in acetylcholine levels which may have
and prefrontal cortex, temporal cortex (middle gyrus, impact on cognition and memory. Diabetes is a risk
parahippocampus, and uncus), and cerebellum. Both factor for decline in cognitive. Hyperglycaemia and
Type 1 and type 2 diabetes are associated with impaired hypoglycaemia may result from poor self management
cognition; the current statistically analyzed data suggests of diabetes which can lead to cognitive decline. (12)
a stronger association of cognitive decline with T2DM.
Early Cognitive impairment is observed in individuals Insulin crosses the blood brain barrier and binds
who have impaired blood fasting glucose. (8) with insulin receptor. Insulin plays an important
role in cognitive function and also in food intake.
The various studies have shown that prevalence Insulin is present in abundance in cerebral cortex and
of diabetes is higher in men than women, but there are hippocampus which play important role in memory. Due
more women Suffering with diabetes than men in recent to insulin resistance there is decrease in insulin receptors
years. Similar results have been observed related to the and decrease insulin in brain. It result impairment in
proportion of females was much higher than the males cognition. For some time, cognitive decline has been
suffering with diabetes in our study. Studies have truly reported in patients receiving insulin therapy. A recent
delineated that cognition impairment correlates with the study showed that up to half of all cases of Alzheimer’s
glycaemic control as well as the duration of diabetes. disease are attributable to potentially modifiable risk
factors – diabetes, midlife hypertension, midlife obesity,
Mohammed Abdul Hannan Hazari and others
smoking, depression, low education level and physical
concluded in the study that due to long duration
inactivity. Most of these risk factors also contribute to
specifically exceeding 5 years of onset of diabetes
the incidence or progression of diabetes mellitus.(13)
showed prominent decline in cognition in as Diabetes
is considered a potential atherogenic factor. Also
Conclusion
hypertension along with Diabetes further increases the
risk of cognitive decline.(10) In type 2 diabetes mellitus, Study concludes that 22% Diabetic patients had
chronic hyperglycemia can be cause of cognitive decline. moderate cognitive impairment (MCI) wherein they
(10) exhibited no correlation between Cognition and duration
since diagnosed to be diabetic. Furthermore there exist
Medha N. Munshi concluded in the study that a weak linear relationships exist between cognition,
poor glycaemic control i.e. Hypoglycemia and chronic Age and HbA1c and strong linear relationship between
hyperglycemia can factor that can lead to cognitive cognition and BMI in Patients with diabetes. The other
dysfunction better management of Diabetes is required modifiable and non modifiable risk factors were smoking,
 150 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

family history of diabetes, Hypertension which coexist Diabetes Care. 2017 Apr 1;40(4):461-7.
in patients with diabetes contributing towards potential 6 Alberti KGMM, Zimmet PZ. Definition, diagnosis
cognitive decline irrespective of the age of the patients. and classification of diabetes mellitus and its
complications. Part 1: diagnosis and classification
Acknowledgement: We express sincere gratitude
of diabetes mellitus. Provisional report of a
towards Dr Shreepad Bhatt for his support and
WHO consultation. Diabet Med 1998; 15: 539–
cooperation for referring patients from multiple Diabetic
553CrossRefPubMed.
clinics. We would also like to thank Department of
Physiotherapy Pune , teaching Non teaching faculty for 7 Mohan D, Iype T, Varghese S, et al. A cross-
their support during the research work. sectional study to assess prevalence and factors
associated with mild cognitive impairment among
Conflict of Interest: Nil older adults in an urban area of Kerala, South
India. BMJ Open2019;9:e025473. doi:10.1136/
Funding : Nil
bmjopen-2018-025473
Ethical Clearance: Ethical clearance was obtained 8 Zilliox LA, Chadrasekaran K, Kwan JY, Russell
from institutional ethical committee. JW. Diabetes and Cognitive Impairment. Curr Diab
Rep. 2016;16(9):87. doi:10.1007/s11892-016-
References 0775-x
1 Modugula S Naga Swetha, Srinivasa S.V, Abhishek 9 Shanmugapriya S, Dhandapani N, Saravanan T. A
Kumar Verma, Prabhakar K; Study of Risk Factors study comparing cognitive function assessment in
of Mild Cognitive Impairment in Patients with type-2 diabetes mellitus using Rowland Universal
Type 2 Diabetes Mellitus; Int J Sci Res Publ (2017) Dementia Assessment Scale and Mini Mental State
7(11) (ISSN: 2250-3153). http://www.ijsrp.org/ Examination 2018 | Volume: 7 | Issue Number: 3 |
research-paper-1117.php?rp=P716986 Page: 184-190.
2 Omorogieva Ojo, and Joanne Brooke, “Evaluating 10 Hazari MA, Reddy BR, Uzma N, Kumar BS.
the Association between Diabetes, Cognitive Cognitive impairment in type 2 diabetes mellitus.
Decline and Dementia,” International Journal Of International Journal of Diabetes Mellitus. 2015
Environmental Research And Public Health, 2015, May 1;3(1):19-24
vol. 12, no. 7, pp. 8281–8294. 11 Van den Berg E, De Craen AJ, Biessels GJ,
3 Dr.Pournima A Pawar,Dr Ujwal Yeole, Nikita Gussekloo J, Westendorp RG. The impact of
Kadam, Dr Rasika Panse. Effect of inspiratory diabetes mellitus on cognitive decline in the oldest
muscle training on autonomic symptoms in of the old: a prospective population-based study.
patients with type ii diabetes.International journal Diabetologia. 2006 Sep 1;49(9):2015-23.
of Allied Medical Sciences and clinical Research 12 Omorogieva Ojo, and Joanne Brooke, “Evaluating
2018;6(4):922-928. the Association between Diabetes, Cognitive
4 Panse R, Deshpande M, Yeole U et.al. Effect of Decline and Dementia,” International Journal Of
brain gym® exercises on balance and risk of fall Environmental Research And Public Health, 2015,
in patients with diabetic neuropathy. International vol. 12, no. 7, pp. 8281–8294,.
Journal of Science & Healthcare Research. 2018; 13 Kawamura T, Umemura T, Hotta N. Cognitive
3(4): 257-262. impairment in diabetic patients: can diabetic control
5 Munshi MN. Cognitive dysfunction in older adults prevent cognitive decline?. Journal of Diabetes
with diabetes: what a clinician needs to know. Investigation. 2012 Oct;3(5):413-23.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 151

A Study on Antibiotic Utilization in Pediatric Hospitalized

Patients and Antibiotic Stewardship

Ratikanta Tripathy1, Shantadeepa Chopdar2, Nirmal Kumar Mohakud3, Suresh Chandra Pradhan4,
Prasanna Kumar Panda5
1AssociateProfessor , Dept. of Pharmacology, KIMS Hospital, Bhubaneswar, 2 M. Pharma (Pharmacology),
Bhubaneswar, University Dept. of Pharmaceutical Sciences, Utkal University, Bhubaneswar, 3Associate Professor,
4Professor, Dept. of Pharmacology, KIMS Hospital, Bhubaneswar, 5Professor, Pharmacology, University Dept. of

Pharmaceutical Sciences, Utkal University, Bhubaneswar

Abstract
Background: There is an increasing trend of use of antibiotics in pediatric ward/intensive care unit has
resulted in increasing health care costs and the emergence of resistant bacteria. Objective: We evaluated
the utilization of antibiotics in a pediatric teaching hospital aiming to identify targets for improvement of
prescription. Methods: Clinical, laboratory and treatment data of patients hospitalized in patient department
(IPD) and a pediatric intensive care unit (PICU) were prospectively collected during a 6-months period. A
subsequent review of the collected data by a pediatric infectious disease specialist, taking into consideration
existing in-house treatment guidelines, was carried out .Results: Most common age group receiving
antibiotics are between 1-5 years of age. Ceftriaxone alone and in combination with other antibiotics
was most commonly prescribed (71.4%). Average number of antibiotics per patient was 1.2 and 70% of
patients were on single antibiotic. Conclusion: The most cause of hospitalization in our set up is due to
gastrointestinal diseases and the antibiotics used frequently is ceftriaxone. It is high time for continuous
education of doctors on judicious antibiotic use and strict implementation of existing guidelines for it.
Improvement in the availability of rapid diagnostic methods to discern viral from bacterial infections may
help reduce the numbers of empiric therapies in favor of pathogen-targeted therapeutic treatments.

Key Words: Antimicrobials,Infections, Pediatrics, Stewardship,antibiotic utilization

Introduction common cold, upper respiratory tract infection and

surgical prophylaxis.1 Antibiotics are the most commonly
The goals of antimicrobials chemotherapy may
prescribed medicines in children with highest incidences
involve the time course events of infection. This may
found in preschoolers. It has been documented that the
be prophylactic, pre emptive, empiric, definitive or
prescribing doctors lack the knowledge about antibiotics
suppressive.1 The empirical therapy involves in giving
which leads to irrational prescribing and adds to the
antimicrobial agents without confirming infection with
medical expenses.2,3 However, hospitals are considered
evidence of the microorganism from the culture and
to be the centre of antimicrobial resistance owing to the
sensitivity. Standard medical treatment depends upon
higher use of broad-spectrum agents in both adults and
the accurate diagnosis and optimal use of antibiotics.
children 2.
Antimicrobials agents are potentially toxic and may
promote resistance in microorganism, very often, there According to the results of various antibiotic drug
agents are prescribed irrationally in conditions like utilization studies, 50% to 85% of children receive
antibiotics in developed and developing countries.4
In European countries and the United States, 23-
Corresponding Author:
38% of in-patients are given some kind of systemic
Nirmal Kumar Mohakud
antibiotic treatment. Antibiotics take the lead among
Associate Professor, Dept. of Paediatrics,
most commonly used drugs in Turkey and account for
KIMS Hospital, Bhubaneswar. 0674-2725228
 152 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

20% of the drug market.5 Unfortunately, 20-50% of StataCorp LLC). Descriptive statistics followed by cross
antibiotic treatment is used irrationally. In India the tabulation was employed to pro- vide the frequency and
sale of antibiotics is on the rise with 40-60% increase percentage distributions of the vari ables included in the
observed over last five years.6 The fact that one of study. The result was presented using tables, figures, and
the most important causes of acquiring antibiotic pie charts.
resistance is the lack of rational antibiotic use has been
reported in many studies and has taken its place in the Results
literature as evidence. Inappropriate use of antibiotics Figure 1 shows the use of antimicrobials in pediatric
leads to some undesired effects such as an increase in ward and PICU patients. A total of 133 patients were
mortality and morbidity, drug toxicity and interactions, selected in the study period rceived antibiotics during
extended periods of hospitalization, and an increase in their hospital stay. It shows that ceftriaxone alone and in
expenditures.7 This problem has been largely observed in combination with other antibiotics were most commonly
developing countries through inappropriate prescribing prescribed (71.4%) antibiotics. Piperacillin Tazobactum
habits, over interested desires to treat every infection & Cefpodoxime were prescribed in 9.8% of cases each.
children are mostly suffering from. The present study Ciprofloxacin (1.5% cases), Co-amoxyclav (3% cases)
was designed to determine the antimicrobial utilization were used in minimally.
pattern in a tertiary care hospital and to ascertain the
resulting treatment consequences in a selected pediatric
in patients and also intensive care unit.

Materials and Method

This work was a prospective, observational and
cross sectional study conducted in the department
of paediatrics in collaboration with department of
pharmacology, Kalinga Institute of Medical Sciences
(KIMS), Bhubaneswar, a tertiary care hospital of
Eastern Odisha, in the duration of March to August Figure no. 1 : Use of anti-microbials in pediatrics ward and
2018. This hospital is a 1750 bedded teaching and super pediatric intensive care unit (n= 133)
speciality hospital. In this study paediatric patients aged (+) denotes in combination with other anti-
1month-14 years admitted to IPD & PICU prescribed microbials.
with antibiotics were included.
Figure 2 shows the organ system involvement of the
All the consecutive cases those were eligible for pediatric patients. Gastrointestinal system is involved in
the study during the study period within 6 months was 27.8% of cases followed by 21% cases where systemic
taken into consideration. Institutional ethical committee infection prevailed. Less commonly involved systems
approval was obtained from hospital and parents given were respiratory (12.8%) and Cetral Nervous System
consent were included in the study. (11.8%). Skin was least commonly involved in 1.5 %
cases.
Properly designed form sheet was used for data
collection. It includes socio-demographic and clinical
characteristics of pediatric patients as well as patterns
of antimicrobial utilization during the study period. The
format includes degree of polypharmacy of all drugs
and antimicrobials in particular, dosage regimen, route
of administration, prevalence of single and combination
antimicrobials, and prevalence of disease states to which
antimicrobials were prescribed, among others.

The collected data were compiled, tabulated and

entered in Microsoft Excel 2014. The statistical analysis Figure. 2: Morbidity pattern of pediatric inpatients and
of data is done by STATA 15.1(College Station, TX: pediatric intensive care unit (n=133)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 153

As Shown in Figigure 3 maximum number of month.

children belong to 1-5 years age groups (45%) followed
by 6-10 years age groups in 23% of cases. Children less Table3: Distribution of duration of stay in
than 1 year age group and 11-14 years constitute the hospital
lowest (16%) among all cases.
Number of days No. of patient Percent (%)

1-7 94 70.67

8-15 25 18.79

16-30 8 6.01

≥31 6 4.51
Figure no.3 : Age distribution of patients
Table 1 shows distribution of patient in relation to Discussion
route of antibiotic administration. Maximum patients
Antibiotics are most commonly prescribed and
(82.7%) were administered intravenous antibiotics
effective drugs which are used to treat microbial
whereas only 4.5 % cases administered with oral
infections. The present study was conducted in the
antibiotics.
department of paediatric IPD (In-Patient Department)
Table 1 :Patient distribution regarding route of & PICU (Paediatric Intensive Care Unit), KIMS,
administration of antibiotic Bhubaneswar between March to August 2018. A total
number of 133 patients of 1mo -14 years were included
Route of Antibiotic comprising of 120 IPD and 13 PICU patients.. We
No. of patient compared the demographic profile of our patients with
administration
that of other studies done in pediatric population in
IV 110 (82.7%) regard to the antibiotic utilization.

Oral 06 (4.5%) The present study shows the percentage of female

patients (61.6%) was more than the male patients
Both 17 (12.8%) (38.4%), whereas other previous studies had shown the
males majority.8-11 This may be due to perceived male
Table 2 shows maximum patients (70%) received child bias has grasually changing in the society due to
antbiotic monotherapy, 27% cases received 2 antibiotics increase female lireracy and education. Also a study
and only 3% cases were on 3 or more number of by Laya et al had stated that the equal ratio of males
antibiotics. and females indicate the current trend equality of both
sexes.12
Table 2: Patient distribution regarding number
of antibiotics received As evident from this study , the maximum number of
paediatric patients belonged to the age group of 1-5 years
No. of Antibiotic No. of patient followed by the group of <1 year which were 45.11%
and 16.54% respectively.This may be due to immature
1 93 (70%) immunity system in the age group of 1-5 years, which
made them more prone to infections. Our finding was
2 36 (27%) similar compared to some other studies.8

≥3 04 (3%) In this study, most frequent clinical indication

for which antimicrobials were prescribed was gastro
Table 3 shows maximum no of patients i. e. 70.67% intestinal tract infection i.e. 27.82% followed by
were admitted in the hospital for 1-7 days. The duration systemic infection with fever 21.05% which was similar
of hospital stay was 8-15 days in 18.8 % cases. Only 4.5 to the study done by Shivaleela et. Al.8 Another study
% of children stayed in the hospital for more than one had shown that most frequent infection was respiratory
tract infections.12 As our study was conducted during the
 154 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

months of winter and summer season, GI tract infections to study of Shivaleela et. al and this was comparable to
were more prevalent. the study of Choudhury et. al (29%). 8,16. Out of 30% of
cases having more than 2 antibiotics only 3 % cases had
The study shows the use of antibiotics were three or more antibiotics were used. In present study,
accounting 22.32% of prescriptions in IPD and PICU. most common route of antibiotic administration was
A study conducted in Nagpur in 2008 which included found to be I.V route (82.7%) followed by oral route
paediatric outpatient prescription of 500 in a Bombay (4.5%). The same study done by Shivaleela et. al and
tertiary care hospital showed antibiotics constituted 79% Tadesse et. al.8,10 This study was conducted on admitted
per prescription.13 However a study done by Sunil Krande cases, so most common route of administration was I.V
et. al showed the use of antibiotic per prescription to be route.
39.6%.14 Its an indication that antibiotic stewardship
program in this institute has an impact on antibiotics According to our study, the mean duration of stay in
prescription. hospital was 9.5 which was nearby similar to the study
of Srivastava et.al (7.3) and Roy et. al (6.3) and also it
Table 4: Comparision of our study with other was compared to Gupta et. al (5.28) and Rasheed et.
studies in regards to number of drugs and antibiotics Al (4.5).17-20 It may be due to 14 patients who stayed
used for more than 20 days because of chronic illness like
tuberculosis, post encephalitis sequelae and cerebral
No. of antibiotics
Study No. of drugs used palsy leading to increase in hospital stay as compared
used
to other studies. But in majority (89%) of children had
Our study,2018 5.55±2.24 1.24±0.49 average duration of hospital stay was around 7 days.
Shivaleela et. al, Our study will be of help to develop evidence
4.26 2.13
2014
based medicine with high quality information in the
Gizework et. al, health care facilities. Further, standard treatment
1.70±0.93 1.45±0.59
2015
guidelines may be developed like in CMC Vellor for
Table 4 shows the average number of drugs antimicrobial uses in adults.21 Similar guidelines may be
prescribed per patients was 5.5 and average number developed to treat paediatric patients. This will minimize
of antibiotics prescribed per patients was 1.2. But the the off level use of medicines for pediatric use which is
studies showing result on average number of drugs and very wide spread in India.22 Research questions relevant
antibiotics as per patient was less from our studies.8,9 to India getting especially on antimicrobial resistant
The WHO recommends that the average number is lacking.Our study will be of help in evidence based
of drugs per prescription should be less than two.15 guidelines for making for treatment of pediatric patients.
In present study this number is more than two, so it
Limitations of the study:
indicates polypharmacy. The average number of drugs
per prescription value should be low as possible to This study was conducted for period of 6 month
prevent the unfavorable outcomes of polypharmacy such extending from March to August 2018. As the study
as increased risk of drug interactions, increased cost of was not conducted by full year as a result the seasonal
therapy, non-compliance and emergence of resistance variations in paediatric illness was not documented.
in case of use of antimicrobials. Since these patients
were treated in tertiary care hospital & some of them Conclusion
were critically ill, therefore number of drugs used was
The most cause of hospitalization in our set up is
more. On the other hand our study showed average no
due to gastrointestinal diseases and the antibiotics used
of antimicrobial was 1.2. Therfore rational antimicrobial
frequently is ceftriaxone. Efforts need to be undertaken
therapy has been followed in the studied institute.
towards continuous education of doctors on judicious
As per the study of Achalu et.al, 22.8 % cases antibiotic use, as well as ensuring compliance with
prescribed with single antibiotic, and two antibiotics existing guidelines. Improvement in the availability of
were prescribed in 51.5% cases.10 In our study the rapid diagnostic methods to discern viral from bacterial
single antibiotic was prescribed in 70% cases. Multiple infections may help reduce the numbers of empiric
antibiotics were prescribed in 28.6% patients according therapies in favor of pathogen-targeted therapeutic
treatments.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 155

Conflict of Interest – None 11. Mohakud NK, Mishra M, Tripathy R, Mishra

M. Incidence and risk factors for prolonged
Source of Funding- Self stay in children hospitalized with pneumonia.
Ethical Clearance – Yes Journal of Clinical and Diagnostic Research.
2018;12(8):SC12-SC14.
References 12. Rad LV, Alekhya M. Prescribing pattern of
antibiotics in pediatric inpatient department of
1. Tawanda G. General principles of antimicrobial
a tertiary care teaching hospital in Bangalore. J
therapy. In: Brunton LL, Hilal-Dandan R,
Pharm Bioall Sci.. 2015;10(4):26-32.
Knollman BC, editors. Goodman and Gilman’s The
pharmacological basis of therapeutics. New York: 13. Pandey AA, Thakre SB, Bhatkule PR. Prescription
Mc Graw Hill; 2018. p. -962. analysis of pediatric outpatient practice in Nagpur
city. Indian J Community Med. 2010;35(1):70-3.
2. Hamilton-Miller JM. Use and abuse of antibiotics.
Br J Clin Pharmacol. 1984;18(4): 469-74. 14. Karande S, Sankhe P, Kulkarni M. Patterns
of prescription and drug dispensing. Indian J
3. Kulkarni RA, Kochhar PH, Dargude VA,
Pediatr. 2005(Feb);72(2):117-21.
Rajadhyakshya SS, Thatte UM. Patterns of
antimicrobial use by surgeons in India. Indian J 15. How to investigate drug use in health facilities:
Surg. 2005;67:308-15. selected drug use indicators. Geneva: World Health
Organization; 2010:WHO/DAP/93.
4. Paluk E, Katzentein D, Frankish CJ, Herbert CP,
Miler R, Speert D et al. Prescription practices and 16. Choudhury DK, Bezbaruah BK. Antibiotic
attitudes toward giving children antibiotics. Can prescriptions pattern in paediatric in-patient
Fam Physician. 2001;47:521-7. department Guwahati medical college and hospital,
Guwahati. J Appl Pharm Sci. 2013;3(8):144-8.
5. Blondeau JM. Appropriate antibiotic use - past
lessons provide future directions. In: Low DE, 17. Srivastava R, Stone BL, Patel R, Swenson
editor. Appropriate Antibiotic Use. Worcester: The M, Davies A, Maloney CG et.al. Delays in
Royal Society of Medicine Press Limited; 2000. p. discharge in a tertiary care pediatric hospital. J
1-10. Hosp Med. 2009; 4(8):481-5.
6. Lawrence R, Jeyakumar E. Antimicrobial 18. Roy RN, Shrivastava P, Das DK, Saha I, Sarkar
resistance: A cause for global concern. BMC Proc. AP. Burden of hospitalized pediatric morbidity
2013;7(Suppl 3):S1. and utilization of beds in a tertiary care hospital
of Kolkata, India. Indian J Community Med.
7. Singhal H, Kaur K, Zammit C et al. Wound
2012;37(4):252-5.
infection. Emedicine.2008. (http://emedicine.
medscape.com/article/188988- overview). 19. Gupta SK, Sarmah BK, Tiwari D, Thapa S.
Pattern of pediatric admissions in a tertiary
8. Shivaleela D, Jagadeesh DK, Vedavathi D,
care hospital of central Nepal. J Nepal Med
Chidanand D. A study of prescription pattern
Assoc. 2015;53(198):118-22.
of antibiotics in pediatric in-patients of Mcgann
teaching hospital Shivamogga institute of medical 20. Rasheed J, Wakeel N, Aleem T, Khalid M, Zafar
sciences (SIMS), Shivamogga, Karnataka. IOSR- F. Pattern and outcome of pediatric admissions
Journal of Dental and Medical Sciences (IOSR- in a tertiary care hospital Multan. Pak Paed J.
JDMS). 2014(Dec);13(12):67-71. 2017;41:168-173.
9. Alemnew G, Atnafe SA. Assessment of the pattern 21. Antibiotic guidelines for adults. Hospital
of antibiotics use in pediatrics ward of Dessie infection control committee, Christians Medical
Referral Hospital, North East Ethiopia. Int J Med College,Vellor; 2018.
Sci. 2015(Jan);7(11):1-7. 22. Koli PG, Kshirsagar NA, Shetty YC, Mehta
10. Achalu TS, Yimam B, Kebede TM. Antibiotics D, Mittal Y, Parmar U. A systematic review of
utilization pattern in pediatric ward: the case from standard treatment guidelines in India. Ind J Med
tertiary teaching hospital, South west Ethiopia. Int Res. 2019;149(6):715-29.
J Curr Res Med Sci. 2015;2(9):54-61.
 156 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Understanding the Basics of Research as a Beginner: A

Highlighter

Ravishankar M.V,1 Vidya C.S. 2

1Assistant Professor, 2Associate Professor Dept. of Anatomy JSS Medical College JSS Academy of Higher
Education & Research, Mysuru

Abstract
Research has grown beyond leaps and bounds; scientific progress solely depends on inquisitiveness and
tireless coordination of teamwork. The word research is so attractive for a beginner, the student fraternity is
overwhelmed about this process. Irrespective of any field, now the research is becoming an indispensable
part of the educational system. This article is intended to create basic awareness about research and its
components, especially for the research-oriented students in the field of medical, paramedical, allied health
sciences, etc.

Key words: Research, bioethics, clinical trials, good clinical practice

Introduction medications for several human ailments for thousands of

years. Based on its principles, Ayurveda has mentioned
Biomedical research is based on fundamental
therapeutic interventions, and a number of herbs and
biological scientific principles, which will focus on
mineral formulations applied directly to the human
personal healthcare and public health. Basic research is
subjects with the sole purpose of alleviating human
also called as bench side research; it deals with in-vitro
sufferings2,3.
and in vivo experimental models involving the organisms
or animals to obtain a valid outcome to further try on Classification of type of study:
the humans. When the basic research results are tried on
clinical patients it is called translational research, which Basic research: the basic medical research deals
is solely intended to trial the results of basic research with understanding the functional, cellular or molecular
from bench side to bedside, clinically by using patients mechanisms in primates through in vivo or invitro
virtually1. studies.

Research is practiced by humans since the time of Preclinical research: preclinical research deals with
evolution on earth. In history, the ancient practice of the study on humans, which further supports the clinical
folklore medicine stands as the best example for the trials on patients.
oldest model for clinical research; with the time it has
Clinical research: it is conducted on patients in the
gradually evolved through trial and error method. India
hospital or on the selected population; it is supervised by
is at the forefront of contributing to the field of clinical
physicians.
research; medical science like Ayurveda, Siddha,
Unani; their medical literature has mentioned the use of What is the research question...?

It is the main inquiry of the issue which needs to

Corresponding author: be addressed through research. The research question
Dr. Vidya C.S should be clear, targeted and simple.
Associate Professor, Department of Anatomy
JSS Medical College, JSS Academy of Higher What is a pilot study...?
Education & Research, Mysuru-570015
It is the study performed on a small scale by
Mob: 9449679386, E-mail: [email protected]
using a minimum number of participants/subjects.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 157

This study gives every opportunity to the researcher/ basic research experiments on animals; because in
investigator to understand all aspects of the main study history, we have learned about the adverse effects of
including its feasibility, sample size, time duration, drugs that were used directly on patients. Causing harm
troubleshooters, etc. to the animals can’t justify the human benefit. But still,
animal-based research outcome retains its importance in
What are the study parameters...? several aspects including, toxicological studies, where
Parameters are study exponents in the research; the animal experiment model stands as an inevitable tool
which are later subjected to analysis. in supporting the increasing hierarchy of evidence.

Bioethics In the present situation to justify the rationality and

inevitability of the use of animals in the experiments we
Bioethics deals with the study of ethical dimensions need to follow principles of 4R.
of medicine and biological sciences.
Replacement: Use of alternate to animal model Ex:
Important principles of bioethics are including in silico i.e. use of computer modeling, in vitro cell line
Autonomy (respect to self-governing), Beneficence studies, etc.
(best interest of the subject), Non-maleficence (causing
no harm) and Justice (fair treatment)4 Reduction: Method which minimizes the number of
animals in experiments
Basic research in non-human primates:
Refinement: It deals with the reduced invasiveness,
Research on non-human primates is a by adopting improved, non-invasive, non-painful
prerequisite for conducting trials on subsequent procedures by using the most appropriate methods6.
levels. Animal experiments mean, the use of animals
preferably mammals in the experiments for education and Rehabilitation: As a 4th component, the
research. The basic experiments use nonhuman primates rehabilitation of animals will be done after its justified
like rats, mice, rabbits, hamsters, guinea pig, monkey, usage6.
chimpanzee, dog. It can also be done by using fruit flies, Toxicity study: it is a branch of science deals with
cell lines, fish, etc. There are millions of animals that will the toxins and poisons and their effect and treatment.
be sacrificed worldwide for the sake of research every As per US food and drug administration (FDA), for
year. Experiments performed by using both vertebrates the development of a new drug entity, it is essential to
and non-vertebrates, but using the vertebrates will be conduct toxicity tests in the biological subjects7.
taken into account as they are under more strict ethical
vigilance. For research, all these animals should be Trials before regulations
procured from the authorized breeders who are registered
under CPCSEA (committee for control and supervision In the olden days, before formulating guidelines for
of experiments on the animal) guidelines or from the clinical research activities, any individual or group of
recognized higher research centres. people would be a part of the research event; it was tried
on the helpless community like war prisoners or people
Importance of animal testing in biomedical who convicted under crime, children, patients, aged
research people, etc. The direct use of drugs like thalidomide
and Elixir Sulfanilamide on humans has resulted in
In the field of biomedical research, the use of the the death of the study participants. Based on such
animal model experiments stands as “Hall Mark” of an consequences of unethical trials on humans, the present
interventional research study. The great scientists like era has formulated a code that is mainly focused on
Aristotle, Erasistratus Galen, etc. have tried their initial obtaining voluntary consent. By considering the above
experiments on the animals for scientific purposes5. discrimination in the clinical research, a judgment
Age back, the use of animals got much attention, formulated with a code known as “Nuremberg code”
particularly to test the surgical procedures or use of which has streamlined the research at all levels with
drugs or devises before applying them clinically to the sole intention to protect the safety and dignity of the
humans. In spite of heavy criticism by the public and participants to achieve more precise and valid outcome8.
the animal protection activists there is a rise in several
 158 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

History of Clinical trials Role of statistics in research

The credit of clinical research goes to a Scottish Since the time of conception of the research
physician Dr. James Lind, M.D. (1716–1794) has treated protocol, the statistics play an important role to format
the disorder called scurvy in sailors, where patients were different components of research like study design,
presented with the sign of bleeding through their gums. conduct, sample size, data analysis, reporting, etc. they
He has noticed that the administration of the orange are essential to derive a valid and precise conclusion.
and lemon has shown drastic improvement in their
condition9. What is the placebo effect...?

Regulations of clinical trials: Placebo is an inert substance without any therapeutic

value; it is used to compare with standard control
Good Clinical Practice (GCP): It is an international groups. The psychosomatic profile is an important
ethical and scientific standard protocol for conducting factor to be considered in assessing the placebo drug
biomedical and behavioral research involving human response. The placebo effect can be better appreciated in
participants; which protects participants’ safety, rights the alleviation of symptoms of the pain rather than any
and confidentiality at all levels10. other condition15.

International Conference on Harmonization Clinical trials

(ICH): It is an international council that bringing together
the regulatory authorities and pharmaceutical industry to Clinical trials are research study on human subjects,
discuss the technical aspects of drug registration. ICH’s which is intended to evaluate the effect of biomedical
regulations are intended to achieve greater harmony interventions like vaccines, drugs, treatments, devices,
worldwide to ensure safety, effectiveness, and quality new ways of using known drugs or to study drug
of medicines; which are developed and registered in a interactions, etc. The study may also include the
hassle-free manner11. evaluation of behavioral interventions16.

Institutional Ethics Committee (IEC): It plays a The ultimate goal of CT is to ascertain the drug
role in appointing members; it will review the protocol safety of the subject, risk and benefit ratio before its
and informed consent forms (ICF), and periodic final approval for marketing. There are many factors
progress of the study12 involved in research, out of which some are can be
controlled, and some others are beyond one’s control.
World medical declaration of Helsinki: It is Randomization means being nonselective to any
developed by the World Medical Association (WMA) application or intervention. Randomization in clinical
in the year 1964; it is including ethical guidance for trials is considered as the basis for the “Evidence-based
physicians and all other participants in the research team Medicine”17.
involving in clinical trials on human subjects. This rule
binds all the research participants to the applicable law Blind experiments
under its declaration13 Bias is the main concern of the clinical trials where
Role of the investigator: all trial investigations blinding becomes essential to reduce the bias and increase
are conducted by qualified and trained persons who are the validity of the outcome. Blinding is a process
personally supervising the work. where one or the other participants in the study were
deliberately kept unaware of intervention. Blinding
Sponsor for trials: is an important factor to ensure objectivity in the
clinical trial by avoiding or preventing the conscious
The sponsor for a clinical trial may include an and unconscious bias in the study18.
individual, an industry, an institution, etc. which takes
the responsibility of initiation, management, financing, Types of blind trials:
and auditing. They are also taking the responsibility
of subjecting the study participants under sufficient Open clinical trials: it is the trial where all the
insurance coverage, and compensating the subjects in level of study participants in the research group will
any untoward incidence or reactions14. be knowing the intervention.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 159

Single-blind study: where the subject alone in the Phase 0: It is an Exploratory Investigational New
research study is unaware of intervention. Drug (IND) Study. It will be conducted first on humans;
it is also known as human micro-dosing studies by using
Double-blind study: where the subject, as well as the sub-therapeutic dose. It is conducted by using 10-
the researcher both, are unaware of the intervention 15 numbers of limited volunteer healthy human subjects
Triple-blind study: where the subject, researcher, to understand the pharmacokinetics, pharmacodynamic
and analyser are unaware of intervention. activity, and safety of a new drug or a molecule.

At the end of the study result analysis, all masked Phase I or Clinical pharmacology trial: It is also
or blinded interventions will be disclosed. called “First in Man”, done in small groups with 20-
100 in number in healthy volunteers. It is to assess
Protection of subjects safety through pharmacovigilance and the details of
the pharmacokinetic and pharmacodynamic effects of
The protection of the clinical trial participants at a drug. Dose escalation trial can give an idea about the
all levels is an important issue. Concerned authorities appropriate maximum tolerable dose which can be used
should take care of all necessary precautions to address under subsequent trials.
personal, social and legal issues during and after
completion of trials. Any relevant issues should be Phase II or Exploratory Trial; the third phase
addressed, and it should be properly compensated for of the clinical trial can be done in 200-300 number of
the loss. It is essential to ensure proper compensation for larger healthy human volunteers. It is done in Phase I
all the study participants who are involved in the clinical A is to assess the clinical efficacy or biological activity,
trials. and Phase II B is to assess and match the optimum dose,
benefit with minimum side effects
Importance of Informed Consent (IC)
Phase III trial or Confirmatory trial: It is a
Clinical trial participants are strictly volunteer in its randomized control multicentric trials in a large number
true sense without coercing them for any benefit. of volunteer patients in a group of 300-3000 or more.
Informed consent is an important prerequisite Such trials are more expensive, time-consuming and
before allocating any human subject to the clinical trials. difficult to handle, especially while dealing with chronic
Privacy and confidentially of IC should be maintained disease conditions or disease with a long latency/
in all the circumstances. It is very much essential to incubation period.
know whether the subject is a literate or illiterate, or Phase IV or Post-marketing surveillance:
whether he is fit to give valid consent. The investigator Called post-marketing surveillance trial. It involves a
should explain and clarify all the doubts of participants pharmacovigilance study after receiving permission to
regarding the research protocol before taking consent19. market an approved drug. If the drug/treatment is found
Types of clinical trials satisfactory in three phases, then it will be approved
under the country’s national regulatory authority for
Screening trial: screening for the possibility of its use in the general population. Phase IV trials are
occurrence of diseases in a healthy population invariably always under the research radar. 20,21

Prevention trail: it deals with the prevention of Multicentric clinical trials

disease by using supplements, vaccines, devices, lifestyle
modifications, etc. It includes a large number of participants from
different parts of the world, including a wide range of
Diagnostic trail: it deals with the accuracy of the populations; which will compare the results of different
disease centers.

Treatment trail: it deals with the effectiveness of Accessibility of clinical trial reports
treatment in diseased
Accessing clinical trial data or information is an
Conventionally the CT is having the following important prerequisite to tackle the challenges before
phases: considering them under policymaking. Archiving the
 160 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

clinical trial documents is a must, which helps to analyze Code 70 Years Later. JAMA. 2017;318(9):795-
the data retrospectively in a systematic manner. Now 796.
online updates are available on the registered websites 9. Trohler U,James Lind and scurvy. JLL Bulletin:
which are developed at the national institute of health Commentaries on the history of treatment evaluation
under the national library of medicine. CT information Available from https://www.jameslindlibrary.org/
is always accessible to any common man, through articles/james-lind-and-scurvy-1747-to-1795/.
website clinicaltrials.gov and also through Cochrane
10. Guideline for Good Clinical Practice –ICH
Library, it is a collection of databases in medicine and
Available from URL:https://www.ich.org ›
other healthcare specialities22,23. The ultimate goal
fileadmin › Guidelines › Efficacy › E6_R1_
of accessing the clinical trial results is to introduce
Guideline.
newer government policies and regulations to provide
improvised health care facilities for the benefit of the 11. Guideline for Good Clinical Practice – ICH https://
population at large. www.ich.org › Guidelines › Efficacy › E6 › E6_R1_
Guideline.
Conclusion 12. Central Drugs Standard Control Organization,
Directorate General of Health Services, India.
For a beginner, the present review will highlight the
Good Clinical Practices for Clinical Research in
components of basic research, preclinical and clinical
India. Available from: http://cdsco.nic.in/html/
research. It has created basic awareness about the ethical
gcp1.html .
factors involved in the research at different levels.
13. Declaration of Helsinki - World Health Organization
Ethical Clearance: Obtained from Institution Available from: https://www.who.int › bulletin ›
ethical committee archives by World Medical Association.

Conflict-of-Interest: Nil 14. Indian GCP Guidelines. 2004. Available

from: http://www.cdsco.nic.in/html/GCP1.html
Source of Funding: Self funding 15. Colloca L, Benedetti F. Placebos and
painkillers: Is mind as real as matter? Nature
References Reviews. Neuroscience. 2005;6(7):545–552.
1. Translational science spectrum. Available from: 16. “Clinical Trials”. Bill and Melinda Gates
https://ncats.nih.gov › files › translation-factsheet Foundation. Available from: https://docs.
2. Prasad LV. In: Indian System of Medicine and gatesfoundation.org › documents › clinical_trials
Homoeopathy Traditional Medicine in Asia. Roy 17. DH Au, Castro M and Krishnan J A. Selection
C R, Muchatar R U, Editors. New Delhi: WHO- of Controls in Clinical Trials:Introduction and
Regional Office for south-east Asia; 2002: 283– Conference Summary. Proc Am Thorac Soc Vol 4.
286. 2007; 567–569.
3. Ravishankar, Bplaysand Shukla, V.J. Indian 18. Kao LS, Aaron BC, Dellinger EP. Trials and
systems of medicine: A brief profile. Afr J Tradit tribulations: Current challenges in conducting
Complement Altern Med. 2007 Feb16;4(3):319-37 clinical trials. Arch Surg. 2003 Jan; 138(1):59-62.
4. Beauchamp TL, Childress JF. Principles of 19. ICMR Ethical Guidelines for Biomedical Research.
Biomedical Ethics. 5th ed. Oxford: Oxford Available from: www.cns.iisc.ac.in › wordpress ›
University; 2001. wp-content › uploads › 2017/01 › ethical.
5. Rachel Hajar MD . Animal testing in medicine. 20. Kumar S, Rubinstein L, Kinders R, Parchment
Heart Views. 2011; 12(1): 42. RE, Gutierrez ME, Murgo AJ, et al. Phase 0 clinical
6. Mandal J , Parij S C. Ethics of involving animals in trials: conceptions and misconceptions. Cancer
research. Trop Parasitol. 2013; 3(1): 4–6. J. 2008;14(3):133-7.
7. The Drug Development Process. Available from: 21. Thorat S B, Banarjee S K, Gaikwad D D, Jadhav S
https://www.fda.gov ›For Patients › Approvals › L, Thorat R M. Clinical trial: a review. International
Drugs › ucm405382 . Journal of Pharmaceutical Sciences Review and
8. Moreno J D, Schmidt U, Joffe S, MD, The Nuremberg Research. 2010: 1 (2):101-106.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 161

22. Clinical Trials.gov - National Library of Medicine 23. Deborah H. Charbonneau. The Cochrane Library. J
– NIH. Available from: https://www.nlm.nih.gov › Med Libr Assoc. 2005; 93(3): 409–410.
archive › news › press_releases › clntrlpr00.
 162 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Food Insecurity, Standard of Living and Nutritional Status

of People Living with Hiv/Aids (Plhas) on Art : Rural–Urban
Differences

Ravishekar N Hiremath1, Shailaja S Patil2, DB Kadam3

1
PhD Student, Department of Community Medicine, BLDEA’s Shri BM Patil Medical College, Bijapur,
Karnataka, India, 2Professor and Head, Department of Community Medicine, BLDEA’s Shri BM Patil Medical
College, Bijapur, Karnataka, India, 3Professor and Head (Retd), Department of Medicine, BJ Medical
College, Pune, Maharashtra, India

Abstract

Background: Synergistic effect of malnutrition, food insecurity and poor standard of living pour significant
changes and poor outcome in already compromised PLHAs due to increased financial burden as well as
emotional breakdown.

Objective: To assess the nutritional status , food insecurity and standard of living (SLI) with rural urban
differences and their association if any among the PLHAs who have been stablished with one year of
treatment

Methodology: A facility based cross-sectional study on PLHAs was carried out in tertiary care centre of
western Maharashtra with a sample size of 246. Data was collected by means of pretested semi structured
questionnaire after taking Institutional clearance. Strict confidentiality was maintained throughout the study.

Results: The mean age of the study participants was 43.37 years with majority (50.9% rural, 39% Urban)
were secondary class educated. Only 20% of urban and 8.5% of rural had income above 10,000 per month.
Maximum (48.2 %) of rural were doing heavy works (construction/agricultural) while majority of urban
were unemployed (30.5%) followed by business (21%) work. 36.9% (Rural) and 28.6 % (Urban) had spouse
positive for HIV status. Even after one year of treatment, only 36.9% rural and 41% urban PLHAs were
having CD4 count above 500. 49.6% (Rural) and 46.7% (Urban) were food insecure while 27.7% (Rural)
and 14.3% (Urban) had low standard of living. 36.2% (Rural) and 30.5% (Urban) were undernutrition with
51.8% (Rural) and 54.3% (Urban) having abnormal waist circumference. BMI Category had statistically
significant association with SLI and food insecurity in urban participants while it was not statistically
associated with rural participants

Conclusions: Inspite of freely delivered ART for one year and majority having good adherence rate, there
were actionable changes in nutritional changes among PLHAs of both rural and urban areas. Neglected
factors like food insecurity and standard of living needs to given special focus to affectively crub the high
incidence of undernutrition among them. Immediate long term measures need to be taken to provide them
adequate food and basic amenities of life with secure Job status.

Key Words: HIV, Nutritional status, food insecurity, standard of living

Introduction
Corresponding Author:
Ravishekar N Hiremath, Department of Community HIV/AIDS is modern day epidemic with estimated
Medicine, BLDEA’s Shri BM Patil Medical College, total of 36.7 million people living with HIV/AIDS
Bijapur, Karnataka, India. (PLHAs) globally1 and 21.17 lakhs Nationally2. With
E-mail: [email protected] sustained international focus and recent scientific
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 163

advancement, measures are been taken to curtail the Standard of living (SLI) as per previous studies7,8,9, the
epidemic. In this view, Global strategy has been adopted sample size was calculated as 246. Adult PLHAs who
to end the AIDS epidemic by 2030 with zero new HIV came for collecting the medicines, after completion of
infections, HIV related deaths and discrimination and one year of treatment and consented to be part of the
making people live longer healthier life3. study were included in the study based on systematic
random selection. PLHAs with permanent residence
With the latest WHO and NACO policy of starting were taken for the study while migratory PLHAs with
the Anti-Retroviral treatment (ART) at the diagnosis opportunistic infections, HIV wasting syndrome and
level, will go a long run in making PLHAs lead a happy those who didn’t consent for the study were excluded.
comfortable life similar to any lifestyle disorders like Institutional clearance was obtained, Informed consent
diabetes and hypertension. However there are various was taken from all study participants as per format and
other factors which would determine how well PLHAs strict confidentiality was maintained throughout the
lead their life and maintain their clinical stability. study
Important among them are socio-economic conditions
and nutritional status which form the pillars for ART Data Collection
accessibility, adherence, action and disease stability per
se. Data was collected by means of pretested semi
structured questionnaire which included basic
Nutritional status depends on various factors such demographic profile along with anthropometric
as food insecurity, standard of living, income status, measurements, clinical parameters, food insecurity
awareness level, diet-drug interaction, loss of weight scale10 and parameters assessing household status using
due to opportunistic infections and disease per se4. standard of living scale11. Urban/rural status, Standard
of living, food insecurity and nutritional status were the
Synergistic effect of malnutrition, food insecurity main variables in the study. Data was entered in excel
and poor standard of living pour significant changes sheet and was analyzed using stata version 10 and rural
and poor outcome in already compromised household urban differences among various variables was studied.
conditions due to increased financial burden as well as
emotional breakdown. With this even a minor amount Standard of living (SLI) index was defined in terms
of weight loss would result in significant morbidity of ownership of household goods (as per the NFHS-
and decreased survival rate among PLHAs5. It is also 2 survey principals11) by adding the nine components
hypothesized that rural people maybe incurring higher (Table 1). Out of total score of 9, household with 1-3
impact due to these as compared to urban PLHAs due to marks were labelled as low SLI, 4 to 6 scores as medium
lack of resources, income generation and facilities hinting SLI and 7 to 9 scores were labelled as high SLI. All
the need for a study these differences. Undernutrition is households were categorized into food secure and Food
thus one the significant factor for increased morbidity insecure by means of WHO Household food insecurity
and mortatality among PLHAs inspite of ART and access scale (HFIAS) Measurement Tool10. Nutritional
highlight the importance of measures to be taken to status was categorized into underweight, Normal and
improve nutrition including food security and standard overweight based on WHO BMI (Body mass Index)
of living in addition of free ART availability6. classification for Asians

In view of above, this study was carried out among Results

the PLHAs who have been stablished with one year of
treatment with the objective to assess the nutritional The mean age of the study participants was 43.37
status , food insecurity and standard of living (SLI) with years with majority (50.9% rural, 39% Urban) were
rural urban differences and their association if any secondary class educated. 22.9% of urban and 8.5% of
rural were college and above educated. 20% of urban
Methodology and only 8.5% of rural had income above 10,000 per
month. Maximum (48.2 %) of rural were doing heavy
A facility based cross-sectional study on people works (construction/agricultural) while majority of
living with HIV/AIDS was carried out in tertiary urban were unemployed (30.5%) followed by business
care centre of western Maharashtra. Considering the (21%) work. 36.9% (Rural) and 28.6 % (Urban) had
prevalence of food insecurity, undernutrition and spouse positive for HIV status. 51.1% (rural) and 41%
 164 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

(urban) were female

Table 1 : Household Characteristics of study participants

RURAL URBAN
Accommodation Frequency Percent Frequency Percent
Own 93 66.0% 66 62.9%
Rent 48 34.0% 39 37.1%
Fuel Frequency Percent Frequency Percent
Charcoal 5 3.5% 0 0.0%
Gas 134 95.0% 99 94.3%
Kerosene 1 0.7% 6 5.7%
Nil 1 0.7% 0 0.0%
House type Frequency Percent Frequency Percent
Kuchha 15 10.6% 7 6.7%
Pucca 107 75.9% 77 73.3%
Semi-Pucca 19 13.5% 21 20.0%
Latrine Frequency Percent Frequency Percent
Open 6 4.3% 3 2.9%
Own 91 64.5% 72 68.6%
Public 44 31.2% 30 28.6%
Light Frequency Percent Frequency Percent
Electricity 141 100.0% 105 100.0%
Persons per room Frequency Percent Frequency Percent
<=2 persons 18 12.8% 23 21.9%
3 – 5 persons 79 56.0% 57 54.3%
> 5 persons 44 31.2% 25 23.8%
Property (Land) Frequency Percent Frequency Percent
No 106 75.2% 72 68.6%
Yes 35 24.8% 33 31.4%
Source of drinking water Frequency Percent Frequency Percent
Pipe 102 72.3% 94 89.5%
Public 9 6.4% 8 7.6%
Pump 13 9.2% 3 2.9%
Tanker 1 0.7% 0 0.0%
Well 16 11.3% 0 0.0%
Water processing Frequency Percent Frequency Percent
Aquaguard 0 0.0% 1 1.0%
Boil 8 5.7% 4 3.8%
Filter 26 18.4% 17 16.2%
Nil 107 75.9% 83 79.0%
Total 141 100.0% 105 100.0%
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 165

Table 2 : ART and CD4 Characteristics of study participants

RURAL URBAN

Adherence Frequency Percent Frequency Percent

< 90% 3 2.1% 4 3.8%

> 90% 138 97.9% 101 96.2%

Total 141 100.0% 105 100.0%

ART initiation Frequency Percent Frequency Percent

At the time of detection 126 89.4% 97 92.4%

< 2 years of detection 2 1.4% 1 1.0%

2- 5 years of detection 8 5.7% 3 2.9%

> 5 years of detection 5 3.5% 4 3.8%

Total 141 100.0% 105 100.0%

CD4 Counts Frequency Percent Frequency Percent

<=500 89 63.1% 62 59.0%

> 500 52 36.9% 43 41.0%

Total 141 100.0% 105 100.0%

Fig 1 : Nutritional status of PLHAs of study participants

166 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Fig 2: Food insecurity status of study participants

Fig 3: Standard of living status of study participants

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 167

Table 3 : Association of Nutritional status and standard of living of study participants

SLI - RURAL SLI - URBAN

BMI Category
Low Mid High Total P-value 1 2 3 Total P-value

Undernutrtion 18 28 5 51 10 20 2 32
Row % 35.3 54.9 9.8 100.0 31.3 62.5 6.3 100.0
Col % 46.2 32.9 29.4 36.2 66.7 27.0 12.5 30.5

Normal 12 28 8 48 2 28 9 39
Row % 25.0 58.3 16.7 100.0 0.422 5.1 71.8 23.1 100.0
Col % 30.8 32.9 47.1 34.0 13.3 37.8 56.3 37.1 0.010

Overweight/Obese 9 29 4 42 3 26 5 34
Row % 21.4 69.0 9.5 100.0 8.8 76.5 14.7 100.0
Col % 23.1 34.1 23.5 29.8 20.0 35.1 31.3 32.4

TOTAL 39 85 17 141 15 74 16 105

Row % 27.7 60.3 12.1 100.0 14.3 70.5 15.2 100.0
Col % 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Table 4 : Association of Nutritional status and food insecurity of study participants

Food Insecurity - Rural Food Insecurity - Urban

BMI Category Insecure Secure Total P-value Insecure Secure Total P-value

Undernutrtion 21 30 51 10 22 32
Row % 41.2 58.8 100.0 31.3 68.8 100.0
Col % 30.0 42.3 36.2 20.4 39.3 30.5

Normal 30 18 48 15 24 39
Row % 62.5 37.5 100.0 38.5 61.5 100.0
Col % 42.9 25.4 34.0 30.6 42.9 37.1

0.0836
0.0026
Overweight/Obese 19 23 42 24 10 34
Row % 45.2 54.8 100.0 70.6 29.4 100.0
Col % 27.1 32.4 29.8 49.0 17.9 32.4

TOTAL 70 71 141 49 56 105

Row % 49.6 50.4 100.0 46.7 53.3 100.0
Col % 100.0 100.0 100.0 100.0 100.0 100.0

ART adherence was above 90% (as per pill count) among 89.9% rural and 96.2% urban. Majority (92.4% urban,
 168 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

89.4% rural) had started their ART at the time of detection. rural and 53.3% of urban were food secure. The higher
Even after one year of treatment, only 36.9% rural and percentage of undernutrition in rural (36.2%) and urban
41% urban PLHAs were having CD4 count above 500. (30.5%) areas inspite of one year of free ART probably
49.6% (Rural) and 46.7% (Urban) were food insecure hints at higher level of food insecurity (Urban – 49.6%,
(Fig 2) while 27.7% (Rural) and 14.3% (Urban) had Urban-46.7%) among them. In our study, BMI had
low standard of living (Fig 3). 36.2% (Rural) and 30.5% statistically significant association with food insecurity
(Urban) were undernutrition with 51.8% (Rural) and among Urban PLHAs only but not the rural ones
54.3% (Urban) having abnormal waist circumference.
BMI Category had statistically significant association Dasgupta P et al13 in a study in Darjeeling, India
with SLI and food insecurity in urban participants while showed that 50.9% of the PLHAs were food insecure.
it was not statistically associated with rural participants Higher education, higher standard of living and males
has statistically significantly associated with high food
Discussion security while poor morbidity status, more people with
HIV positive status in family were associated with high
Nutritional status has multidimensional effect on food insecurity. PLHAs used to take loans , burrow
HIV disease progression. It hampers immune system, money from family, friends and banks to cope up with
thereby increase the frequency, severity, duration and financial hardship.
complications of infections, the symptoms of which lead
to increase weight loss and thereby starts the viscous Gebremichael DY et al5 conducted a study in
cycle. In our study, in rural areas, majority (36.2%) were Central Ethiopia showed that 23.6% of PLHAs were
undernutrition while in urban areas majority (37.1 %) malnutrition, 35.2% were food insecure. Important
had normal BMI followed by 32.4% obese/overweight factors which led to malnutrition were no job, clinical
and 30.5% being undernutrition. The higher number of morbidity, low CD4 counts and opportunistic infections
undernutrition in rural areas may be due to most PLHAs and importantly the food insecurity similar to our study.
in rural areas had income less than 5000 (77.3%) than Similar findings were also seen in a study carried out by
urban areas (42.8%) and majority were doing Heavy Thapa R et al14 in Nepal where in one out of five PLHAs
(construction/agriculture) job getting less pay and more were undernourished and important contributing factors
energy expenditure. To co-relate undernutrtion, majority being low literacy, low CD4 counts, home care, clinical
(63.1%) of rural had CD4 count less than 500, even after morbidity and opportunistic infections. The study also
ART of one year. assessed the Quality of life domains among the PLHAs
and found to be statistically significant association with
In a study carried out in Iran by Hamzeh B et al12, Body mass Index.
mean BMI of PLHAs men and women was 22.12 and
25.54 KG/m2. Although the malnutrition was seen in Water sources, water processing technique, sanitary
42.2 % but undernutrtion was seen only in 11.08% and facilities, overcrowding and house type which determine
rest were obese/overweight. Majority of undernurtion the standard of living have an important influence on
was seen in men and married PLHAs and main reason the health of household members, especially PLHAs.
was low consumption of diet as compared to standard In our study, only 12.1% rural and 15.2% urban were
recommendations. In the contrary, in our study, the having high standard of living while majority (Rural –
undernutrtion was quite high (36.2% Rural and 30.5% 60.3%, Urban -70.5%) were having middle SLI. As per
Urban) with low CD4 counts (less than 500) inspite NHFS 2 survey11, Standard of living index was low in
majority of them had 90% ART adherence for one year, 24.1 % of Urban and 61.7% rural households with Bihar
(57%) being highest in low SLI where as in our study on
While another study carried out by Anand D et al7 PLHAs households - 27.7% rural and 14.3% urban had
in India showed mean BMI of PLHAs was 19.73 KG/m2 low SLI which had influence on nutritional status. We
with 40 % undernutrtion among PLHAs which was much couldn’t find any other studies comparing the standard
higher as compared to our study among both rural and of living among rural and urban PLHAs
urban PLHAs and major reason was poor consumption
of diet (both quantity and quality). Conclusions
Food insecurity being an important marker for Inspite of freely delivered ART for one year
malnutrition even in PLHAs. In our study only 50.4% of and majority having good adherence rate, there were
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 169

actionable changes in nutritional changes among PLHAs (7). Anand D, Puri S. Anthropometric and nutritional
of both rural and urban areas. With freely available ART, profile of people living with HIV and AIDS in
the neglected factors like food insecurity and standard of India: an assessment. Indian J Community Med
living needs to given special focus among both Urban 2014;39:161-8
and rural areas to affectively crub the high incidence (8). Osei-Yeboah J, Owiredu WKBA, Norgbe GK
of undernutrition among them. Immediate long term et al.Quality of Life of People Living with HIV/
measures need to be taken to provide them adequate AIDS in the Ho Municipality, Ghana: A Cross-
food and basic amenities of life with secure Job status. Sectional Study. AIDS Research and Treatment.
2017.
Conflict of Interest – Nil
(9). Tesfaye M, Kaestel P, Olsen MF et al. Food
Source of Funding- Self insecurity, mental health and quality of life among
people living with HIV commencing antiretroviral
Ethical Clearance – Taken
treatment in Ethiopia: a cross-sectional study.
Health and Quality of Life Outcomes. 2016; 14
References
(10). Coates J. Swindale A, Bilinsky P. Household
(1) Global HIV & AIDS statistics - 2019 fact Food Insecurity Access Scale (HFIAS) for
sheet. Available at https://www.unaids.org /en/ Measurement of Food Access: 2007. Available
resources/fact-sheet. Accessed on 15 Aug 2019 at http://www.fao.org/fileadmin /user_upload /
(2) NACO report 2016-17. Available at http://naco. eufao-fsi4dm/doc-training/hfias.pdf. Accessed on
gov.in/sites/default /files/NACO% 20ANNUAL 15 Aug 2019
%20REPORT %20 2016-17.pdf. Accessed on 15 (11). National Family Health Survey (NFHS-3) 2005–
Aug 2019 06 INDIA. 2007. Available at http://rchiips.
(3) WHO. Global health sector strategy org/NFHS/NFHS-3%20Data/VOL-1/India_
on HIV 2016–2021 towards ending volume_I_corrected_17oct08.pdf. Accessed on
AIDS. Available at https://apps.who. 15 Aug 2019
int/iris/bitstream/handle/10665/246178/ (12) Hamzeh B, Pasdar Y, Darbandi M, Majd SP,
WHO-HIV-2016.05-eng.pdf;jsessionid Reza Mohajeri SA. Malnutrition among patients
=2F2E0E21C7530786BFF1C098725 suffering from HIV/AIDS in Kermanshah, Iran.
BA05E?sequence=1. Accessed on 15 Aug 2019 Ann Trop Med Public Health 2017;10:1210-4
(4) Thuppal SV, Jun S, Cowan A, Bailey RL. (13) Dasgupta P, Bhattacherjee S, Das DK. Food
The Nutritional Status of HIV-Infected US Security in Households of People Living With
Adults. Curr Dev Nutr. 2017;1(10) Human Immunodeficiency Virus/Acquired
(5) Gebremichael DY, Hadush KT, Kebede EM, Immunodeficiency Syndrome: A Cross-sectional
Zegeye RT. Food Insecurity, Nutritional Status, Study in a Subdivision of Darjeeling District,
and Factors Associated with Malnutrition West Bengal. J Prev Med Public Health.
among People Living with HIV/AIDS Attending 2016;49(4):240–248.
Antiretroviral Therapy at Public Health Facilities (14) Thapa R, Amatya A, Pahari DP, Bam K. Newman
in West Shewa Zone, Central Ethiopia. BioMed MS. Nutritional status and its association with
Research International.2018. quality of life among people living with HIV
(6) Hiremath RN, Patil SS, Yadav AK. Nutritional attending public anti-retroviral therapy sites of
status of people living with HIV/Acquired Kathmandu Valley, Nepal.AIDS Research and
immunodeficiency syndrome - A cross-sectional Therapy. 2015;12
study. Asian Journal of Pharmaceutical and
Clinical Research. 2018; 11(7); 456-9,
 170 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Evaluation of Lung Function in Automobile Diesel Mechanics

in A Semi Urban Town of South India- Kumbakonam Urban
Rural Epidemiological Study – KURES 6

M.R.Suchitra1, S. Parthasarathy2
1
Assistant Professor, Department of Biochemistry and Biosciences, Sastra University, Thanjavur, India,
2Professor, Department of anesthesiology, Mahatma Gandhi Medical College and Research Institute.,

Sri Balaji Vidyapeeth university, Puducherry –India, 3Associate Professor, Department of General medicine,
Mahatma Gandhi Medical college and research institute., Sri Balaji Vidyapeeth university, Puducherry –India

Abstract
Automobile mechanics are constantly exposed to dust from the exhausts of petrol and diesel. We recruited
50 petrol two wheeler mechanics and subjected them to lung function tests. All were non-smokers without
any respiratory symptoms. All mechanics were regular workers with a minimum of three years and at least
an exposure of 5 hours of more per day. They were explained about the methodology and asked to attempt
three times and the best of three were selected. The incidence of obstructive lung disease (FEV1/FVC< 70
%) was only 2 %. But the incidence of reduction of effort independent MEF 25- 75 in a significant manner
is around 38 % which coincided with reduction in PEFR values. ⁅FEV1 = Forced expiratory volume in 1
second. PEFR = peak expiratory flow rate. MEF ( 25-75) = mean forced expiratory flow between the 25%
and 75% of the FVC.⁆ We did not find any correlation with body mass index. We did not resort to analyses of
deterioration of lung function with differing exposure years with a low sample size. We suggest that a regular
PEFR with practice of established preventive measures may prevent the progress from asymptomatic illness
to a symptomatic stage in such health workers.

Key words: spirometry, lung function, automobile, mechanics

Introduction was done in a semi urban town of South India in March

- 2019. After approval from the ethics committee
Automobile repair workers of the informal sector
(IRBSTH- 103/2019), automobile especially two
are frequently exposed to dusts, chemicals and toxic
wheeler mechanics working in the small town were
substances which are harmful to their health. The small
enumerated. Among these mechanics, regular workers
auto-body repair workshop is actually an industry in
with a minimum of three years and at least an exposure
which workers are exposed to hazardous amounts of
of 5 hours of more per day were selected. This number
airborne contaminants. Auto mechanics have risks of
was based from an experience from the auto mobile
inhalational lung injury from both fine and particulate
engineer rather any scientific background as there
matters, gasoline, petroleum products and many
were no earlier clear-cut demarcations regarding this
other hydrocarbons1. Chattopadyaya 2has reported an
exposure limits in earlier studies. Around sixty seven
incidence of 25 % obstructive lesions and 21 % restrictive
such persons were spotted out of which seventeen did
lesions on automobile mechanics. Hence with such a
not give consent for the study. Hence we did pulmonary
high incidence of abnormalities in lung function tests in
function tests for all the fifty mechanics who fit into
the background, we wished to find out the incidence of
the category of three years and five hours. The study
such defects in our semi urban town of India.
did not include road side mechanics. All the mechanics
were studied with --Spirolab-III, a calibrated spirometer
Methods
with built in computer program; they were explained
This observational epidemiological study of lung about the equipment and then the procedure of doing
function among automobile petrol/diesel mechanics
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 171

the test. All the mechanics were given three chances FEV1 = Forced expiratory volume in 1 second
to use and the best test was taken for the study. The
study variables were Forced Expiratory Volume in 1 PEFR = peak expiratory flow rate.
second (FEV1), Forced Vital Capacity (FVC), Peak MEF ( 25-75) = mean forced expiratory flow
Expiratory Flow Rate (PEFR), FEF 25-75, age, smoking between the 25% and 75% of the FVC
habit, duration of work, years of experience, and any
respiratory symptoms. Considering the literacy of From the gross data, it can be easily assumed that
mechanics, the reference values being for non-Indians, there is no gross dysfunction in volumes of mechanics.
we considered a FEV1/FVC % of less than 70 % was The values were near normal in majority of mechanics.
significant for obstructive lung disease. Any FVC less There was only patient who showed a FEV1/FVC
than 70% was considered restrictive. We took 70 % as percentage of 66% and hence deemed as obstructive.
the value to detect any milder form of obstruction in There was neither a single case of restrictive lesion or
such asymptomatic cases. The incidence of combined combined lesion. The mean PEFR was 233 litres which
diseases was also noted. With such less sample size, we was less than the expected. Nineteen out of fifty patients
did not resort to sub classifying the same with duration had an MEF 25-75 value of less than 70 %. Out of the 19
of exposure and lung function. All data were fed into patients 11 had a value of less than 50%. As such there
computer and SPSS version 20 was used. Any untoward was no awareness about exposure and lung function in
event was recorded. any of the mechanics.

Results Discussion
Out of the seventy people who fulfilled the inclusion Automobile repair mechanics are engaged in a
criteria, only, fifty mechanics were willing to undergo variety of activities which include mechanical work,
the study. The demographic data is tabled in Table 1. body repair and reconstruction, re-treading of tyres,
spray painting and repair of battery. This work routine
Mean ± Std.Deviation exposes them to various occupational health hazards
and dangers. In a study of 151 automobile male workers
Age (years) 37.44 ± 11.4 earlier, obstructive impairment was noticed in 25.83% of
the workers while restrictive impairment was in 21.19%
Weight (kilograms) 65.54 ± 13.69
of the workers. Mixed disease was seen in 10.6% of the
Height (cm) 155.06 ±11.07 workers. The study included smokers and nonsmokers.2
The incidence in our study was very less compared to
BMI 27.27 ±5.18 them; they have also differentiated the mechanics with
age and found out the differences. As such we have not
All the fifty mechanics were non-smokers without done such comparison. We have found only one case
any history of wheezing or allergic bronchitis. The mean which corresponds to a 2% incidence of obstructive
years of exposure to dust were 10.46±5.22. The mean lesion. In a study by Krishnakumar3 et al, 56.7% of
hours of exposure per day were 6.38±0.67 hours. The workers had some form of defective pulmonary function.
details of lung function among the mechanics are tabled Smoking, increased duration of working hours and years
below. of work showed significant pulmonary impairment. But
our incidence is very low. In a few Nigerian studies4,5.,
Table 2 showing the pulmonary function test
the authors have claimed a reduction of FVC and FEV1
values: (mean±SD)
even with five years of exposure. The PEFR was not
FVC (litres) 3.48± 0.88 significantly changed in their study. Dahlquist et al 6have
FVC % of predicted 109.3±32.2 found out a significant reduction of lung function in
FEV1 % 89.22±13.95 mechanics especially exposed to asbestos. As they have
FEV1/FVC % 74.83±11.95
found a reduction in major components of pulmonary
function tests, they have not looked into the details of
PEFR 233.22±89.89
MEF 25 even though those values were also decreased.
MEF(25-75) litres 2.37±1.03
In our case there was a significant reduction of MEF-25-
MEF % 77.06±35.05
75 up to 38% of cases. The basic difference is that all our
FVC = forced vital capacity
 172 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

cases were non-smokers and there were no confounding function (i.e MEF25-75) in 38% of cases, which is
variables as such like any other irritant exposure. Alex an early sign of allergen exposure. The PEFR values
et al7 have also demonstrated a decreased lung function coincided with reduction of MEF 25-75 values. We
among petroleum product workers. They had a 50 % suggest that a routine PEFR testing can be done in such
incidence of lung symptoms. In our study there was no workers and protective measures can be taken to prevent
symptom in any of the cases. There were nineteen cases the progress to a significant symptomatic deterioration
of a significant decrease in the MEF 25-75 values. In of lung function in automobile mechanics.
these patients we had a significant reduction of PEFR of
less than 250 litres. Hence in our study, the PEFR and Dr MRS Collected the data, Dr SPS conceptualized
MEF 25-75 values coincided and a reduction was found and Dr MH did the write up
in both values. Our study was restricted to asymptomatic Conflict of Interest – Nil
two wheeler mechanics and hence the sample size was
low. Parker8 et al had described an incidence of 25 % Financial support – partly by Rotary club of
of obstructive lung diseases in automobile workers. In kumbakonam Grand
the same study, they had only FEV1/FVC ratio as a
marker of obstruction as a fiftieth percentile. There was References
no mention about MEF 25-75. Marseglia GL8 et al have 1. Thangaraj S, Shireen N. Occupational health
described that MEF 25-75 is early marker of pulmonary hazards among automobile mechanics working
dysfunction especially allergic bronchitis. Hence in our in an urban area of Bangalore – a cross sectional
case study, we have found out the values of MEF 25- study. Int J Med Sci Public Health. 2017;6:18-22.
75 were significantly decreased. The limitations of our
2. Chattopadhyay O. Pulmonary function in
study were the sample size and absence of age, weight
automobile repair workers. Indian J Community
matched controls in the same population. The major
Med. 2007;32(1):40-3.
new finding which we have found in our study is the
reduction of MEF 25- 75 which is an effort independent 3. Krishna Kumar MK, George LS. Pulmonary
lung function being affected in our cases. Hence by function of automobile repair workers in the
virtue of age, physical exercise and motivation, the informal sector of Raichur urban. Int J Community
performance of FEV1/FVC may be altered while MEF Med Public Health 2017;4:1510-4.
25- 75 can’t be changed by effort9. We had also found 4. Omokhodion FO. Environmental hazards of
that PEFR correlated with MEF 25-75 values. In only automobile mechanics in Ibadan, Nigeria. West Afr
one study by Anupama et al10, they have noted FEF25- J Med 1999; 18(1): 69-72.
75 and found a decrease in 8.57 % which is far less than 5. Akintunde AA, Oloyede TO, Salawu AA Lung
our results. In our study the average BMI was around 27. functions abnormalities among auto mechanics
There were only three cases of BMI more than 35 all of in Ogbomoso, Nigeria: Clinical correlates and
which showed decrease in PEFR and MEF 25-75 but the determinants. Annals of Health Research (4), 2:
FEV1 were normal in these cases. Hence we deduced 120-130.
that the BMI is not affecting the results of our study even
6. Monica Dahlqvist, Rolf Alexandersson and GOran
though we can’t comment with authority as the sample
Hedenstierna. Lung Function and Exposure to
size was low. We planned to take up both petrol and
Asbestos Among Vehicle Mechanics, American
diesel vehicles, but we could muster mechanics with
Journal of Industrial Medicine 1992: 22; 59-68
exposure to petrol exhausts only. The exposure to such
exhausts alone and decreased lung function has not been 7. Reginald G. Alex, Anand Alwan et al. A study on
studied earlier. morbidity among automobile service and repair
workers in an urban area of South India. Indian
Conclusion Journal of Occupational and Environmental
Medicine, 2014: 18, (1), 9-12
The awareness about allergen exposure and lung
8. Parker DL, Waller K, Himrich B, Martinez A,
function is absent among mechanics. The incidence of
Martin F. A cross-sectional study of pulmonary
obstructive lung disease (FEV1/FVC reduction below
function in autobody repair workers. Am J Public
70%) in automobile mechanics is only 2 %. But there
Health. 1991;81(6):768-71.
was a significant decrease in an effort independent
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 173

8. Marseglia GL, Cirillo I, Vizzaccaro A, Klersy C, the diagnosis of obstructive lung diseases. J. bras.
Tosca MA, La Rosa M et al. Role of forced pneumol. [Internet]. 2010 Feb [cited 2019 Apr 06]
expiratory flow at 25-75% as an early marker of ; 36( 1 ): 44-50.
small airways impairment in subjects with allergic 10 Anupama N Sonu Ajmani, Vishnu Sharma M, ,
rhinitis. Allergy Asthma Proc. 2007 (1):74-8. Ganaraja B, Subbalakshmi N K, , Bhagyalakshmi
9. Rodrigues Marcelo Tadday, Fiterman-Molinari K, Shiela R Pai. Analysis of dynamic pulmonary
Daniel, Barreto Sérgio Saldanha Menna, Fiterman function in automobile mechanics IJBR 2012: (2)
Jussara. The role of the FEF50%/0.5FVC ratio in 374-7
 174 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Estimation of Thyroid Stimulating Hormone Level in Normal

Female School Children in A Semi Urban Indian Town
- Kumbakonam Urban Rural Epidemiological Study-
KURES -2

M.R.Suchitra1, T.S.Shanthi2, S. Parthasarathy3

1
Assistant Professor, Department of Biochemistry and Nutrition,, SASTRA University, India,
2Consultant Obstetrician, ST Hospital, Kumbakonam, 3Professor, Department of anesthesiology, Mahatma Gandhi
Medical College and Research Institute, Sri Balaji Vidyapeeth university, Puducherry –India

Abstract
Symptoms of thyroid dysfunction are non-specific, yet common and hence screening for abnormalities
becomes a necessity. To identify subclinical thyroid dysfunction and offer them the correct medical treatment
especially in adolescent female children is an excellent option as a public health prophylactic measure.
Hence in this study, we sampled 264 asymptomatic school female children for TSH and found an incidence
of 3.4% of high TSH (>5). On the other side, the lower values were found in six (if TSH <0.5) or only
two children (if TSH < 0.4). The mean with standard error of TSH values were 2.99 ±0.567. The fasting
status was not complied with, and all were random blood samples. All children with abnormal results were
counselled with parents and necessary medical advice given. This prevalence is the lowest among similar
studies done in any Asian country which is a new finding in our study. Only one child showed a value of 150
who was given drugs and followed up. We theorize that this lesser incidence may be partly due to the study
being done in a delta area of a semiurban town.

Key words: children, female, TSH, hypothyroidism, subclinical,

Introduction south India1, the incidence of thyroid dysfunction is

around 11.7%. There are a few studies which state that
Subclinical hypothyroidism (SCH) is more
the incidence of subclinical hypothyroidism is around
a biochemical than a clinical condition which is
4.15 to 13 % in Asian pregnant population2,3.. In view
characterized by serum levels of Thyroid Stimulating
of such variations, we proposed to conduct estimation
Hormone (TSH) above the defined upper limit of
of TSH levels in normal asymptomatic female school
reference range, but with normal concentration of
children in kumbakonam, a semiurban town of South
thyroid hormones. There are no frank clinical features of
India.
hypothyroidism. It’s still not clear that these clinically
normal children will go in future to develop increased Aims
incidence of complications. As such there are very few
studies which randomly sample normal children in Indian The primary aim was to find out the incidence of
semi urban population. In a study of young females in subclinical hypothyroidism in female school children in
kumbakonam , a semiurban town of India.

Communicating author : The other aims were to counsel the students and
Dr. S. Parthasarathy MD. DNB. PhD parents and the need for drug therapy in affected children
Professor, Department of anesthesiology
Mahatma Gandhi Medical college and research institute Material and Methods:
Puducherry – South India, [email protected] This prospective epidemiological observational
mobile : + 91 9047034042 study was conducted in a semiurban town of India
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 175

with a population of 150000 in October 2018. It was the application of Qualtrix software in sample size
done in school going female children between 15 – 17 estimation for epidemiological studies was done. For a
years of age. The institutional review board (IRBSTH study to have 90 % confidence level and a margin of
02/2018) has approved the proposal to conduct the error 5 %, a sample size of 252 was necessary. Hence
study. The administration of the school has accepted to a sample size of 264 was made in our study. All data
conduct the study. The procedure of collecting blood were entered in an excel spread sheet and fed into the
from children was explained to parents in vernacular statistics software SPSS 20.0 for descriptive statistics
language and consent was obtained from each of them. and confidence intervals.
TSH assay was done in all the collected blood samples
Results
as a screening test for thyroid disease. TSH assay was
done using electro chemiluminescence immunoassay to All the 264 subjects completed the study. There were
the accuracy guidelines given by WHO as standard. no untoward events. All the children were females in the
age group of 15-17. The mean with standard error of
Abnormal TSH values were grouped into two TSH values were 2.99 ±0.567.The descriptive statistics
categories: is tabled below (see Table 1). Only 9 children out of
• TSH elevation: TSH of more than 5 mIU/ml 264 had a TSH value of more than 5. The incidence of
abnormally high TSH is 3.4 %. One child had a value
• Suppressed TSH: TSH <0.4 mIU/ml. of 150, yet she did not have symptoms. Only two out of
264, had a value less than 0.4. but children with values
All the subjects with abnormal TSH were instructed between 0.4 and 0.5 were four in number. Hence If 0.5
to come for follow‑up with parents for further testing had been the cut off for a low TSH , 6 out of 264 had
and advice. a low TSH values which is around 2.27%.Hence the
abnormal TSH values overall is only 5.67%. The parents
Statistics were called and a counselling session was held along
With a town population of 150000 and a target with students giving them proper advice regarding drug
population of 3500 of the age group described above, intake and further tests.

Table 1 showing descriptive statistics

Statistic Std. Error
Mean 2.998862 .5672822
95% Confidence Interval for Lower Bound 1.881869
Mean Upper Bound 4.115855
5% Trimmed Mean 2.289267
Median 2.155000
Variance 84.958
TSH Std. Deviation 9.2172453
Minimum .0600
Maximum 150.0000
Range 149.9400
Interquartile Range 1.5600
Skewness 15.548 .150
Kurtosis 248.642 .299
 176 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Discussion Conclusion
The prevalence of thyroid disorders especially In a sample epidemiological survey of subclinical
subtle subclinical dysfunctions depends on a number hypothyroidism in asymptomatic semi urban school
of factors such as age, sex, geographical factors and female children of India, we found a mean TSH value
iodine intake. The focus should be young females, as a of 2.99 mIU/l. Lower TSH values (<0.4) were noted
lot of menstrual problems with infertility is on the rise only in two children. The prevalence of subclinical
with a possible link with thyroid disorders. Nair et al hypothyroidism (TSH >5) was 3.4% only which is far
4demonstrated that TSH levels showed a statistically less than the previous studies. We probably hypothesize
significant decrease postprandial when compared to that the decreased incidence may be due to the fact that
fasting values. Our samples were taken randomly. Early study being conducted in a delta area of a semiurban
and effective treatment of any thyroid disorder will ensure town.
a safe pregnancy with minimal maternal and neonatal
complications5. Hence any screening at the age of 15 – Financial Support – Partly funded by Rotary
17 and their correction may be highly useful in reducing club of kumbakonam grand and KRG nursing home
infertility and pregnancy associated complications. kumbakonam.
Hence in this study, we focussed on adolescent female Conflict of Interest – Nil
children. Kumaravel et al1 have shown a prevalence of
TSH abnormalities in young females as 12.5 % with a Dr. MRS designed and conducted the study. DR.TSS
higher TSH in 9.7 %. In a study in Lebanese children6, helped in data collection. Dr. SPS did the supervision
the prevalence was found to be 5.4%- 5.7 %. The mean with write up.
serum TSH 2·57–3·6 mIU/l for boys and 1·83–3·58
mIU/l for girls in an Indian study by Marvaho et al7, But References
our study proved the subclinical hypothyroid values to 1. Velayutham Kumaravel, Selvan SS, Unnikrishnan
be less than that of the earlier studies to be only 3.4%. AG. Prevalence of thyroid dysfunction among
But the prevalence of lower TSH values coincides with young females in a South Indian population. Indian
earlier studies by kumaravel et al. In yet another study in J Endocr Metab 2015;19:781-4.
Indian population, the prevalence of high TSH is around
2. Dhanwal DK, Bajaj S, Rajput R, et al. Prevalence of
7.7 %. The authors have also correlated the TSH values
hypothyroidism in pregnancy: An epidemiological
with abnormal lipid profiles which we have not done8.
study from 11 cities in 9 states of India. Indian J
Many of the studies were not clearly mentioning the
Endocrinol Metab. 2016;20(3):387-90.
timing of taking the blood sample whether it’s fasting or
postprandial. We conducted the study in children where 3. Yassaee F, Farahani M, Abadi AR. Prevalence of
they have taken a very mild breakfast 4 hours ago. We subclinical hypothyroidism in pregnant women in
consciously omitted children from the study who have tehran-iran. Int J Fertil Steril. 2014;8 (2):163-6
symptoms and are on thyroid drugs. One patient of our 4. Nair R, Mahadevan S, Muralidharan RS, Madhavan
study where the TSH was 150 also did not know she S. Does fasting or postprandial state affect thyroid
was a hypothyroid. She was prescribed drugs with a function testing? Indian J Endocrinol Metab. 2014;
follow up advice of a complete thyroid profile check- 18(5):705-7.
up along with antibody titres. None of the children with 5. Ramprasad M, Bhattacharyya SS, Bhattacharyya
subclinical thyroid dysfunction had goitre in our study. A. Thyroid disorders in pregnancy. Indian J
We did not enquire whether they are on iodine rich diet Endocrinol Metab. 2012;16 (Suppl 2):S167-70.
or not, as the area of the study is a delta. Nonrandomized
6. Gannagé-Yared MH, Balech N, Farah V, Antar
continuous sampling may be a limitation in our study.
M, Saliba R, Chahine E. Pediatric TSH Reference
Only two out of 264 children had a TSH value below 0.4
Intervals and Prevalence of High Thyroid
which is also less than the earlier studies. These patients
Antibodies in the Lebanese Population. Int J
were also advised to have follow up for full thyroid
Endocrinol. 2017:6372964.
profile testing.
7. Marwaha, R.K., Tandon, N., Desai, A. , Kanwar,
R., Grewal, K., Aggarwal,R. et al. Reference range
of thyroid hormones in normal Indian school‐age
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 177

children. Clinical Endocrinology, 2008; 68: 369- children and adolescents of northern Andhra
374. Pradesh population and its association with
8. Rao PTS, Subrahmanyam K, Prasad DKV. hyperlipidemia. Int J Res Med Sci 2017;5:5168-74.
Prevalence of subclinical hypothyroidism in
 178 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A Review on Medical Tourism in India

S.Gunaseelan1, N.Kesavan2
1Assistant Professor, Department of Commerce, Vels Institute of Science, Technology and Advanced Studies,
Pallavaram, Chennai; 2Assistant Professor, Department of Commerce, Annamalai University, Deputed to
Sethupathy Govt. Arts College, Ramanathapuram

Abstract
Developing country India is the place for medication at an affordable cost than other developed countries
in the world. The tourists have been visiting India along with aim of medication needs in various sources of
Indian medication services. The Yoga, Ayurveda, Unani, Homeopathy, Siddha, spiritual medication, Mooligai
hills station hospitality services and government of India has been providing multi-specialty and higher
medical services to the general public at a cheaper cost. The state governments of India and union territory
governments are also doing the medication services to the residents of India and also NRIs. Along with the
stream of medication service, the private sectors have emerged in a higher end level of medication services
as corporate as well as general public utility services with an affordable cost spent by the beneficiaries along
with the government health insurance schemes assistances. These infrastructures of India is looking ahead
the other countries are mostly utilized the medication services. These are increased now a day, through
medical tourism. There is an evident in Indian economy the tourism is one of the indicators to enhance the
GDP, among the general tourism, medical tourism is a major apportion of economic resources scattered
throughout the country. Particularly in Tamilnadu, Chennai, Coimbatore, Madurai, and Vellore are the major
cities attracted other countries people have frequently visited hospitals of government and private corporate
hospitals with good results. The present article revealed the previous studies in health tourism in India.

Keywords: Medication, Tourism, Reviews of Medical Tourism

Introduction with marketing, finance, insurance, transport, corporate,

human resources and other electronics communication
Tourism is a relaxation of human being visiting
and technology. The wellness tourism is the emerging
various parts/places of the world after attaining certain
marketing environments booming in an exuberant level
needs as per their financial strengths. But, in the case of
due to corporate investors are concentrating medication
medical tourism is a need of patients and their capacities
industries. It results, franchise of corporate hospitals
in the ground of financial supports to take the medical
promulgated new ventures on different facilities
treatment. The tourism is in the behind of various modes
(transport, residence, physicians, guides and assistances,
of transports. The selection of medical tourism is also
medical technicians, labs and diagnosis centre and
impacted on the time, demand, money, availability,
the like) linked with medication industries in certain
political, natural calamities, national securities and other
packages as per the needs of the customers/patients.
uncontrollable economic conditions. In this juncture,
authors have revealed previous studies in the field of Support of Medical Tourism
medical tourism in India for the past two decades from
1999 to 2018. The authors have collected the previous There are several supporting systems have been done
studies from the available information from the various for the betterment of medical tourism such as medical
sources of books, journals, magazines, newspapers, and educational institutes conducting seminar, workshop
websites. and symposia; government initiations on publicity and
promotional activities for the medical tourism. Many
Medical Tourism of the international brands are promoting the medical
tourism (Incredible India, and Wellness or Medical
The concept of medical tourism has interlinked
Tourism Service Providers).
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 179

Present Scenario of Indian Health Care Sector1 during FY15-17. Gross healthcare insurance premium in
the month of September 2017 stood at US$ 2.7 billion.
With increasing urbanisation and problems related Strong mobile technology infrastructure and launch of
to modern-day living in urban settings, currently, about 4G is expected to drive mobile health initiatives in the
50 per cent of spending on in-patient beds is for lifestyle country.
diseases; this has increased the demand for specialised
care. In India, lifestyle diseases have replaced traditional Cycle tel Humsafar is a SMS based mobile service
health problems. Most lifestyle diseases are caused by designed for women, it enables women to plan their
high cholesterol, high blood pressure, obesity, poor family in a better way. Mobile health industry in India
diet and alcohol Vaatsalya Healthcare is one of the first is expected to reach US$ 0.6 billion by 2017. Digital
hospital chains to start focus on Tier 2 and Tier 3 for Health Knowledge Resources, Electronic Medical
expansion. To encourage the private sector to establish Record, Mobile Healthcare, Electronic Health Record,
hospitals in these cities, the government has relaxed Hospital Information System, PRACTO, Technology-
the taxes on these hospitals for the first five years. enabled care, telemedicine and Hospital Management
Many healthcare players such as Fortis and Manipal Information Systems are some of the technologies
Group are entering management contracts to provide gaining wide acceptance in the sector. AIIMS has
an additional revenue stream to hospitals. Telemedicine converts all its payment transaction as cashless, for
is a fast-emerging sector in India; major hospitals which it has associated with mobile wallet company.
(Apollo, AIIMS, Narayana Hrudayalaya) have adopted (MobiKwik, in January 2017) A new trend is emerging
telemedicine services and entered into a number of PPPs. as luxury offerings in healthcare sector. More than
As of FY16, telemedicine market in India was valued at essential requirements, healthcare providers are making
US$ 15 million and is expected to rise at a CAGR of 20 offerings of luxurious services. For example: pick and
per cent during FY16-20, reaching to US$ 32 million by drop services for patient by private helicopters and
2020. luxurious arrangements for visitors to patient in hospital.
The Indian medical tourism industry is expected to reach
Telemedicine can bridge the rural-urban divide US$ 6 billion by 2018 from US$ 3.0 billion in April
in terms of medical facilities, extending low-cost 2017, growing at a CAGR of 27 per cent over 2013-
consultation and diagnosis facilities to the remotest of 16. The number of foreign tourists coming to India for
areas via high-speed internet and telecommunication. medical purposes rose by almost 50 per cent to 201,333
Developments in information technology (IT) and in 2016 from 134,344 in 2015. Cost of surgery in India
integration with medical electronics, has made it is nearly one-tenth of the cost in developed countries.
possible to provide high quality medical care at home at There are 21 Joint Commission International (JCI) -
affordable prices. It enables the customers to save upto accredited hospitals in India and growing.2
20-50 per cent of the cost. The home healthcare market
stood at US$ 3.2 billion in 2016 and is estimated to reach Reviews of Literature
US$ 4.46 billion by the end of 2018 and US$ 6.21 billion
by 2020. Literature evident is the base of conceptual and
civilized development. The followings table consisted
In FY18 (till September 2017), gross direct premium relevant literatures in the aspects of medical or wellness
income from health insurance stood at 23.90per cent of tourism. The table also segregates as name of the
overall gross direct premium income for non life insurance author(s), year of publication, subject area of medical
segment. Health insurance is gaining momentum in tourism, problems, findings, suggestions, and conclusion.
India; witnessing growth at a CAGR of 23.6 per cent
 180 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table.no.1

Name of the
Year Title Findings/Problems/Suggestions Factor
Author

Tamil Nadu has immense natural and cultural resources, giving

ICT/biotech
Tamil Nadu: The it great potential to launch into one of India’s - and even the
development
Lydie Ehouman Path to Becoming regions-top tourist destinations. Furthermore, ICT/ biotech
2002 and direct
et al India’s Leading development and direct foreign investment can be tapped into
foreign
State both for ICT solutions to tourism management and marketing
investment
challenges, and as a source of financing high-level travelers.

India has launched a big initiative to woo medical tourism from

Canada, showcasing the country’s high-end and much cheaper
Top Indian
healthcare industry to Canadians. Lots of Canadians are already High-end and
The Hindu hospitals woo
2009 coming to India for medical treatment because of long waiting much cheaper
News medical tourism
period here...even for an MRI you have to wait for three to four healthcare
from Canada
months. After the IT sector, the Indian medical tourism sector
is the next big thing.

A large number of corporate hospitals and specialized

Government hospitals make the State world renowned for
cost effective treatment and postoperative facilities. There are
Tourism and Time, Cost,
Tamilnadu three important components that make Tamil Nadu a favoured
Culture Department, convalesce
Govt. Policy 2011 medical tourism spot. There is no waiting time for the patients.
Tourism Policy and Physicians
Note The cost of treatment is less compared to the West. The
Note 2010-2011 Conveniences
patients can convalesce at their convenience in the hospitals.
Specialised doctors and well equipped Para-medical staff have
made this possible by their dedicated efforts.

Priority needs to be given to data capture, both in individual

Medical tourism: countries and in the international system. Without data, it will
A review of the be impossible to assess the impact of opening trade in health
Richard Smith literature and services on the importing and exporting countries. Further,
2011 analysis of a role Need of Data
et al countries need to consider aspects of trade from the perspective
for of greater bi-lateral initiatives, weighing up possible benefits
bi-lateral trade and risks from engaging in trade relationships with different
countries individually.

The growth of medical tourism in India contributes for the

Medical Tourism in infrastructure
development of infrastructure in medical facilities, medical
India-Its Strength, in medical
sciences, national income, employment opportunities and
Rose Mary 2014 Weakness, facilities
urbanization. Study has argued to minimize or reduce the
Opportunities and policy
adverse effects of medical tourism through proper policy
and Threats framework
framework.

An evaluation of Medical tourism providers should try to maintain service

Lakhvinder
2014 medical tourism in quality and vigorously strive to make India the world leader in Service Quality
Singh
India medical tourism, a path it is certainly on.

Conclusion policy framework, Infrastructural development of the

Medication Service Provider (MSP), Need of data of
From the above Meta analysis of review of
Indian MSP, Need of expertise, New structure of medical
literature authors have found that the Indian medical
tourism, Packages, Policy framework of government,
tourism is expected to meet the challenges, such as
Service quality and Supporting health care. Hence, the
Branding, Cost of medication, Fake insurance claims,
new research on medical tourism should focus the above
FDI, Foreign exchange, Hospital standardization and
area will give a fruitful idea to develop the medical
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 181

tourism in India. 4. Manpreet Kaur, “An emerging destination for

Medical tourism :A Study of India”, Scholarly
Ethical Clearance : Completed Research Journal for Humanity Science & English
Source of Funding : Self Language, OCT –NOV(2017), VOL-4/24
5. Mohammad Amiri , “Medical tourism in India:
Conflict of Interest : Nil current scenario”, International Journal in
Management and Social Science, (March, 2017)
References Vol.05 Issue-03,
1.. Rose Mary.S.S, “Medical Tourism in India- 6. Lydie Ehouman, Sandra Fried, Theresa Mann and
Its Strength, Weakness, Opportunities Haroon Ullah, “Tamil Nadu: The Path to Becoming
and Threats”, Scholar World- IRMJCR (2014) Vol. India’s Leading State”, Strategy Paper: New Era of
2 (1) pp 116-120 Fiscal Consolidation, 2002
2. Lakhvinder Singh, “An evaluation of medical 7. The Hindu News, “Top Indian hospitals woo
tourism in India”, African Journal of Hospitality, medical tourism from Canada”, Toronto, November
Tourism and Leisure(2014) Vol. 3 (1) - 21, 2009 TNGOVT, “ Tourism And Culture
3. Patil chetan Vitthal, Amrutkar Rupesh subhash, Department, Tourism Policy Note 2010-2011”, p
Bhavna R Sharma, and M. Ramachandran, 15
“Emerging Trends and Future Prospects of Medical 8. Richard Smitha, Melisa Martínez Álvareza, Rupa
Tourism in India”, J. Pharm. Sci. & Res. (2015) Chandab, “Medical tourism: A review of the
Vol. 7(5), 248-251 literature and analysis of a role for bi-lateral trade”,
Health Policy 103 (2011) 276– 282
 182 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Ophthalmomyiasis Due to Oestrus Ovis Complicated with

Methicillin Ressistant Staphylococcus Aureus. First Report
Near Coastal Area

Shaik Khaja Moinuddin1, Anandi.V, Amirtha C2

1
Research Scholar, 2Professor, Department of Microbiology, Vinayaka missions medical college &Hospital,
Karaikal, Puducherry, India, 3MS (OG) Post graduate, Balaji medical college and hospital, Chennai, India

Abstract
Ophthalmomyiasis, is the infestation of any anatomic structure of the eye. Larvae of sheep nasal botfly,
Oestrus ovis is the most common cause of human ophthalmomyiasis. A 19-year-old male, presented to
the ophthalmology outpatient department with a 1 day history of moving foreign body sensation, redness,
and excessive watering from his right eye. Multiple larvae were found on bulbar conjunctiva. Larvae were
removed and identified as Oestrus ovis. Bacterial infection was proved by isolating a heavy growth of
methicillin resistant Staphylococcus aureus(MRSA) from conjuctival swabs. Dsual infection of parasitic
and bacterial infection of young male adult is proved and also found to be a rare dual manifestation of eye.
Hence this case is being reported here.

Key words: Dual infection, Oestrus ovis, Staphylococcus aureus.

Introduction Oestrus ovis and Staphylococcal infections have not

been reported in Indian literature and is being reported
Myiasis is the term applicable to the infestation
here as a rare case report.
of human beings and other vertebrates with the larvae
(maggots) of Diptera flies. Different parts of the human Case Report
body may get affect due to myiasis infestation. Most
commonly skin and body cavities (mouth, nostrils, A 19 year-old male, fisherman by occupation,
ear and eye.). Involvement of any anatomical site of presented to the ophthalmology outpatient department
eye is called as Ophthalmomyiasis. [1] Larvae, most with a 1-day history of moving foreign body sensation,
commonly, attack the external surface of the eyes or redness, and excessive watering from his right eye,
ocular adnexia, e.g. the lids, conjunctiva or lacrimal following insect hit into his eye while riding motor bike
ducts (external ophthalmomyiasis). In uncommon through sheep raising areas. He gave no past history of
instances they may penetrate into the eyeball itself ocular or medical problems.
(internal ophthalmomyiasis) or may involve the orbit
On examination, his visual acuity was 20/20 in
(orbital myiasis).[2] From different parts of the world
both eyes. Eyelids of the affected eye were absolutely
ophthalmomyiasis have been reported. [3]. Mostly
normal. The conjunctiva was mildly congested with
reported were from rural areas and had history of contact
profuse lacrimation. On slit-lamp examination, multiple,
with cattle. [4] Oestrus ovis is the most common cause
tiny and translucent worms, 1–2 mm in size, crawling
of human ophthalmomyiasis.[5] Dual infection due to
over the bulbar conjunctiva were seen. Anterior chamber
was found to be normal. Using 4% xylocaine drops as
Corresponding Author:
topical anesthesia, 8 worms were removed manually
S.Khaja moinuddin
with the help of sterile forceps. While removing worms
Research Scholar, Department of microbiology
mechanically with the help of forceps, they were tightly
Vinayaka missions medical college &Hospital,
adhering to the bulbar conjunctiva. After removal of all
Karaikal -609609, Puducherry, India
larvae, three swabs were collected for bacteriological
Email: [email protected]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 183

and mycological culture. Two swabs were inoculated Oestrus ovis Other agents involved in causing myiasis
on bacteriological media such as blood agar, chocolate are Rhinoestrus purpureus , Dermatobia. hominis ,
agar and Mac Conkey agar. One swab was inoculated on Chrysomya. bezziana , Lucilia spp. , and Cuterebra[2]
Sabouraud s dextrose agar and processed according to
standard microbiological procedures.[6] Morphologically adult bot fly resembles honeybee,
which is yellow to gray brown, 10– 12 millimeters
Laboratory findings: long. The gravid fly deposits larvae (Oestrus ovis) in
or around the nostrils of cattle (host). These early stage
On microscopic examination, spindle-shaped larvae (first instar) deposited, adheres to the mucous
skeleton with multiple segments and intersegmental membranes within the nasal cavities, then transform
spine bands were seen. The larvae also showed a pair of to second instars and crawl till the sinuses, where they
sharp dark brown oral hooks and tufts of numerous brown develop further and mature into third instars, which are
hooks on the anterior margin of each body segment and shed out for pupation under the soil [9]. The life cycle of
they were identified as Oestrus ovis.[Figure] this parasite is variable, from couple of weeks to many
Staphylococcus aureus was isolated from months, depending on changes in the atmosphere. [10]
bacteriological media was found to be methicillin resistant Man is accidental host, with the eye being point of
Staphylococci and it was sensitive to, chloramphenicol, adherence for larvae. In man, the larvae cannot be alive
Moxifloxacin and cefazolin. No fungus was isolated beyond the early larval stage and are believed to die
from Sabouraud dextrose agar even after 14 days. within ten days if not taken out [11] Although the threat
The patient improved dramatically after a mechanical of orbital penetration and future serious consequences
removal of the larvae and a topical application of seems to be low, it is prudent to get rid of the larvae from
antibiotic (Moxifloxacin) –steroid combination therapy. the mucosa of conjunctiva promptly.
When the patient came for a follow-up after five days, External ophthalmomyiasis usually presents with
he was completely relieved of his symptoms of foreign ocular itching, foreign body sensation and a watery-
body sensation and excessive watering. mucopurulent discharge confined to the conjunctiva. [11]
Draining of conjunctival sac with saline is ineffective
in cleasing out the larvae. Larvae hold the conjunctiva
firmly with the help of tiny spines on its outer surface
and anterior hooks. Possibilities of misdiagnosis as viral
or allergic conjunctivitis is not uncommon. External
ophthalmomyiasis typically happens in the summer and
autumn which differs from other microbial conjunctivitis,
which may occur throughout the year.

A heavy growth of Staphylococcus aureus was

isolated from conjunctival swab after 24 hours of
incubation at 37 0 C. Based on this preliminary report
of Staphylococcus aureus, the patient was started on
moxifloxacin and the patient recovered completely.
Antibiotic susceptibility testing by Kirby Bauer
Oestrus ovis larvae
disk diffusion method also revealed susceptible to
Discussion moxifloxacin. The patient had bacterial infection
Hope was the first person to describe myiasis. [7] following the traumatic episode by the bot fly which
Worldwide, human myiasis is distributed with various could be during the hit by the bot fly or due to the rubbing
species and larger abundance in poor socioeconomic of the eye by the patient.
areas of tropical and semitropical countries. [2] Ocular
Conclusion
involvement happens in less than 5 percent of all cases
of human myiasis. [8] The most common cause of A rare case of co infection of external
external ophthalmomyiasis is the larvae of sheep botfly, ophthalmomyiasis due to Oestrus ovis and methicillin
 184 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

resistant Staphylococcus aureus(MRSA). Early diagnosis Oestrus ovis. East African Med J 1975; 52: 167-
and prompt initiation of appropriate interventional 169.
procedure to remove the Oestrus ovis and anti bacterial 5. Dunbar J, Cooper B, Hodgetts T, Yskandar H, Thiel
treatment saved an eye. PV, Whelan S, et al. Clin Infect Dis 2008;46:124-6.
Source of Funding- Self      6. Forbes BA, Sahm DF, Weissfeld AS. Chapter
13, Overview of bacterial identification methods
Conflict of Interest- Nil and strategies. Bailey and Scott’s diagnostic
Microbiology, 12th ed. St.Louis: Mosby; 2007. p.
Ethical Clearance: Taken from institutional ethical
216-47.
committee.
7. Hope FW: On insects and their larvae occasionally
References found in the human body. Trans R Soc Entomol
1840, 2:256-271
1. Gursel, M., Almemir, O.S., Ozgur, Z., Ataoglu, T.
8. Pandey A, Madan M, Asthana AK, Das A, et al.
A rare case of gingival myiasis caused by Diptera
External ophthalmomyiasis caused by Oestrus ovis:
(Calliphoridae). J Clinic Periodontol. 2002;29:777–
a rare case report from India. Korean J Parasitol
780
2009;47:57–9
2. Fabio Francesconi, Omar Lupi. Myiasis. Clinic
9. Zumpt P. Myiasis in man and animals in the
Microbiol Rev 2012;25:79-104.
Old World. London: Butterworths; 1965.
3. Elliot, R.H., Quoted by Sivaramasubramaniam and PMid:14272962.
Sadanand, Brit. J. Ophthalmol 1968; 52: 64
10. Hall M, Wall R. Myiasis of Humans and Domestic
4. Patel SJ. Extra-ocular myiasis due to the larva of Animals. Adv Parasitol 1995; 35: 257-334.
11. Sreejith R S, Reddy A K, Ganeshpuri S S, Garg
P. Oestrus ovis ophthalmomyiasis with keratitis.
Indian J Med Microbiol 2010;28:399-402
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 185

A Psychological Perspective of Craving Towards Pornography

and Its Effect on Relationship Satisfaction and Sexual Attitude

Samiksha Jain1, Neelam Pandey2, Sakshi Mehrotra2

1Research Scholar, 2Supervisor, Amity Institute of Psychology and Allied Sciences, Amity University,
Uttar Pradesh, Noida, India

Abstract
Media has been defined as “mediated experiences”. It consists of all kinds of medium such as print media,
audio, video, electronic media etc. Furthermore, this brings up the issues like pornography or sexually
explicit materials which can hampers an individual interpersonal and intrapersonal relationships. The
present study aimed to understand the effect of craving towards on relationship satisfaction and sexual
attitude among dating and non-dating males. The sample of 150 males were divided into two groups namely,
dating and non-dating (21-28 years) were given a questionnaire to measure pornography craving, couple
satisfaction, four forms of sexual attitude (permissiveness, birth control, communion, instrumentality). The
main purpose of the study was to study the difference in level of pornography craving among dating and
non- dating males and to explore the relationship between pornography craving and relationship satisfaction,
sexual attitude among dating and non-dating males. The study however attempts to find the difference in
components of sexual attitude of dating and non-dating males. The obtained data was analysed by MANOVA
and correlation. As predicted, significant negative correlation was obtained, between pornography craving
and relationship satisfaction, two forms of sexual attitude (permissiveness and instrumentality). The result
indicates that there exists no significant difference in pornography craving among dating and non-dating
males. Also, there exists a significant difference in one form of sexual attitude (permissiveness) among
dating and non-dating males.

Keywords: Pornography, craving, relationship satisfaction, sexual attitude, dating, non-dating males

Introduction According to Hald & Malamuth (2008), pornography

is a “material intended to cause sexual arousal or sexual
The internet is a global network that helps us to
excitement.”[6] “It is a material which creates the feeling
get connected to other networks. It is the source or
of sexual arousal and contains detailed elucidation of
medium that communicates any meaning or purpose or
sexual acts involving the nether regions” (Reid and
something to which we can attach up a meaning. The
colleagues, 2011)[14]. The use of sexual attitude and
emerging trends of internet addiction have also started
behavior are predicted by exposure to sexually explicit
giving new opportunities of sexual exposure to all the
content (i.e. pornography) in adult magazines, X-rated
people across the world.
movies and internet. It has been found that two- third
The topic of sexuality is always left unspoken in (66%) of males and one third (39%) of females had seen
developing country and always subject to limitations. In at least one form of sexually explicit media in past year.
ancient India, sexual arousal was the well-known concept Also, the study showed that males who are exposed
given by Kamasutra written by Mallanaga Vatsyayana to such media earlier predicts more permissive sexual
during the 2nd or 5th century. It was considered to be the norms, having oral sex and sexual intercourse 2 years
integral part in adult’s life. Major changes occurred after later and decrease in gender role attitude (Brown, J. D.,
the entry of britisher and wherein the Indian culture got & L’Engle, K. L., 2009).[2] The appetite for pornography
mixed up with the moral standards of Victorian system is increasing at a rapid rate because of three factors:
and now the recent technology has given a new shape to accessibility, affordability and anonymity.
the sex culture in India.
 186 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Internet connected devices have allowed individuals investigated relationship between viewing X-rated
of different age groups to consume, create and distribute movies and relationship among people who are single
sexually explicit material worldwide. (Flood, 2007; and are into a romantic relationship. It was found that
Haggstrom-Nordin, Sanberg, Hanson, & Tyden, 2006; 76.8% men and 31.6% women reported that they view
Lo & Wei, 2005; Wolak, Mitchell, & Finkelhor, 2007). and around 44.8% men and women view SEM with
[3]
Pornhub, an adult site in 2015 came up with the their partners. Also, it was found that people who had
annual report or data and revealed that India is the third never seen SEM reported higher relationship quality
country which brought maximum traffic to the site. Top in terms of communication, relationship adjustment,
three ranking of countries are: United States, United commitment, sexual satisfaction and infidelity than those
Kingdom and India. But data revealed that as far as the who watch SEM alone. People who view pornography
duration of the visit is concerned, countries on first and with their mate depicts high zeal and sexual satisfaction
second ranking are same but Canada have come up to as compare to those who watch such movies solitary.[11]
the third rank. And India is holding up the fourth rank.
According to Pornhub 60% of the viewer’s use mobile Sex need not involve romantic intimacy but romantic
phone to access such videos whereas 27% of viewers intimacy involves sex. Braun-Courville, D. K., & Rojas,
access computers M. (2009) explored the exposure to sexually explicit
web-sites, adolescent sexual attitude and behaviours.
Human beings are known as social animals. People Results indicated that adolescents who are exposed to
suffer when they are deprived of social contacts with sexually explicit websites are more likely to engage
others and the core element is “our need for intimate themselves in multiple lifetime sexual partners, usage
relationship”. Our relationship with others is the one of substance such as alcohol at the last encountered
of the important factors in our lives. They bring us sexual activity, were engaged in anal sex and had more
happiness when everything is going well and sorrow than one sexual partner in last 3 months. Also, it was
when they are going through a bad phase. found that adolescents who visited to such sites show
high degree of sexual permissiveness as compared to
Watching sexually explicit material with female ones who never visited to such sites.[1] Kim, E. H., &
centric attribute was associated with affirmative results Jeon, G. Y. (2007) investigated the ecological variables
of sexually explicit materials on sex life and also on how of adolescent sexual behavior where behaviour was
other genders make perception on women. Whereas, categorized into four groups such as organism (sexual
men reported negative effects on the same measure. attitude, dating experience etc.), microsystem (parent-
(French, I. M., & Hamilton, L. D. 2017).[4] And this adolescent communication about sexuality, peer
online sexual activity is also affecting the relationship relationship etc.), mesosystem (family-peer, family-
in some or the other way. Research studies suggest school relationship) and exosystem (pornography and
that men show positive attitude about their partner’s neighbourhood). It was found that though all the groups
online sexual activity and are less likely to express their affect the adolescent’s sexual behavior but majorly
concerns whereas women are more open to new things organism group have the greatest impact on the sexual
and they easily talk about what they want sexually. But behavior of the adolescents.[7] Luder, M. T., et al. (2011)
negative impacts were also identified where women compared the sexual behavior of adolescents who were
expressed less sex as a result of online sexual activity or were not exposed to online pornography. It was found
and men were less aroused by real sex as a result of that vulnerability to X-rated movies is not associated
online sexual activity (Grov, C., et al 2011)[5]. Also, with hazardous sexual behaviors and that the inclination
recent study suggested that 89% of Chinese participants of vulnerability does not seem to have any influence on
who were in a committed relationships experiences risky sexual behaviors among adolescents.[10]
OSA in past 12 months even when they had a real-
life partner. Results indicated that men showed higher Consequences of watching pornography
frequency of watching all subtypes of OSA as compared
to women. Also individual with low relationship quality 1. Individual: According to Zillmann, D., &
of life includes low relationship satisfaction, insecure Bryant, J. (1988), high exposure to pornography leads
attachment and negative communication patterns and men to judge their mates as sexually less attractive,
engages themselves more frequently in OSAs (Li, D., which in turn leads to less satisfaction with their
& Zheng, L., 2017) [9]. Maddox, A. M., et al (2011) affection, physical appearance, and sexual behavior[16].
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 187

2. Family: The use of pornography by parents • There would be a significant relationship

have a lot of impact on children when they encounter between pornography craving and relationship
the situation involving sexually implicit material by satisfaction.
their parents such as masturbation, phone sex, parental
conflicts, pornographic addicted parents etc (Schneider, • There would be a significant relationship
J. P., 2000) [13]. between pornography craving and sexual attitude among
dating and non-dating males.
3. Clinical: Brown and L’Engle (2009) conducted
a longitudinal study of adolescents (N = 967) regarding • There would be a significant difference in sexual
sexual harassment as a manifestation of sexual attitude among dating and non-dating males.
aggression. It was found that 76% of adolescent males
commit some form of sexual harassment using some
Method
kind of sexually explicit material. Also, data revealed Participants
that males who were exposed to pornography in early
adolescence were more likely to engage in molestation The sample consists of two different groups namely,
activities in middle adolescence. [2] dating males and non-dating males (21-28 years). The
sample was collected from participants residing in Delhi
This research paper has emphasized to understand NCR on the basis of socio-demographic details such as
the impact of pornography craving on relationship Age, Education qualification, occupation, relationship
satisfaction and sexual attitude among dating and non- status, duration of relationship (more than 6 months) and
dating males accessing sexually explicit material.

Objectives of the study Instruments

1) To study the difference in level of pornography Pornography Craving Questionnaire developed by

craving among dating and non- dating males. 2) To Shane Kraus and Harold Rosenberg (2014). The reliability
explore the relationship between pornography craving and validity were well established. Cronbach internal
and relationship satisfaction among dating and non- validity of alpha = 0.94[8]. The Couple Satisfaction
dating males. Index developed by Funk, J.L. & Rogge, R.D. (2007) is
a 32 items scale designed to measure one’s satisfaction
3) To explore the relationship between Pornography in a relationship. It has strong convergent validity and
Craving and Sexual Attitude among dating and non- high internal consistency. Brief Sexual Attitude Scale
dating males. developed by Hendrick, Hendrick, & Reich (2006). It
4) To study the difference in components of sexual has the following alphas: Permissiveness = .93; Birth
attitude of dating and non-dating males Control = .84; Communion = .71; Instrumentality = .77.

Hypotheses of the study: Results

• There would be a significant difference in level After collecting the data from the sample population.
of pornography craving among dating and non-dating Statistical analysis was conducted and following were
males. analysed from the results obtained:

TABLE 1: Showing the Mean, Standard Deviation of sample on Pornography Craving, Couple Satisfaction
and components of Sexual attitude (Permissiveness, Birth control, Communion, Instrumentality) among
Dating and Non-dating males.

Dimensions Male N Mean Std Deviation

Non dating 76 2.9641 1.10870

Pornography craving
Dating 74 2.8809 1.30147
 188 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Cont... TABLE 1: Showing the Mean, Standard Deviation of sample on Pornography Craving, Couple
Satisfaction and components of Sexual attitude (Permissiveness, Birth control, Communion, Instrumentality)
among Dating and Non-dating males.

Couple satisfaction Dating 74 133.2432 24.26498

Non dating 76 2.7605 .78708

Permissiveness
Dating 74 3.1324 .94378

Non dating 76 1.7026 .77039

Birth control
Dating 74 1.5073 .83599

Non-dating 76 1.9684 .84982

Communion
Dating 74 1.8189 0.70316

Non-dating 76 3.0184 .82441

Instrumentality
Dating 74 3.1459 0.89338

TABLE 2: Showing Correlation of sample on Pornography Craving and couple satisfaction and
components of Sexual Attitude.

Pornography Birth Couple

Permissiveness Communion Instrumentality
Craving Control Satisfaction

Pornography
-0.251** 0.003 -0.145 -0.295** 0.303**
Craving

Permissiveness -0.251** 0.045 0.136 0.280** 0.493**

Birth Control 0.003 0.045 0.411** -0.054 0.058

Communion -0.145 0.136 0.411** 0.118 0.025

Instrumentality -0.295** 0.280** -0.054 0.118 0.354**

Couple Satisfaction 0.303** 0.493** 0.058 0.025 0.354**

**Correlation is significant at the 0.01 level (2-tailed).

TABLE 3: Showing the F values of components of sexual attitude among Dating and Non-dating males

Source Dependent Variable F Sig.

Permissiveness 6.884 .010

Birth control 2.216 .139

RELATIONSHIP
STATUS Communion 1.374 .243

Instrumentality .826 .365

Pornography Craving 0.178 0.674

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 189

Discussion relationships. These findings are supported by research

done by Wiederman, M. W. (1997) found that men were
We are living in an age of dwindling relationships
more likely than women to report in engaging in extra
wherein one of the key factors these days is the use of
marital sex. And no gender difference was found among
technology because the lot of time that people previously
the participants younger than 40 years of age. Research
used to give to their personal relations has now gone
also found that there is a strong association between
to the use of laptops, mobile phones or technological
permissive sexual attitudes and behavior and exposure
equipment. It also led to issues of sex exposure to your
to music videos in females as compared to males due to
sexually explicit material to everyone across the world.
unsatisfactory family environment [15].
This brings about issues such as pornography which can
hamper the satisfaction that the person draws from a
Conclusion
real relationship. The current study aimed to look at the
impact that the virtual exposures can have on real life The present study was aimed to determine the
relationships. effect of craving towards pornography on relationship
satisfaction and sexual attitude among dating and non-
The results indicate that there exists an insignificant dating males. The differences could be the result of
relationship between pornography craving among dating cultural differences since the sample was taken from
and non-dating males. Hence, the hypothesis was not urban population. This study helped us to sensitize the
supported. The reason for no significant relationship current status of Indian relationships which are getting
found between dating and non-dating males might be affected due to the accessibility and availability of
due to the dearth of sample size. Though, there is a slight content such as pornography. Further, such studies can
difference in the mean of dating scores and non-dating help psychologist to create an intervention plans to
scores i.e. dating mean score is lower than non-dating balance out the behaviors which are getting affected due
scores. This indicates that both the groups watch such to this.
content on nearly equal level.
Conflict of Interest: NIL
The present study found that there was a negative
correlation (-0.303) between pornography craving Source of funding: Self
and couple satisfaction. This indicates that higher is
Ethical Clearance: Taken from Ethical committee
crave for pornography, lower will be the relationship
of Amity Institute of Psychology and Allied Sciences,
satisfaction. These findings are supported by one of the
Amity University, Noida.
researches by Maddox, A. M., et al (2011) investigated
relationship between viewing X-rated movies and
References
relationship among people who are single and are into
a romantic relationship. It was found that 76.8% men 1. Braun-Courville DK, Rojas M. Exposure
and 31.6% women reported that they view and around to sexually explicit web sites and adolescent sexual
44.8% men and women view SEM with their partners. attitudes and behaviors. Journal of adolescent health.
Also, it was found that people who had never seen 2009 Aug 1;45(2):156-62.
SEM reported higher relationship quality in terms of
2. Brown JD, L’Engle KL. X-rated: Sexual
communication, relationship adjustment, commitment,
attitudes and behaviors associated with US early
sexual satisfaction and infidelity than those who watch
adolescents’ exposure to sexually explicit media.
SEM alone. Also, there exists negative correlation (p<
Communication Research. 2009 Feb;36(1):129-51.
0.01) between pornography craving and permissiveness
and instrumentality i.e. higher pornography craving will 3. Flood M. Exposure to pornography among youth
lead to lower permissiveness and instrumentality. [11] in Australia. Journal of Sociology. 2007 Mar;43(1):45-
60.
The result in table 3 indicates that there is a
significant effect at one of the components of sexual 4. French IM, Hamilton LD. Male-centric and
attitude i.e. “permissiveness” and insignificant effect on female-centric pornography consumption: Relationship
other components such as “birth control”, “communion”, with sex life and attitudes in young adults. Journal of sex
“instrumentality”. This might be because people, & marital therapy. 2018 Jan 2;44(1):73-86.
specifically the males are more open towards their sexual
 190 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

5. Grov C, Gillespie BJ, Royce T, Lever J. Perceived 11. Maddox AM, Rhoades GK, Markman HJ. Viewing
consequences of casual online sexual activities sexually-explicit materials alone or together:
on heterosexual relationships: A US online Associations with relationship quality. Archives of
survey. Archives of Sexual Behavior. 2011 Apr Sexual Behavior. 2011 Apr 1;40(2):441-8.
1;40(2):429-39. 12. Malamuth NM, Addison T, Koss M. Pornography
6. Hald GM, Malamuth NM. Self-perceived effects and sexual aggression: Are there reliable effects
of pornography consumption. Archives of sexual and can we understand them?. Annual review of
behavior. 2008 Aug 1;37(4):614-25. sex research. 2000 Mar 1;11(1):26-91.
7. Kim EH, Jeon GY. The ecological variables 13. Schneider JP. Effects of cybersex addiction on
affecting adolescent’s sexual behavior. Journal the family: Results of a survey. Sexual Addiction
of the Korean Home Economics Association. & Compulsivity: The Journal of Treatment and
2007;45(7):71-91. Prevention. 2000 Jan 1;7(1-2):31-58.
8. Kraus SW. Excessive appetite for pornography: 14. Reid RC, Li DS, Gilliland R, Stein JA, Fong T.
Development and evaluation of the Pornography Reliability, validity, and psychometric development
Craving Questionnaire (PCQ-12) (Doctoral of the Pornography Consumption Inventory in
dissertation, Bowling Green State University). a sample of hypersexual men. Journal of Sex &
9. Li D, Zheng L. Relationship quality predicts online Marital Therapy. 2011 Oct 1;37(5):359-85.
sexual activities among Chinese heterosexual men 15. Wiederman MW. Extramarital sex: Prevalence
and women in committed relationships. Computers and correlates in a national survey. Journal of Sex
in Human Behavior. 2017 May 1;70:244-50. Research. 1997 Jan 1;34(2):167-74.
10. Luder MT, Pittet I, Berchtold A, Akré C, 16. Zillmann D, Bryant J. Pornography’s impact on
Michaud PA, Surís JC. Associations between sexual satisfaction 1. Journal of Applied Social
online pornography and sexual behavior among Psychology. 1988 Apr;18(5):438-53.
adolescents: Myth or reality?. Archives of sexual
behavior. 2011 Oct 1;40(5):1027-35.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 191

A Descriptive Study to Assess the Effect of Habitual Usage

of Mobile Phone on the Sleep Quality among Adolescents in
Selected Colleges, Chennai

Sandhya R1, Sujitha Jebarose T1

1
Assistant Professor, Faculty of Nursing, Dr.M.G.R. Educational and Research Institute, Chennai

Abstract
Background: Smartphone has become an indispensable part of our day to day living due to its countless
advantages. This habituated the people to become more dependent on mobile phones especially the
adolescent age group. They become addicted to mobile technology which in turn declines their cognitive
function , academic performance and a poor sleep pattern.

Objective: The purpose/ intention of the study is to assess the sleep disturbances due to the use of mobile
phones especially in the night among adolescents.

Materials & Method: A descriptive study conducted on students from selected arts and science colleges in
Chennai. The sample size was 100 adolescents selected through simple random sampling technique. Mobile
phone use questionnaire, Modified Pittsburgh sleep quality index (PSQI) were used to Assess the Effect of
Habitual Usage of Mobile Phone on the Sleep Quality

Results : The results revealed that most of them (38%) received text messages every night, majority of
them (43%) sent text messages every night . Majority of them (55%) have experienced sleep latency and
sleep disturbances (atleast once a week), most of them (53%) had varied sleep duration. This study analyzed
that use of mobile phone every night is significantly associated with quality of sleep at P < 0.001 (highly
significant)

Conclusion: This study findings shows that habitual usage of mobile phones during night especially after
lights are out invariably affects the sleep quality among adolescents

KeyWords: mobile Phones ,sleep quality,adolescents.

Introduction on technology. Adolescents are at an age where good

quality sleep, mental and physical wellbeing is of
Background: Mobile devices have become widely
utmost importance. Sadly, to keep up with today’s fast
prevalent over the past decade, the declining cost and
paced, technologically oriented society, they engage in
increasing computational power of mobile devices,
habitual mobile phone use which affects their cognitive
such as smart phones and tablet computers, has created
function and general wellbeing. “It is believed that sleep
a revolution in personal communications(1)(10). Mobile
is a restorative process and a basic biologic need,” said
devices have a remarkable ease of access due to instant-
Dr. Neil Kline, “When humans are deprived of sleep,
there are many body systems that fail. Not only do our
Corresponding Author performance, memory and attention span suffer, our
Ms. Sandhya . R immune system and endocrine system is also impaired.”
M.Sc(Nursing).,Assistant Professor, Faculty of Deep sleep is essential as it is the time when the body
Nursing, Dr.M.G.R. Educational and Research Institute, rejuvenates cells and repairs damage suffered during the
Chennai, Tamilnadu, India. Contact No. 7358219035. day. Melatonin, a hormone which regulates the sleep is
e-mail id – [email protected]. suppressed due to the exposure of blue light from the
 192 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

mobile screen. This causes intruption in the initiation mobile phone, or audio player in bed before going to
and regulation of sleep cycle. sleep with insomnia, daytime sleepiness among 532
students aged 18 - 39. The results showed that mobile
Habitual use of cell phones late at night after phone usage for playing/surfing/texting was positively
lights are out is particularly popular among younger associated with insomnia
generations for talking or mailing messages. Moreover,
it is a mere entertainment object and serves to keep them Hence, it is important to have an accurate
in constant contact with their peers. Due to uncontrolled understanding of the impact of mobile phone on health
use of mobile devices they become dependent to it to develop strategies to overcome the adverse effects and
termed as Nomo phobia. Difficulty in “shutting off” enhance the quality of life.
leads to various sleep disturbances leading to insomnia ,
tiredness , headache, dizziness, irritability. This lack of Objective
sleep can result in attention disorders and poor academic To assess the Impact of Mobile Phone Usage on the
performance in adolescents. Sleep Quality among adolescents.
A cross sectional study was done by Munezawa et
al., 20112 in order to find out the association between
Materials and Method
the use of mobile phones after lights out and sleep The present study was a descriptive study conducted
disturbances among Japanese adolescents. The study on students from selected arts and science colleges in
findings revealed that mobile phone use after lights Chennai. The sample size was 100 adolescents selected
out has significant association with all forms of sleep through simple random sampling technique. Data was
disturbance. collected using a demographic questionnaire, mobile
phone use questionnaire , Modified Pittsburgh sleep
The recent studies reported that the habitual mobile quality index . Ethical commitee clearence was obtained
phone usage causes marked decline in academic from Institutional Review Board (IRB). The aim and
performance3. Li et al. (2015) reported that under the purpose of this study was explained to the study
graduate students (n = 516) participated in the study participants and the confidentiality was assured to them.
by competing the validated surveys assessing their cell Data was collected by the above said questionnaire.
phone use, locus of control, sleep quality, academic
performance, and reduced subjective well-being. This Results
study concluded that use of the cell phone in the class,
and at bedtime has a negative effect on sleep quality and Overall, 100 students participated in this study, of
academic performance. which, 62% were females and 38% were males, 48%
were aged 18 – 20 years, 52% were aged between 20 –
Fossum et al., 2014; Li et al., 2015; Exelmans & Van 22 years,95% were single, 5% got married. Out of 100
den Bulk, (2016)4 examined the association between the students, 50% are studying literature, 50% are studying
use of a television, computer, gaming console, tablet, computer science. Majority of the students 83% did
not have any other occupation, while 17% are working
besides studying.
Table 1: Frequency and Percentage Distribution of Mobile Phone Usage among Adolescents

More Than Once in 1 - 3 Times in a

Type of Use Every Night Once in a week Never
a Week Month

Receiving text
38 ( 38 %) 30(30%) 20 (20%) 7 (7%) 5(5%)
messages

Sending text messages 43 (43%) 37 (37%) 8 (8%) 8(8%) 4(4%)

Receiving phone calls 26 (26%) 30 (30%) 25 (25%) 10 (10%) 9(9%)

Calling 18 (18%) 15 (15%) 30 (30%) 20 (20%) 15 (15%)

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 193

The above table depicts that, Most of them (38%) Table 3: Association Between Mobile phone
receive text messages every night, majority of them usage and the sleep quality
(43%) send text messages every night , while 4% of
the study participants never send text messages in the Sleep quality
night.26% of the study participants receive phone calls Mobile phone
every night while 30% receive phone calls in the night usage
Chi square P value
more than once a week and 9 % of the study participants
never receive phone calls in the night. Approximately
30% of them make phone calls once in a week during 0.001*
Every Night 11.45*
(Significant )
night time, while 18% make phone calls every night and
15% never make calls in the night. More Than Once a
7.65 0.01
Week
Table 2: Frequency and Percentage Distribution
of the Sleep Quality among Adolescents Once a Week 6.75 0.01

Components of Mean and 1 - 3 Times a Month 2.04 0.10

Frequency and
Pittsburgh Sleep Quality standard
percentage
Index deviation
It is inferred from the above table that use of
mobile phone every night is significantly associated with
M- 2.12,SD -
Sleep latency 55 (55%) disturbances in the quality of sleep at P < 0.001 (highly
0.81
significant).
M-2.17 , SD –
Sleep duration 53 (53%)
0.80 Discussion

Sleep disturbance (at least M- 2.29 , SD

Overall, 100 students participated in this study, of
55 (55%) which, 62% were females and 38% were males, 48%
once a week) – 0.73
were aged 18 – 20 years, 52% were aged between 20 –
Habitual sleep efficiency 30 (30%)
M- 2.56 , SD 22 years,85% were single, 15% got married. Out of 100
– 0.50 students, 50% are studying literature, 50% are studying
computer science. Majority of the students 83% did
M- 2.7, SD –
Subjective sleep quality 17 (17%) not have any other occupation, while 17% are working
0.56
besides studying.
Use of sleep medications
0 0 Frequency and Percentage Distribution of Mobile
(at least once a week)
Phone Usage among Adolescents
Daytime dysfunction (at M- 2.7 ,SD
30 (30%)
least once a week) -0.47 Most of them (38%) receive text messages every
night, majority of them (43%) send text messages every
M- 14.14 night, while 4% of the study participants never send
SD- 3.92 text messages in the night.26% of the study participants
receive phone calls every night while 30% receive phone
The above table depicts that majority of them (55%) calls in the night more than once a week and 9 % of the
have experienced sleep latency and sleep disturbances study participants never receive phone calls in the night.
(atleast once a week) ,most of them (53%) had varied Approximately 30% of them make phone calls once in
sleep duration , 30 % of them had day time dysfunction a week during night time, while 18% make phone calls
and habitual sleep efficiency is reduced but none were every night and 15% never make calls in the night.
using sleep medications
Davey S, Davey A. (2014)5.conducted a mixed
method study to assess the smart phone addiction
among adolescents and its consequent impact on their
health. Systematic review was done using websites of
 194 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

EMBASE, MEDLINE, PubMed, Global Health, Psyc- Amra B, AliShahsavari, (2017)7 associated sleep
INFO, Biomed-Central, and Web of Science, Cochrane and late-night cell phone use among 2400 adolescents
Library, and world library - World-Cat, Indian libraries aged 12-18 yrs in Iran. Age, body mass index, sleep
such as National Medical Library of India from 1 duration, cell phone use after 9 p.m., and physical
January, 1995 to March 31, 2014. Finally, meta-analysis activity were documented. The Pittsburgh Sleep Quality
on only Indian studies was done using Med-Calc Index questionnaire was used to assess the quality of
online software. A total of 45 articles were considered sleep. 1270 participants reported to use cell phone
in systematic-review globally; later on 6 studies out after 9 p.m. Overall, 56.1% of girls and 38.9% of boys
of these 45 related to Smartphone’s addiction in India reported poor quality sleep, respectively. Wake-up time
were extracted to perform meta-analysis, in which total was 8:17 a.m. (2.33), among late-night cell phone users
1304 participants (range: 165-335) were enrolled. The and 8:03 a.m. (2.11) among non-users. Most (52%) late-
smart phone addiction magnitude in India ranged from night cell phone users had poor sleep quality. Sedentary
39% to 44% as per fixed effects calculated (P < 0.0001). participants had higher sleep latency than their peers.
Smartphone addiction damages the interpersonal skills Adjusted binary and multinomial logistic regression
and can lead to significant negative health risks and models showed that late-night cell users were 1.39 times
harmful psychological effects among Indian adolescents. more likely to have a poor sleep quality than non-users
(p-value < 0.001).
The Present study conducted is also among
adolescents who are at an urge of smart phone addiction. Association Between Mobile phone usage and the
sleep quality
Frequency and Percentage Distribution of the
Sleep Quality among Adolescents This study analysed that use of mobile phone every
night is significantly associated with disturbances in the
Majority of them (55%) have experienced sleep quality of sleep at P < 0.001 (highly significant).
latency and sleep disturbances (at least once a week)
,most of them (53%) had varied sleep duration , 30 The above findings are consistent with a cross
% of them had day time dysfunction and habitual sectional study conducted by Sahin S, Ozdemir K,
sleep efficiency is reduced but none were using sleep (2013)8 conducted to assess the mobile phone addiction
medications. level in university students between 01 November 2012
and 01 February 2013, to examine several associated
The results are consistent with a study conducted factors and to evaluate the relation between the addiction
by Orzech K, Grandner M, et.al (2016)6. Aimed at level and sleep quality.. The study group included 576
investigating the association between the self-reported students. The Problematic Mobile Phone Use Scale was
sleep patterns and digital media use in a first-year used for evaluating the mobile phone addiction level
University student (N = 254, 48% male) population. and the Pittsburgh Sleep Quality Index for assessing
Students tracked their sleep through daily online diaries the sleep quality. The study group consisted of 296
and provided digital media use data in 15-min blocks for (51.4%) females and 208 (48.6%) males. The mean age
2 h prior to bedtime on nine occasions. A longer duration was 20.83 ± 1.90 years (min:17, max:28). The addiction
of digital media use was associated with reduced total level was determined to be higher in the second-year
sleep time and later bedtime, while greater diversity of students, those with poor family income, those with type
digital media use was associated with increased total A personality, those whose age for first mobile phone is
sleep time and earlier bedtime. Analysis of activities 13 and below and those whose duration of daily mobile
in the last hour before bedtime indicated that activity phone use is above 5 hours (p < 0.05 for each). The sleep
type plays a role in digital media’s effect on sleep, with quality worsens with increasing mobile phone addiction
computer work, surfing the Internet, and listening to level (p < 0.05).
music showing the strongest relationship to multiple
sleep variables. These findings have implications for Exelmans L, Van den Bulck J (2015)9 assessed
physical and mental health of University students and the bedtime mobile use and the sleep quality among
can inform design of devices to minimize negative 844 Flemish adults (18–94 years old). Self-reported
effects of digital media on sleep. sleep quality, daytime fatigue and insomnia were
measured using the Pittsburgh Sleep Quality Index
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 195

(PSQI), the Fatigue Assessment Scale (FAS) and the Adolescent: A Nationwide Cross Sectional Survey.
Bergen Insomnia Scale (BIS), respectively. Data were Sleep.2011 August; 34(8):1013-1020.doi: 10.5665/
analyzed using hierarchical and multinomial regression SLEEP.1152.
analyses. Half of the respondents owned a smart phone, 3. Li,J.,Lepp.A.,Barkley.J. Locus of control and cell
and six out of ten took their mobile phone with them phone use: Implications for sleep quality, academic
to the bedroom. Sending/receiving text messages and/ Performance, subjective wellbeing. Computers
or phone calls after lights out significantly predicted in human behavior. 2015 Nov ;52:450-457.
respondents’ scores on the PSQI; particularly longer doi:10.1016/j.chb.2015.06.021
sleep latency, worse sleep efficiency, more sleep
4. Kawada,T.,Kataoka,T., Tsuji,F.et.al. The
disturbance and more daytime dysfunction. Bedtime
relationship between a night usage mobile phone and
mobile phone use predicted respondents’ later self-
sleep habit and the circadian typology of japanese
reported rise time, higher insomnia score and increased
students aged 18-30yrs.Psychology.2017 January;
fatigue. Age significantly moderated the relationship
8(6):892-902. doi:10.4236/psych.2017.86058.
between bedtime mobile phone use and fatigue, rise
time, and sleep duration. An increase in bedtime mobile 5. Davey’s & Davey. A. Assessment of smart phone
phone use was associated with more fatigue and later Addiction in Indian Adolescents: A mixed method
rise times among younger respondents (≤ 41.5 years old study by systematic - review and metaanalysis
and ≤ 40.8 years old respectively); but it was related to approach. International Journal of Preventive
an earlier rise time and shorter sleep duration among Medicine.2014Dec (cited 2019 March 24);
older respondents (≥ 60.15 years old and ≥ 66.4 years 5(12):1500-1511. Available from:http://www.ncbi.
old respectively). nlm.nih.gov/pmc/articles/PMC4336980/
6. Orzeck.K, Grandner, Roane Carskadon,M .Digital
Conclusion media use in the 2 h before bedtime is associated with
sleep variables in university students. Computers in
The habitual usage of mobile phones at late-night
human Behaviour.2016 Feb; 55 (part A): 43-50.
has a significant effect with poorer sleep quality among
doi: https://doi.org/10.1016/j.chb.2015.08.049.
adolescents.Findings reveals that mobile phone use
at bedtime is negatively related to sleep outcomes. 7. Amra.B.,Shahsavan.A.,Moghadam.,et.al. The
Longer average screen-time was associated with shorter association of sleep and late –night cell phone
sleep duration and worse sleep-efficiency. The sleep use among adolescents. Journal de pediatria.2017
quality worsens with increasing smart phone addiction Nov-Dec; 93(6):560-567. doi:10.1016/j.
level. Young people suffer more than the older adults. jped.2016.12.004.
Adolescents have to be motivated to have an adequate 8. Sahin.S., Ozdemir.K., Unsal.A,Temiz.N.
sleep for a better physical and mental wellbeing. Evaluation of mobile phone addiction level and
sleep quality in university students. Pakistan
Funding: No funding sources journal of medical science. 2013 July-Aug (cited
Conflict of Interest: None declared 2019 March 25); 24(9):913-918. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/
References PMC3817775/
9. Exelmans.L, Bulck.J. Bedtime mobile phone
1. Zarghami,M., Khalilian,A., Setareh.J, Salehpour,G.
use and sleep in adults. Social Science &
The impact of using cell phones after light out on
Medicine.2016 Jan; 148:93-101.doi: 10.1016/j.
sleep quality ,headache, tiredness, and distractibility
socscimed.2015.11.037
among students of a university in the north of
Iran. Iran Journal of Psychiatry and Behaviour 10. Khan.M., Nock.R, Gooneratne.N. Mobile
Sciences.2015 December; 9(4).doi:10.17795/ Devices and Insomnia: Understanding Risks and
ijpbs-2010. Benefits.CurrentSleepMedicineReports. 2015
Dec;1(14):226-231. doi:10.1007/s40675-015-
2. Munezawa,T., Kaneita,Y.,Osaki,Y. et.al. The
0027-7.
Association between use of mobile phones after
lights out and sleep disturbances among Japanese
 196 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A Descriptive Study to Assess the Effect of Habitual Usage

of Mobile Phone on the Sleep Quality among Adolescents in
Selected Colleges, Chennai

Sandhya R1, Sujitha Jebarose T1

1
Assistant Professor, Faculty of Nursing, Dr.M.G.R. Educational and Research Institute, Chennai

Abstract
Background: Smartphone has become an indispensable part of our day to day living due to its countless
advantages. This habituated the people to become more dependent on mobile phones especially the
adolescent age group. They become addicted to mobile technology which in turn declines their cognitive
function , academic performance and a poor sleep pattern.

Objective: The purpose/ intention of the study is to assess the sleep disturbances due to the use of mobile
phones especially in the night among adolescents.

Materials & Method: A descriptive study conducted on students from selected arts and science colleges in
Chennai. The sample size was 100 adolescents selected through simple random sampling technique. Mobile
phone use questionnaire, Modified Pittsburgh sleep quality index (PSQI) were used to Assess the Effect of
Habitual Usage of Mobile Phone on the Sleep Quality

Results : The results revealed that most of them (38%) received text messages every night, majority of
them (43%) sent text messages every night . Majority of them (55%) have experienced sleep latency and
sleep disturbances (atleast once a week), most of them (53%) had varied sleep duration. This study analyzed
that use of mobile phone every night is significantly associated with quality of sleep at P < 0.001 (highly
significant)

Conclusion: This study findings shows that habitual usage of mobile phones during night especially after
lights are out invariably affects the sleep quality among adolescents

KeyWords: mobile Phones ,sleep quality,adolescents.

Introduction phones and tablet computers, has created a revolution in

personal communications(1)(10). Mobile devices have a
Background:
remarkable ease of access due to instant-on technology.
Mobile devices have become widely prevalent Adolescents are at an age where good quality sleep,
over the past decade, the declining cost and increasing mental and physical wellbeing is of utmost importance.
computational power of mobile devices, such as smart Sadly, to keep up with today’s fast paced, technologically
oriented society, they engage in habitual mobile phone
use which affects their cognitive function and general
Corresponding Author: wellbeing. “It is believed that sleep is a restorative
Ms. Sandhya . R , process and a basic biologic need,” said Dr. Neil Kline,
M.Sc (Nursing)., Assistant Professor, Faculty of “When humans are deprived of sleep, there are many
Nursing, Dr.M.G.R. Educational and Research Institute, body systems that fail. Not only do our performance,
Chennai, Tamilnadu, India. memory and attention span suffer, our immune system
Contact No. 7358219035. and endocrine system is also impaired.” Deep sleep is
e-mail id – [email protected] essential as it is the time when the body rejuvenates cells
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 197

and repairs damage suffered during the day. Melatonin, mobile phone, or audio player in bed before going to
a hormone which regulates the sleep is suppressed due to sleep with insomnia, daytime sleepiness among 532
the exposure of blue light from the mobile screen. This students aged 18 - 39. The results showed that mobile
causes intruption in the initiation and regulation of sleep phone usage for playing/surfing/texting was positively
cycle. associated with insomnia

Habitual use of cell phones late at night after Hence, it is important to have an accurate
lights are out is particularly popular among younger understanding of the impact of mobile phone on health
generations for talking or mailing messages. Moreover, to develop strategies to overcome the adverse effects and
it is a mere entertainment object and serves to keep them enhance the quality of life.
in constant contact with their peers. Due to uncontrolled
use of mobile devices they become dependent to it Objective
termed as Nomo phobia. Difficulty in “shutting off” To assess the Impact of Mobile Phone Usage on the
leads to various sleep disturbances leading to insomnia , Sleep Quality among adolescents.
tiredness , headache, dizziness, irritability. This lack of
sleep can result in attention disorders and poor academic Materials and Method
performance in adolescents.
The present study was a descriptive study conducted
A cross sectional study was done by Munezawa et on students from selected arts and science colleges in
al., 20112 in order to find out the association between Chennai. The sample size was 100 adolescents selected
the use of mobile phones after lights out and sleep through simple random sampling technique. Data was
disturbances among Japanese adolescents. The study collected using a demographic questionnaire, mobile
findings revealed that mobile phone use after lights phone use questionnaire , Modified Pittsburgh sleep
out has significant association with all forms of sleep quality index . Ethical commitee clearence was obtained
disturbance. from Institutional Review Board (IRB). The aim and
the purpose of this study was explained to the study
The recent studies reported that the habitual mobile participants and the confidentiality was assured to them.
phone usage causes marked decline in academic Data was collected by the above said questionnaire.
performance3. Li et al. (2015) reported that under
graduate students (n = 516) participated in the study Results
by competing the validated surveys assessing their cell
phone use, locus of control, sleep quality, academic Overall, 100 students participated in this study, of
performance, and reduced subjective well-being. This which, 62% were females and 38% were males, 48%
study concluded that use of the cell phone in the class, were aged 18 – 20 years, 52% were aged between 20 –
and at bedtime has a negative effect on sleep quality and 22 years,95% were single, 5% got married. Out of 100
academic performance. students, 50% are studying literature, 50% are studying
computer science. Majority of the students 83% did
Fossum et al., 2014; Li et al., 2015; Exelmans & Van not have any other occupation, while 17% are working
den Bulk, (2016)4 examined the association between the besides studying.
use of a television, computer, gaming console, tablet,

Table 1: Frequency and Percentage Distribution of Mobile Phone Usage among Adolescents

More Than Once in 1 - 3 Times in a

Type of Use Every Night Once in a week Never
a Week Month

Receiving text messages 38 ( 38 %) 30(30%) 20 (20%) 7 (7%) 5(5%)

Sending text messages 43 (43%) 37 (37%) 8 (8%) 8(8%) 4(4%)

Receiving phone calls 26 (26%) 30 (30%) 25 (25%) 10 (10%) 9(9%)

Calling 18 (18%) 15 (15%) 30 (30%) 20 (20%) 15 (15%)

 198 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

The above table depicts that, Most of them (38%) Table 3: Association Between Mobile phone
receive text messages every night, majority of them usage and the sleep quality
(43%) send text messages every night , while 4% of
the study participants never send text messages in the Sleep quality
Mobile phone
night.26% of the study participants receive phone calls
usage
every night while 30% receive phone calls in the night Chi square P value
more than once a week and 9 % of the study participants
never receive phone calls in the night. Approximately Every Night 11.45* 0.001* (Significant )
30% of them make phone calls once in a week during
More Than Once
night time, while 18% make phone calls every night and 7.65 0.01
a Week
15% never make calls in the night.
Once a Week 6.75 0.01
Table 2: Frequency and Percentage Distribution
of the Sleep Quality among Adolescents
1 - 3 Times a
2.04 0.10
Month

Components of Mean and

Frequency and
Pittsburgh Sleep Quality
percentage
standard It is inferred from the above table that use of
Index deviation mobile phone every night is significantly associated with
disturbances in the quality of sleep at P < 0.001 (highly
Sleep latency 55 (55%)
M- 2.12,SD - significant).
0.81

M-2.17 , SD Discussion
Sleep duration 53 (53%)
– 0.80
Overall, 100 students participated in this study, of
Sleep disturbance (at least M- 2.29 , SD which, 62% were females and 38% were males, 48%
55 (55%)
once a week) – 0.73 were aged 18 – 20 years, 52% were aged between 20 –
M- 2.56 , SD 22 years,85% were single, 15% got married. Out of 100
Habitual sleep efficiency 30 (30%) students, 50% are studying literature, 50% are studying
– 0.50
computer science. Majority of the students 83% did
M- 2.7, SD –
Subjective sleep quality 17 (17%)
0.56 not have any other occupation, while 17% are working
besides studying.
Use of sleep medications
0 0
(at least once a week) Frequency and Percentage Distribution of Mobile
Daytime dysfunction (at M- 2.7 ,SD
Phone Usage among Adolescents
30 (30%)
least once a week) -0.47
Most of them (38%) receive text messages every
M- 14.14 night, majority of them (43%) send text messages every
SD- 3.92 night, while 4% of the study participants never send
text messages in the night.26% of the study participants
The above table depicts that majority of them (55%)
receive phone calls every night while 30% receive phone
have experienced sleep latency and sleep disturbances
calls in the night more than once a week and 9 % of the
(atleast once a week) ,most of them (53%) had varied
study participants never receive phone calls in the night.
sleep duration , 30 % of them had day time dysfunction
Approximately 30% of them make phone calls once in
and habitual sleep efficiency is reduced but none were
a week during night time, while 18% make phone calls
using sleep medications
every night and 15% never make calls in the night.

Davey S, Davey A. (2014)5.conducted a mixed

method study to assess the smart phone addiction
among adolescents and its consequent impact on their
health. Systematic review was done using websites of
EMBASE, MEDLINE, PubMed, Global Health, Psyc-
INFO, Biomed-Central, and Web of Science, Cochrane
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 199

Library, and world library - World-Cat, Indian libraries duration, cell phone use after 9 p.m., and physical
such as National Medical Library of India from 1 activity were documented. The Pittsburgh Sleep Quality
January, 1995 to March 31, 2014. Finally, meta-analysis Index questionnaire was used to assess the quality of
on only Indian studies was done using Med-Calc sleep. 1270 participants reported to use cell phone
online software. A total of 45 articles were considered after 9 p.m. Overall, 56.1% of girls and 38.9% of boys
in systematic-review globally; later on 6 studies out reported poor quality sleep, respectively. Wake-up time
of these 45 related to Smartphone’s addiction in India was 8:17 a.m. (2.33), among late-night cell phone users
were extracted to perform meta-analysis, in which total and 8:03 a.m. (2.11) among non-users. Most (52%) late-
1304 participants (range: 165-335) were enrolled. The night cell phone users had poor sleep quality. Sedentary
smart phone addiction magnitude in India ranged from participants had higher sleep latency than their peers.
39% to 44% as per fixed effects calculated (P < 0.0001). Adjusted binary and multinomial logistic regression
Smartphone addiction damages the interpersonal skills models showed that late-night cell users were 1.39 times
and can lead to significant negative health risks and more likely to have a poor sleep quality than non-users
harmful psychological effects among Indian adolescents. (p-value < 0.001).

The Present study conducted is also among Association Between Mobile phone usage and the
adolescents who are at an urge of smart phone addiction. sleep quality

Frequency and Percentage Distribution of the This study analysed that use of mobile phone every
Sleep Quality among Adolescents night is significantly associated with disturbances in the
quality of sleep at P < 0.001 (highly significant).
Majority of them (55%) have experienced sleep
latency and sleep disturbances (at least once a week) The above findings are consistent with a cross
,most of them (53%) had varied sleep duration , 30 sectional study conducted by Sahin S, Ozdemir K,
% of them had day time dysfunction and habitual (2013)8 conducted to assess the mobile phone addiction
sleep efficiency is reduced but none were using sleep level in university students between 01 November 2012
medications. and 01 February 2013, to examine several associated
factors and to evaluate the relation between the addiction
The results are consistent with a study conducted level and sleep quality.. The study group included 576
by Orzech K, Grandner M, et.al (2016)6. Aimed at students. The Problematic Mobile Phone Use Scale was
investigating the association between the self-reported used for evaluating the mobile phone addiction level
sleep patterns and digital media use in a first-year and the Pittsburgh Sleep Quality Index for assessing
University student (N = 254, 48% male) population. the sleep quality. The study group consisted of 296
Students tracked their sleep through daily online diaries (51.4%) females and 208 (48.6%) males. The mean age
and provided digital media use data in 15-min blocks for was 20.83 ± 1.90 years (min:17, max:28). The addiction
2 h prior to bedtime on nine occasions. A longer duration level was determined to be higher in the second-year
of digital media use was associated with reduced total students, those with poor family income, those with type
sleep time and later bedtime, while greater diversity of A personality, those whose age for first mobile phone is
digital media use was associated with increased total 13 and below and those whose duration of daily mobile
sleep time and earlier bedtime. Analysis of activities phone use is above 5 hours (p < 0.05 for each). The sleep
in the last hour before bedtime indicated that activity quality worsens with increasing mobile phone addiction
type plays a role in digital media’s effect on sleep, with level (p < 0.05).
computer work, surfing the Internet, and listening to
music showing the strongest relationship to multiple Exelmans L, Van den Bulck J (2015)9 assessed
sleep variables. These findings have implications for the bedtime mobile use and the sleep quality among
physical and mental health of University students and 844 Flemish adults (18–94 years old). Self-reported
can inform design of devices to minimize negative sleep quality, daytime fatigue and insomnia were
effects of digital media on sleep. measured using the Pittsburgh Sleep Quality Index
(PSQI), the Fatigue Assessment Scale (FAS) and the
Amra B, AliShahsavari, (2017)7 associated sleep Bergen Insomnia Scale (BIS), respectively. Data were
and late-night cell phone use among 2400 adolescents analyzed using hierarchical and multinomial regression
aged 12-18 yrs in Iran. Age, body mass index, sleep
 200 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

analyses. Half of the respondents owned a smart phone, Sleep.2011 August; 34(8):1013-1020.doi: 10.5665/
and six out of ten took their mobile phone with them SLEEP.1152.
to the bedroom. Sending/receiving text messages and/ 3. Li,J.,Lepp.A.,Barkley.J. Locus of control and cell
or phone calls after lights out significantly predicted phone use: Implications for sleep quality, academic
respondents’ scores on the PSQI; particularly longer Performance, subjective wellbeing. Computers
sleep latency, worse sleep efficiency, more sleep in human behavior. 2015 Nov ;52:450-457.
disturbance and more daytime dysfunction. Bedtime doi:10.1016/j.chb.2015.06.021
mobile phone use predicted respondents’ later self-
4. Kawada,T.,Kataoka,T., Tsuji,F.et.al. The
reported rise time, higher insomnia score and increased
relationship between a night usage mobile phone and
fatigue. Age significantly moderated the relationship
sleep habit and the circadian typology of japanese
between bedtime mobile phone use and fatigue, rise
students aged 18-30yrs.Psychology.2017 January;
time, and sleep duration. An increase in bedtime mobile
8(6):892-902. doi:10.4236/psych.2017.86058.
phone use was associated with more fatigue and later
rise times among younger respondents (≤ 41.5 years old 5. Davey’s & Davey. A. Assessment of smart phone
and ≤ 40.8 years old respectively); but it was related to Addiction in Indian Adolescents: A mixed method
an earlier rise time and shorter sleep duration among study by systematic - review and metaanalysis
older respondents (≥ 60.15 years old and ≥ 66.4 years approach. International Journal of Preventive
old respectively). Medicine.2014Dec (cited 2019 March 24);
5(12):1500-1511. Available from:http://www.ncbi.
Conclusion nlm.nih.gov/pmc/articles/PMC4336980/
6. Orzeck.K, Grandner, Roane Carskadon,M .Digital
The habitual usage of mobile phones at late-night
media use in the 2 h before bedtime is associated with
has a significant effect with poorer sleep quality among
sleep variables in university students. Computers in
adolescents.Findings reveals that mobile phone use
human Behaviour.2016 Feb; 55 (part A): 43-50.
at bedtime is negatively related to sleep outcomes.
doi: https://doi.org/10.1016/j.chb.2015.08.049.
Longer average screen-time was associated with shorter
sleep duration and worse sleep-efficiency. The sleep 7. Amra.B.,Shahsavan.A.,Moghadam.,et.al. The
quality worsens with increasing smart phone addiction association of sleep and late –night cell phone
level. Young people suffer more than the older adults. use among adolescents. Journal de pediatria.2017
Adolescents have to be motivated to have an adequate Nov-Dec; 93(6):560-567. doi:10.1016/j.
sleep for a better physical and mental wellbeing. jped.2016.12.004.
8. Sahin.S., Ozdemir.K., Unsal.A,Temiz.N.
Funding: No funding sources Evaluation of mobile phone addiction level and
Conflict of Interest: None declared sleep quality in university students. Pakistan
journal of medical science. 2013 July-Aug (cited
References 2019 March 25); 24(9):913-918. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/
1. Zarghami,M., Khalilian,A., Setareh.J, Salehpour,G. PMC3817775/
The impact of using cell phones after light out on
9. Exelmans.L, Bulck.J. Bedtime mobile phone
sleep quality ,headache, tiredness, and distractibility
use and sleep in adults. Social Science &
among students of a university in the north of
Medicine.2016 Jan; 148:93-101.doi: 10.1016/j.
Iran. Iran Journal of Psychiatry and Behaviour
socscimed.2015.11.037
Sciences.2015 December; 9(4).doi:10.17795/
ijpbs-2010. 10. Khan.M., Nock.R, Gooneratne.N. Mobile
Devices and Insomnia: Understanding Risks and
2. Munezawa,T., Kaneita,Y.,Osaki,Y. et.al. The
Benefits.CurrentSleepMedicineReports. 2015
Association between use of mobile phones after
Dec;1(14):226-231. doi:10.1007/s40675-015-
lights out and sleep disturbances among Japanese
0027-7.
Adolescent: A Nationwide Cross Sectional Survey.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 201

Neck Circumference as an Indicator of Obesity and Its

Comparison with Body Mass Index and Waist Circumference
in Coastal Karnataka

Sanjay Kini1, Avinash kumar2, Unnikrishnan B3, Siddharudha Shivalli4, Vaman Kulkarni2, Prasanna
Mithra2, Nithin Kumar2
1
Assistant Professor, Department of Community Medicine, KS Hegde Medical Academy (KSHEMA), Mangalore,
2Associate Professor, 3Professor, Department of Community Medicine, Kasturba Medical College, Mangalore,
4Assistant Professor, London School of Hygiene and Tropical Medicine, London

Abstract
Background: Neck circumference can be a simple screening tool for measurement of overweight and
obesity. The present study aims to depict neck circumference as a valid measurement of obesity and tries
to find out its correlation with BMI and waist circumference among young adults in the age group of 20-30
years.

Methodology: A community based cross-sectional study was conducted in 6 coastal villages of Udupi
taluk, Udupi district, Karnataka, among 750 subjects. A pre-tested, semi structured questionnaire was
administered to the study subjects after obtaining their consent. The questionnaire comprised of details on
socio-demographic variables and anthropometric measurements.

Results: The study showed a strong positive correlation (r) between weight (0.7), waist circumference (0.7)
and hip circumference (0.7) with neck circumference among the males, it showed a correlation of (0.6) for
all the parameters like weight, waist circumference and hip circumference among the females. ROC analysis
showed that the cut off for males at 36.25 cm has a sensitivity of 80% and specificity 77% and the area under
the curve is 0.84. Whereas the cutoff for females was found to be 31.75 cm having the sensitivity of 69%
and specificity 77% and the area under curve was 0.73.

Conclusion: Neck circumference (NC) measurement is simple and timesaving screening measure that can
be used to identify overweight and obesity. Patients with NC >36.25 cm cm for men and >31.75 cm for
women require additional evaluation of overweight/obesity.

Key words: Neck circumference, Waist Circumference, obesity

Introduction diet related non-communicable diseases, including

diabetes mellitus, cardiovascular disease (CVD),
As we define the term “globesity” synonymous with hypertension, and certain forms of cancer have a direct
an escalating global epidemic of overweight and obesity, association with obesity2-5.
it is taking over many parts of the world and is seen to be
paradoxically coexisting with undernutrition1. Serious An increased risk of morbidity and mortality is seen
with both generalized and abdominal obesity6-7. Obesity
Corresponding author- is a predisposing factor for cardio-vascular disease
Dr Avinash Kumar (CVD), which is the main cause of obesity related deaths.
Associate Professor, Department of Community Body mass index (BMI), waist circumference, waist–hip
Medicine, Kasturba Medical College, ratio or even hip circumference are various important
Mangalore-575001. risk of CVD in adults8,9. In India, measurement of hip
Email- [email protected] and waist circumference is cumbersome in females due
 202 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

to cultural barrier, which is the main problem with most the study. People with conditions affecting the neck
of these anthropometric measurements. circumference like goiter, cervical lymphadenopathy
and any other neck masses, pregnant women, seriously
The building blocks of the country’s economy as ill patients and those not consenting for the study were
well as country’s health are the young adults. The rates excluded.
for obesity among the 18-30 years old population with
some college education have increased significantly in Sampling
the last decade. In order to have a productive population
it is very important to ensure their healthy health status. Stratified sampling with proportional allocation was
The present study focuses on a new anthropometric used to select the required number of study subjects.
measurement which is neck circumference, as a valid Locality and gender were considered as the basis for
measurement of obesity and aims to find its relation with stratification. The centre of a particular locality was
BMI and waist circumference among young adults. visited by the corresponding author, along with a trained
female assistant (Auxiliary Nurse Midwife) and the
Methodology nearest house was taken as the first house for the study in
that locality. They then moved in one particular direction
Study settings and covered all the houses till they achieved the required
The present study was conducted in Udupi taluk in sample for the locality. At the house, all the members
coastal district of Udupi, Karnataka. satisfying the inclusion criteria were considered eligible
for the study.
Ethical Clearance
Study tool
Ethical clearance was obtained from the Institutional
Ethics Committee of Kasturba Medical College, A pre-tested, semi structured questionnaire was
Manipal University vide letter no: (IEC 216/2012 dated administered to the study subjects after obtaining
12/09/2012) and it followed the tenets of the Declaration their consent. The questionnaire comprised of details
of Helsinki. An informed written consent was obtained on socio-demographic variables and anthropometric
from all the study participants after explaining them the measurements.
purpose of the study in the local language, Kannada. Family structure was categorized as nuclear, joint or
Study design three generation (grandparents, parents and children)11.
Socio-economic status was assessed based on the
A community based cross-sectional study was modified version of Uday Parikh scale for rural areas
conducted in Udupi taluk, Udupi district, Karnataka. in India12. Occupation was stratified as professional,
We selected 6 coastal villages for the study by simple white collared job, skilled worker, semiskilled worker,
random sampling. The total population of the young unskilled worker, housewife, student and unemployed.
adults (20–30 years) in selected 6 villages was 9546 Literacy status was classified as literate (if she can
(males: 4566 and females: 4980). read and write with understanding in any language)
or illiterate (can neither read nor write or can read but
Sample size cannot write in any language) and literacy level was
Sample size was estimated using Epi Info™ 7.1.5 the highest level of education completed (Census India
software. According to a similar study done by Ben- 2011)13.
Noun L et al10, considering sensitivity of 99% at cut off Weight was measured to the nearest 100 g, in light
levels of neck circumference of 37 cm in males and 34 clothing, using a standard weighing machine after
cm in females a sample size of 720 was calculated for correcting the zero error. Height was measured to the
the study. Considering a non-response rate of 5% the nearest 0.5 cm with the person standing upright against
sample size was estimated to be 750. the wall with heels together and touching the wall, and
Inclusion and exclusion criteria the head held in upright position. BMI was classified
according to WHO expert consultation recommendations
All young adults aged between 20-30 years and for Asian population14.
willing to participate in the study were included in
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 203

Waist circumference was measured at the mid-point Results

between the lower margin of the lowest rib and the top
We approached 812 subjects to get the required
of the iliac crest, in mid expiration, in standing position,
sample of 750 (response rate 92.36%). Out of 812
using a stretch resistant tape. Hip circumference was
subjects, 58 subjects denied to consent for the study and
measured at the inter-trochanteric level in standing
4 subjects were excluded as they were in the category of
position, with the tape parallel to the floor.
our exclusion criteria.
Neck Circumference was measured at the mid-point
The present study had a total of 750 study
of the neck, between mid-cervical spine and mid anterior
participants with equal number of males (375) and
neck, to within 1 mm, using non-stretchable plastic
females (375). Out of 375 males 26.7% males were
tape with the subjects standing upright. In men with a
involved in semi-skilled work followed by 22.7% in
laryngeal prominence (Adam’s apple), it was measured
skilled work whereas 44.3% females were homemakers.
just below the prominence. While taking this reading, the
A small percentage (0.8%) were illiterate. Most of the
subject was asked to look straight ahead, with shoulders
study participants were unmarried (68.7%). Of the total
down, but not hunched.
750 subjects, 462 (61.61%) belonged to nuclear family,
Statistical analysis: 259 (34.53%) belonged to joint family and the rest 29
(3.86%) belonged to three generation family.
Data was analyzed using Statistical Package for
the Social Sciences (SPSS) for Windows, Version 16.0.
Chicago, SPSS Inc.

Table 1: Anthropometric measurements of young adults (20-30 years) in selected coastal villages of Udupi
taluk, Karnataka, India

Males (n1 375) Correlation (r) Females (n2 375) Correlation (r) of
Measurements
Mean ± SD of NC with Mean ± SD NC with

Age 25.03 ± 3.37 years - 25.18 ± 3.36 years -

Height 169.90 ± 6.34 cm 0.15 156.17 ± 7.05 cm 0.27

Weight 63.42 ± 105.98 kg 0.77 51.10 ± 9.86 kg 0.69

Waist circumference 78.34 ± 8.20 cm 0.79 70.58 ± 9.47 cm 0.68

Hip circumference 92.83 ± 6.88 cm 0.79 86.43 ± 8.11 cm 0.68

Neck circumference 35.79 ± 2.40 cm - 31.13 ± 2.63 cm -

BMI ≥ 25kg/m2 21.92 ± 3.20 cm - 20.96 ± 4.01 cm -

It was found that 45 (12%) males and 62 (16.5%) females were overweight and 63 (16.8%) males and 45(12%)
females were in pre obese and obese category. It also showed that 58 (15.5%) males and 103(27.5%) females were
underweight, whereas 209 (55.7%) males and 165 (44%) females had normal BMI.

The table no 2 depicts the mean BMI, Waist circumference and Neck circumference among the various categories
of BMI
 204 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 2: Comparison between mean Body mass index (BMI), Waist Circumference (WC), Neck
Circumference (NC) among the various BMI categories (n=750)

Underweight Normal Overweight Obese

Mean ± std dev Mean ± std dev Mean ± std dev Mean ± std dev

Males Females Males Females Males Females Males Females

17.34 21.12 23.77 27.20

BMI 16.73±1.15 20.47±1.26 23.82±0.48 28.46±3.95
± 0.53 ± 1.25 ± 0.77 ± 1.67

Waist
circumference 69.62 61.94±5.13 76.20 70.43±6.70 81.93 75.10±6.27 90.37 84.50±8.82
(cm) ± 3.66 ± 5.20 ± 3.77 ± 7.06

Neck
circumference 33.40 29.36±1.45 35.18 31.02±2.52 36.53 32.23±2.15 39.28 34.10±2.47
(cm) ± 1.20 ± 1.57 ± 1.64 ± 1.94

Neck circumference (NC) showed a positive linear correlation with waist circumference (WC) and weight of the
study participants as shown in the figure no 1 and 2 respectively.

Fig 1: Correlation of WC with NC Fig 2: Correlation of weight with NC

Figure no 3 and 4 shows the ROC curve for males and females respectively. The cut off for males at 36.25 cm
has a sensitivity of 80% and specificity 77% and the area under the curve is 0.84. Whereas the cutoff for females was
found to be 31.75 cm having the sensitivity of 69% and specificity 77% and the area under curve was 0.73.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 205

Studies have showed that the risk of CVD and other

non-communicable disease remains high among the
Asian population even at normal range of BMI14.

The study showed a strong positive correlation

(r) between weight (0.7), waist circumference (0.7)
and hip circumference (0.7) with neck circumference
among the males, it showed a correlation of (0.6) for
all the parameters like weight, waist circumference
and hip circumference among the females. The above
finding is in sync with the study done by Hingorjo MR17
which claimed similar strong correlation between Neck
circumference and Waist circumference. The fact was
also advocated by a study done by Onata et al18 which
reported a strong correlation between BMI and Neck
Fig 3: ROC curve comparing overweight/obesity with NC for
circumference. A strong positive correlation between
males
BMI, waist circumference, and NC was also stated by
Yang GR et al19 which was done among 3000 participants
in China with a mean age of 64.0±10.1 years. Another
study by Ben -Noun et al10 among 979 subjects (460 and
519 Israeli men and women) showed a strong positive
relation between Neck Circumference & BMI for both
men and women in his test samples.

There is a strong positive correlation of NC

with weight and WC in the study subjects. Several
studies have examined the association of conventional
anthropometric measures of obesity with NC20,21.
Neck circumference is a valid marker for identifying
obese individuals and correlated well with other
anthropometric measurements. Neck circumference
Fig 4: ROC curve comparing overweight/obesity with NC for has also been shown to correlate positively with insulin
females resistance and biochemical components of the metabolic
Discussion: syndrome which is a known risk factor of diabetes and
other non-communicable disease10,18,22.
Obesity is the mother of most of the non-
communicable diseases and is one of the modifiable In studies carried out in other countries among
risk factors which contribute significantly to diabetes healthy population, the standard neck circumference
and other non-communicable diseases. India harbors was determined using a BMI index. Also, previous
the highest number of diabetic patient in the world studies in Iran have used cutoff points from studies from
next to China and the number is increasing each day15. other countries or simply used correlation between neck
Contrary to the common believe that non-communicable circumference and variables of interest23-25. However,
disease are more prevalent among people with central in the present study we first calculated proper neck
obesity, Patel P et al16 showed that other risk factors like circumference with receiver output curve and in relation
upper body fat also contributed to the disease number. with BMI ≥ 25 as a valid index of overweight. Using the
Considering the above the risk factors, the current study above mentioned procedure the appropriate cut off for
focusses on upper body obesity by measuring neck males was 36.25 cm whereas the cutoff for females was
circumference. The study tries to emphasize that neck found to be 31.75 cm.
circumference can be used as a marker for obesity with a
cutoff for Indian population. Conclusion
One of the simple and time saving measure that
 206 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

can be used to identify overweight and obese adults 10. Ben-Noun L., Sohar E, Laor A. Neck circumference
is the neck circumference. Using BMI and waist as a simple screening measure for identifying
circumference as standards for obesity grading, men overweight and obese patients. Obesity Research
with neck circumference of 36.25 cm and above & 2001; 9: 470–477
women with neck circumference of 31.75cm and above 11. Park K. Medicine and Social Sciences. Park’s
are considered to be overweight. So evaluation for NCD Textbook of Preventive Medicine. 22nd ed.
risk factors can be done specifically focused on subjects Jabalpur: M/s Banarsidas Bhanot Publishers,
falling under the above mentioned category. 2013:620–53.
Acknowledgement: We acknowledge the ANMs 12. Pareekh U. Mannual of socioeconomic status
who helped us in data collection for the study. (rural). Mansayan 32, Netaji Subhash Marg, Delhi:
1981.
Source of Funding: Nil 13. Office of the Registrar General and Census
Conflict of Interest: None declared Commissioner. Census India 2011. Ministry of
Home affairs. Government of India. New Delhi;
References 2012.
14. WHO Expert Consultation. Appropriate body-mass
1. Controlling the global obesity epidemic. World
index for Asian populations and its implications for
Health Organization. Available from: www.who.
policy and intervention strategies. Lancet 2004;
int/nutrition/topics/obesity/en/.
363(9403):157-63.
2. Ofei F. Obesity - A Preventable Disease. Ghana
15. Kaveeshwar SA, Cornwall J. The current state of
Med J. 2005 Sep; 39(3): 98–101.
diabetes mellitus in India. Australas Med J. 2014;
3. Buttar HS, Li T, Ravi N. Prevention of 7(1): 45–48.
cardiovascular diseases: Role of exercise, dietary
16. Patel P, Abate N. Body Fat Distribution and Insulin
interventions, obesity and smoking cessation. Exp
Resistance. Nutrients. 2013; 5(6): 2019–2027.
Clin Cardiol. 2005 Winter; 10(4): 229–249.
17. Hingorjo MR, Qureshi MA, Mehdi A. Neck
4. Boutayeb A, Boutayeb S. The burden of non-
Circumference as a Useful Marker of Obesity:
communicable diseases in developing countries. Int
A Comparison with Body Mass Index and Waist
J Equity Health. 2005; 4: 2.
Circumference. J Pak Med Assoc 62 (1), 36-40. 1
5. Booth FW, Roberts CK, Laye MJ. Lack of exercise 2012.
is a major cause of chronic diseases. Compr Physiol.
18. Onat A, Hergenc G, Yuksel H, Can G, Ayhan E,
2012 Apr; 2(2): 1143–1211.
Kaya Z, Dursunoglu D. Neck circumference as
6. Fan H, Li X, Zheng L, Chen X, lan Q, Wu H et a measure of central obesity: associations with
al. Abdominal obesity is strongly associated with metabolic syndrome and obstructive sleep apnea
Cardiovascular Disease and its Risk Factors in syndrome beyond waist circumference. Clin Nutr
Elderly and very Elderly Community-dwelling 2009; 28: 46-51
Chinese. Sci. Rep. 6, 21521
19. Yang GR, Yuan SY, Fu HJ, Wan G, Zhu LX, Bu
7. Pradeepa R, Anjana RM, Joshi SR, et al. Prevalence XL, et al; Beijing Community Diabetes Study
of generalized & abdominal obesity in urban & Group. Neck circumference positively related
rural India- the ICMR - INDIAB Study (Phase-I) with central obesity, overweight, and metabolic
[ICMR - INDIAB-3]. The Indian Journal of syndrome in Chinese subjects with type 2 diabetes:
Medical Research. 2015; 142(2):139-150. Beijing Community Diabetes Study 4. Diabetes
8. Pi-Sunyer X. The Medical Risks of Obesity. Care 2010; 33: 2465-7.
Postgrad Med. 2009 Nov; 121(6): 21–33. 20. Nafiu OO, Burke C, Lee J, Voepel-Lewis T,
9. Kini S, Kamath VG, Kulkarni MM, Kamath A, Malviya S, Tremper KK. Neck circumference as
Shivalli S. Pre-Hypertension among Young Adults a screening measure for identifying children with
(20–30 Years) in Coastal Villages of Udupi District high body mass index. Pediatrics 2010; 126: e306-
in Southern India: An Alarming Scenario. PLoS 10.
ONE 2016; 11(4): e0154538
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 207

21. Janosen I, Heymsfield SB, et al. Body mass index and risk factors of coronary artery diseas. J Nurs
and waist circumference independently contribute Midwifery. 2008; 18:28-34.
to the prediction of nonabdominal, abdominal 24. Bizheh N, Abdollahi A, Jaafari M, et al. Relationship
subcutaneous and visceral fat. Am J Clin Nutr between neck circumferences with cardiovascular
2002; 75:683-8. risk factors. J Babol U Med Sci. 2011; 13:36-43.
22. Laakso M, Matilainen V, Keinänen-Kiuk aanniemi 25. Karimipour M, Karimnia A, Rostamzadeh A.
S. Association of neck circumference with insulin Study of neck circumference in patients with
resistance-related factors. Int J Obes Relat Metab coronary heart disease referring to the angiography
Disord 2002, 26(6):873-5 ward of urmia taleghani hospital. J Nurs Midwifery
23. Nasrollah S, Jalalmanesh S. Relation between (Urumia). 2012; 10:82-6.
higher standard neck circumfrence in women
 208 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Potential Role of Electromyography in Kinesiology: A Review

Saranya S1, Poonguzhali S1

Centre for Medical Electronics, Department of ECE, Anna University, Chennai, India

Abstract
Human beings follow a unique bipedal walking pattern referred to as gait and kinesiology is the scientific study
pertaining to movement. Gait analysis has been an evolving area of study and in recent years its application
in the development of orthosis, exoskeletons and rehabilitative devices is inevitable. Electromyogram
(EMG) being a natural occurring physiological signal providing valuable information on neuro-muscular
and musculoskeletal morphologies, its role is indispensable in analysing the underlying cause of movement
pathologies. This paper reviews the contributions of EMG in movement analysis so far and its significance
to the development of patient specific control of orthotic and rehabilitative applications.

Keywords: Gait, Kinesiology, Movement Analysis, Electromyography, orthosis, Exoskeleton.

Introduction bipedal movement referred as Gait is a complex

interaction of the musculoskeletal, sensori-motor and
Locomotion is the primary means of survival of
neural systems that has optimized and stabilized the gait
animal species and myriads of methods have been
pattern of human beings [1].
devised to enable and refine movement. The specialised

. Fig.1. Various Phases of Gait Cycle

Gait is expressed as percentage of gait cycle

Corresponding Author: considering the position of one limb as reference. The
Ms. Saranya S various phases of gait are shown in fig.1. It comprises
Centre for Medical Electronics, Department of ECE, of an initial stance phase during which the reference
Anna University, Chennai, India. limb is always in contact with the ground followed by
Email: [email protected] swing phase that corresponds to the period when foot
Phone: 9941163265 is in the air. Stance phase occupies majority 60% of the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 209

gait cycle with further subphases namely, initial contact, researchers who explored the area of Kinesiological
loading response, midstance, terminal stance, pre swing electromyography for two decades [14,15,16,17,18,19,20,21,22,2
3,24].
and swing phase represents the remaining 40% of gait The studies were critical in understanding the phasic
cycle comprising of initial swing, mid swing, terminal activity of all major muscles individually, providing
swing respectively[2,3]. Analysis of Gait involves two useful insights into the neuromuscular system. An initial
major research components that includes quantification technology review revealed that the studies on dynamic
of biomechanical aspects of gait namely, measurement EMG will parallel and lead to a better understanding
of kinematics (spatio-temporal parameters) and kinetics of kinematics and kinetics for clinical assessment of
(forces and torques) of human joints that govern injuries specifically in the field of sports biomechanics
movement followed by analysing the musculoskeletal [25].

morphologies that support gait predominantly involving

Electromyography(EMG) techniques [5,6,7] The analysis of muscle forces during human
movement were the next benchmark contribution in the
Among the aforementioned technologies, the use of field of movement science. The famous Hill’s muscle
electromyography for comprehensive analysis of gait is model was used to demonstrate a relationship between
at present gaining momentum and has been the current EMG and muscle forces [26] followed by correlating
focus of researchers in this area. Being a naturally muscle force information to dynamic joint moments
occurring physiological signal that gives deep insight during walking[27,28]. Since last decade more research
into muscle activity, EMG explores the biophysical area has been focussed in analysing EMG information along
for understanding human movement. Kinesiological with inertial measurements for movement analysis to
Electromyography applies the potential of EMG in precisely analyse the spatio-temporal parameters of gait
[29,30,31]. The spatial coordinates of anatomical points of
movement analysis and therefore, is an established
subfield of modern locomotion biomechanics [8]. As a the lower limb define a number of spatial parameters and
measure of electrical activity of muscle, its activation temporal parameters refer to time marked events with
patterns & timings can be better quantified to analyse reference to various phases of gait [32,33].
the role of muscles during specific movements thus
helping in developing specific solutions to orthopaedic Pathophysiological Gait
and neuromuscular insufficiency [9,10]. Furthermore, Deviations from the normal phasic sequence
EMG has become an indispensable tool in detecting of bipedal walking is considered as abnormal gait.
and analysing various forms of gait pathologies and its Many factors contribute to gait abnormalities either as
underlying neuromuscular etiology[11]. compensation (antalgic) or consequence of a specific
Current paper will focus on the potential role of impairment (non-antalgic). Antalgic disorders owe to
EMG in gait analysis. The research methods used to compensatory mechanisms which are characterized by
analyse the contribution of different muscle and muscle shortening of stance phase, adapted to prevent pain in
groups during normal/abnormal gait which serves as a the affected leg [34,35,36].
valuable tool in gait rehabilitation is reviewed. Gait disorders are classified into three levels, viz.,
Electromyography in Kinesiology lowest, where disturbance is usually self-limited or
compensated[37], middle, that are mostly multifactorial
State-of-Art involving gait modifications due to spasticity, movement
disorders etc.[38,39] and highest-level disorders that
Electromyography has evolved as a unique method are mostly due to age related factors like dementia,
to monitor and evaluate human movement. As a basic disequilibrium, cognitive and psychogenic disorders
actuator that produces necessary mechanical force to [40,41]
.
cause movement, skeletal muscle and its associated EMG
bridges the underlying physiology and biomechanics As a bottom-up approach, EMG proves to be the sole
significantly contributing to the understanding of Human opportunity for direct analysis of pathophysiological
movement[12,13] mechanisms responsible for gait modifications due to
non-neuronal factors like alterations in passive muscle-
Remarkable contributions in analysing EMG tendon properties [42]. Any compensations during walking
patterns during gait were made by specific group of as a result of cognitive impairment has opened arenas
 210 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

to diagnosis and treatment options[43]. Variations in gait Conclusion

between normal control and subjects with poliomyelitis
Kinesiological Electromyography has evolved in
were analysed based on EMG and accelerometers[44,45]
the past decade to be one of the major biomechanical
Gait Rehabilitation measurement methods without a serious competitive
method within its class. EMG provides a true understanding
Atypical gait patterns that result from joint and objective evaluation of the neuromuscular activation
replacement surgeries and neuromuscular dysfunctions during movement, paving way for considerable analysis.
such as stroke often end up in rehabilitation to restore/ After a serious review performed based on the available
assist normal gait [46]. EMG based evaluation and literature it is concluded that
compensation system for pathological gait due to
neuromotor disorders are popular research interests at • Electromyography can explore the link between
present, since it proves to be the sole opportunity to physiological and biomechanical aspects of movement
identify the desired movement, or to assess the subject’s leading to better diagnosis of movement impairment.
motor capability[47]. EMG appear in lower limb
• The relationship between muscle co-activations
muscles approximately 10ms before the muscle actually
and the distribution of forces among recruited muscles
contracts as an effect of electromechanical delay and
need considerable understanding to discover the
when evaluated within this delay a robust coupling
synergistic control processes involved in regulating
between the human and the machine can be achieved
muscular activity during gait. This can greatly help in
thus allowing for the development of EMG driven
developing EMG based control for assistive devices.
human-machine interfaces[48]. Electromyography based
evaluation on the level of residual activation and neural • Rehabilitation and strength training of muscles
control strategies were used as the primary control for also need good understanding of motor control and
post-stroke patients undergoing Electromechanical gait its underlying rules of neuromuscular system that
training with simultaneous FES[49]. It was seen that coordinates/creates movement.
motor learning is promoted by the use of residual EMG
activity and used to trigger external devices assisting • EMG is one of the major Kinetic variable
movement[50]. that are of interest to uncover clues to neuromuscular
strategies in learning movements and can be used to
Exoskeletons document the temporal location and size of muscular
demands.
An advancement in the field of orthotic development
is the Exoskeleton, an active mechanical device • EMG to muscle force relationships have long
essentially anthropomorphic in nature that work in been an area of research focus. It has great potential for
co-ordination with the operator’s movements either studying altered muscle function due to varying gait
by augmenting the performance of an able-bodied patterns that cannot be readily examined by optimization
wearer or assisting the movements of a physically techniques.
challenged person[51]. To be more precise, exoskeletons
are divided into three broad categories namely, With so many thrust areas of research, Kinesiological
Performance-augmenting Exoskeletons (BLEEX, Electromyography need more focus in the field of
NTU-LEE,HAL-5), Rehabilitation Robots (Locomat, movement science upon overcoming certain limitations.
NaTUre-gaits, WalkTrainer, ALEX, LOPES) and Practical drawbacks related to unpredictable nature of
Mobile Medical Exoskeletons (eLEGS, MIT Medical EMG signals and the occurrence of crosstalk remain to
Exoskeleton, ReWalker, REX Honda Leg,Hybrid Assist be a challenge in analysis. A reliable sensing technology
Leg(HAL)) [52]. Among the successful exoskeletons that that overcomes the effect of crosstalk can surpass the
are developed, HAL uses surface EMG as a sensing challenges related to acquisition. Research findings
modality for control. HAL-based training for improving need to be extended in building commercial EMG based
walking ability or balance and its benefits for patients systems that can be used for diagnosis, treatment and
with chronic stroke, paraplegia and other neuromotor incorporation into assistive technologies as a mode of
disorders has been successfully reported53,54]. sensing and control.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 211

Hence research that focusses more in the analysis Electromyography. Biomechanics in Applications.
of musculoskeletal models scaled and customized to 2011;349–366.
individuals whose EMG and gait data can be used 9. Pasinetti S, Lancini M, Bodini I, Docchio F. A
to simulate the actual action of muscles in normal/ Novel Algorithm for EMG Signal Processing and
abnormal movements and the associated joint forces is Muscle Timing Measurement. IEEE Transactions
needed. Once optimal models are validated, the concept on Instrumentation And Measurement.
can be extended to real time estimation of muscle forces. 2015;64(11):2995–3004.
Overall, Electromyography for kinesiological studies
10. Stefano A, Burrudge J, Yule V, Allen R. Effect
really seem promising in answering many questions
of gait cycle selection on EMG analysis during
related to movement disorders. As an effective tool
walking in adults and children with gait pathology.
for sensing and control, EMG has great potentials to
Gait & Posture, 2004;20(1), 92-101.
be utilised in the field of rehabilitation and assistive
technology. 11. Farina D, Holobar A. Characterization of Human
Motor Units from Surface EMG Decomposition.
Conflict of Interest: The authors do not have any Proc IEEE. 2016;104(2):353–73.
conflicts of interest to disclose 12. Winter DA. Biomechanical motor patterns in
normal walking. Journal of Motor Behavior, 1983;
Funding: This study is institute funded.
15(4), 302–330.
Ethical approval: No Human or Animal studies 13. Peat M, Dubo HI, Winter DA, Quanbury
form a part of this work. AO, Hobson DA, Steinke T, Reimer, G.
Electromyographic temporal analysis of gait:
References normal human locomotion. Arch Phys Med
1. Sousa ASP, Silva A, Tavares JMRS. Biomechanical Rehabil, 1976; 57(9), 415–420.
and neurophysiological mechanisms related to 14. Pedotti A. A study of motor coordination and
postural control and efficiency of movement: A neuromuscular activities in human locomotion.
review. Somatosens Mot Res. 2012;29(4):131–43. Biol Cybern. 1977;26(1):53–62.
2. Hausdorff JM, Ladin Z, Wei JY. Footswitch system 15. Yang JF, Winter DA.Electromyography reliability
for measurement of the temporal parameters of gait. in maximal and submaximal isometric contractions.
J Biomech. 1995;28(3):347–51. Archives of Physical Medicine and Rehabilitation,
3. Harris GF, Wertsch JJ. Procedures for Gait Analysis. 1983; 64(9), 417–20.
Arch Phys Med Rehabil. 1994;75(2):216–25. 16. Winter DA. Pathologic gait diagnosis with
4. Kiss RM, Kocsis L, Knoll Z. Joint kinematics computer averaged electromyographic profiles
and spatial-temporal parameters of gait measured Arch Phys Med Rehabil, 1984;65(7), 393-398.
by an ultrasound-based system. Med Eng Phys. 17. Yang JF, Winter DA. Electromyographic amplitude
2004;26(7):611–20. normalization methods: improving their sensitivity
5. Tao W, Liu T, Zheng R, Feng, H. Gait analysis as diagnostic tools in gait analysis. Arch Phys Med
using wearable sensors. Sensors, 12(2), 2012; Rehabil [Internet]. 1984;65(9):517–21.
2255–2283. 18. Olney SJ, Winter DA. Predictions of knee
6. Muro-de-la-Herran A, García-Zapirain B, Méndez- and ankle moments of force in walking
Zorrilla A. Gait analysis methods: An overview of from EMG and kinematic data. Journal of
wearable and non-wearable systems, highlighting Biomechanics,1985;18(1):9­20.
clinical applications. Sensors (Switzerland). 19. Yang JF, Winter DA. Surface EMG profiles
2014;14(2):3362–94. during different walking cadences in
7. Chen DKY, Haller M, Besiar TF. Wearable lower humans. Electroencephalogr Clin
limb haptic feedback device for retraining foot Neurophysio. 1985;60(6):485–491.
progression Angle and step width. Gait & Posture.
20. Arsenault A, Winter D, Marteniuk R. Bilateralism
2017; 55:177-183.
of EMG profiles in human locomotion. Am J Phys
8. Medved V, Cifrek M. Kinesiological Med. 1986;65(1):1–16.
 212 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

21. Arsenault A, Winter D, Marteniuk R. Is there Journal of Electromyography and Kinesiology.

a ’normal’ profile of EMG activity in 2013; 23(6):1428–33.
gait?,Med. Biol. Eng. Comput. 1986;24(4):337– 32. Chan CC, Liao WH. Temporal gait parameters
343. captured by Surface Electromyography
measurement. 2012 IEEE Int Conf Robot
22. Õunpuu S, Winter DA. Bilateral electromyographical
Biomimetics, ROBIO 2012 - Conf Dig. 2012;1056–
analysis of the lower limbs during walking in normal
61.
adults. Electroencephalogr Clin Neurophysiol.
1989;72(5):429–38. 33. Di Nardo F, Agostini V, Knaflitz M, Mengarelli
A, Maranesi E, Burattini L, et al. The occurrence
23. Scott SH, Winter DA. Technique for interpretation
frequency: A suitable parameter for the evaluation
of EMG for concentric and eccentric contractions
of the myoelectric activity during walking. Proc
in gait. J Biomech. 1989;22(10):1080.
Annu Int Conf IEEE Eng Med Biol Soc EMBS.
24. Winter DA, Scott SH. Technique for interpretation 2015;2015–November:6070–3.
of electromyography for concentric and eccentric
34. Rubino FA. Gait Disorders. Neurologist. 2002;
contractions in gait. Journal of Electromyography
8(4):254-262.
and Kinesiology.1991; 1(4):263–269.
35. Alexander NB, Goldberg A. Gait disorders: Search
25. American Association of Electrodiagnostic
for multiple causes Cleveland Clinic Journal of
Medicine & American Academy of Physical
Medicine. 2005; 72(7):586-599.
Medicine and Rehabilitation. Technology Review:
Dynamic Electromyography In Gait And Motion 36. Gilliss AC, Swanson RL, Janora D, Venkataraman
Analysis. Muscle Nerve. 1999;22(8):233-238. V. Use of Osteopathic Manipulative Treatment to
Manage Compensated Trendelenburg Gait Caused
26. Hof AL, Van den Berg JW. EMG to force
by Sacroiliac Somatic Dysfunction. J Am Osteopath
processing I: An electrical analogue of the
Assoc. 2016;110(2):81.
Hill muscle model. Journal of
Biomechanic.1981;14(11):747–758. 37. Lehmann JF, de Lateur BJ, Price R. Biomechanics
of abnormal gait. Phys Med RehabilClin North Am,
27. Winter DA, Yack HJ. EMG profiles during
1992;3(1):125-138.
normal walking: Stride to stride and inter
subject variability. 38. Bogey RA, Perry J, Gitter, AJ. An EMG-to-
ElectroencephalogrClinNeurophysiol.1987; force processing approach for determining ankle
67(5):402-411. muscle forces during normal human gait. IEEE
Transactions on Neural Systems and Rehabilitation
28. Hof AL, Pronk CN, Van Best JA. Comparison
Engineering. 2005; Vol.13, No.3, pp.302–310.
between EMG to force processing and kinetic
analysis for the calf muscle moment in walking 39. Campbell WW. DeJong’s the Neurologic
and stepping. Journal of Biomechanics. 1987; Examination. 7th ed. Philadelphia: Lippincott
20(2):167–178. Williams & Wilkins, 2013;Chapter 2.
29. Wang Q, Chen X, Wu D, Qian L, Zhang X. 40. Frigo C, Crenna P. Multichannel SEMG in clinical
Acceleration and electromyography (EMG) pattern gait analysis: A review and state-ofthe-art. Clin.
analysis for children with cerebral palsy. 2012 Biomech, 2009;24(3): 236–245.
IEEE 14th Int Conf e-Health Networking, Appl 41. Brunner R, Romkes J. Abnormal EMG muscle
Serv Heal 2012. 2012;(61271138):138–42. activity during gait in patients without neurological
30. Wang P, Low KH. Qualitative evaluations of gait disorders. Gait & Posture. 2008;27(3):399-407.
rehabilitation via EMG muscle activation pattern: 42. Waterval NFJ, Brehm ma, Ploeger HE, Nollet F,
Repetition, symmetry, and smoothness. 2009 Harlaar J. Compensations in lower limb joint work
IEEE Int Conf Robot Biomimetics, ROBIO 2009. during walking in response to unilateral calf muscle
2009;215–20. weakness. Gait & Posture. 2018; 66: 38-44.
31. Di Nardo F, Ghetti G, Fioretti S. Assessment of the 43. Brach JS, VanSwearingen JM, Interventions to
activation modalities of gastrocnemius lateralis and Improve Gait in Older Adults with cognitive
tibialis anterior during gait: a statistical analysis. impairment: A systematic Review. J Am Geriatr
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 213

Soc. 2018; 67(2):381-391. 49. Tong RKY, Ng MFW, Li LSW, So EFM. Gait Training
44. Vidhya L, Saranya S, Poonguzhali S. Analysis of of Patients After Stroke Using an Electromechanical
Lower Extremity Muscle Activation Using EMG. Gait Trainer Combined With Simultaneous Functional
Applied Mechanics and Materials. 2014; 573:797– Electrical Stimulation. Physical Therapy. 2006; 86(9):
802. 1282-1294.
45. Minerva R, Saranya S, Poonguzhali S. Gait50. Pons JL, Moreno JC, Brunetti FJ, Roco E. Lower-Limb
analysis using wearable MEMS Tri-axial Wearable Exoskeleton. Rehabil Robot. 2012;471-498.
accelerometer system. In Applied Mechanics and51. Dollar AM, Herr H. Lower extremity exoskeletons and
Materials. 2014;573:830–835. active orthoses: Challenges and state-of-the-art. IEEE
46. Belda-Lois JM, Horno, SMD, Bosch, IB, Trans Robot. 2008;24(1):144–58.
Moreno JC, Pons JL, Farina D, Rea M.52. Low KH. Robot-assisted gait rehabilitation: From
(2011). Rehabilitation of gait after stroke: a exoskeletons to gait systems. 2011 Def Sci Res Conf
review towards a top-down approach. Journal Expo, DSR 2011. 2011.1-10.
of Neuroengineering and Rehabilitation.53. Kawamoto H, Kamibayashi K, Nakata Y, Yamawaki
2011;8(1):66. K, Ariyasu R, Sankai Y, Sakane M, Eguchi K, Ochiai
47. Horsak B, Schwab C, Baca A, Platzer SG, Kreissl N. Pilot study of locomotion improvement using hybrid
A, Nehrer S, Keilani M, Crevenna R, Kranzl A, assistive limb in chronic stroke patients. BMC Neurol.
Wondrasch B. Effect of lower extremity exercise 2013;13:141.
program on gait biomechanics and clinical54. Kubota S, Nakata Y, Eguchi K, Kawamoto H,
outcomes in children and adolescents with obesity: Kamibayashi K, Sakane M, Sankai Y, Ochiai N.
A randomized control trial. Gait Posture. 2019; Feasibility of rehabilitation training with a newly
70;122-129. developed wearable robot for patients with limited
48. Begovic H, Zhou GQ, Li T, Wang Y, Zheng YP. mobility. Arch Phys Med Rehabil. 2013;94(6):1080–
Detection of the electromechanical delay and its
components during voluntary isometric contraction
of the quadriceps femoris muscle. Front Physiol.
2014;5:1–8.
 214 Indian Journal of Public Health ResearchType
& Development, January
of article: Case report2020, Vol. 11, No. 1

Ophthalmomyiasis due to Oestrus Ovis Complicated with

Methicillin Ressistant Staphylococcus Aureus First Report
Near Coastal Area

Shaik Khaja Moinuddin1, Anandi.V2, Amirtha C3

1
Research Scholar, 2Professor, Department of Microbiology, Vinayaka Missions Medical College & Hospital,
Karaikal, Puducherry, India, 3MS (OG) Post graduate, Balaji medical college and hospital, Chennai, India

Abstract
Ophthalmomyiasis, is the infestation of any anatomic structure of the eye. Larvae of sheep nasal botfly,
Oestrus ovis is the most common cause of human ophthalmomyiasis. A 19-year-old male, presented to
the ophthalmology outpatient department with a 1 day history of moving foreign body sensation, redness,
and excessive watering from his right eye. Multiple larvae were found on bulbar conjunctiva. Larvae were
removed and identified as Oestrus ovis. Bacterial infection was proved by isolating a heavy growth of
methicillin resistant Staphylococcus aureus(MRSA) from conjuctival swabs. Dual infection of parasitic and
bacterial infection of young male adult is proved and also found to be a rare dual manifestation of eye. Hence
this case is being reported here.

Key words: Dual infection, Oestrus ovis, Staphylococcus aureus.

Introduction of human ophthalmomyiasis.[5] Dual infection due to

Oestrus ovis and Staphylococcal infections have not
Myiasis is the term applicable to the infestation
been reported in Indian literature and is being reported
of human beings and other vertebrates with the larvae
here as a rare case report.
(maggots) of Diptera flies. Different parts of the human
body may get affect due to myiasis infestation. Most
Case Report
commonly skin and body cavities (mouth, nostrils,
ear and eye.). Involvement of any anatomical site of A 19 year-old male, fisherman by occupation,
eye is called as Ophthalmomyiasis. [1] Larvae, most presented to the ophthalmology outpatient department
commonly, attack the external surface of the eyes or with a 1-day history of moving foreign body sensation,
ocular adnexia, e.g. the lids, conjunctiva or lacrimal redness, and excessive watering from his right eye,
ducts (external ophthalmomyiasis). In uncommon following insect hit into his eye while riding motor bike
instances they may penetrate into the eyeball itself through sheep raising areas. He gave no past history of
(internal ophthalmomyiasis) or may involve the orbit ocular or medical problems.
(orbital myiasis).[2] From different parts of the world
On examination, his visual acuity was 20/20 in
ophthalmomyiasis have been reported. [3]. Mostly
both eyes. Eyelids of the affected eye were absolutely
reported were from rural areas and had history of contact
normal. The conjunctiva was mildly congested with
with cattle. [4] Oestrus ovis is the most common cause
profuse lacrimation. On slit-lamp examination, multiple,
tiny and translucent worms, 1–2 mm in size, crawling
over the bulbar conjunctiva were seen. Anterior chamber
Corresponding Author
was found to be normal. Using 4% xylocaine drops as
S.Khaja Moinuddin
topical anesthesia, 8 worms were removed manually
Research Scholar, Department of microbiology
with the help of sterile forceps. While removing worms
Vinayaka missions medical college &Hospital,
mechanically with the help of forceps, they were tightly
Karaikal -609609, Puducherry, India
adhering to the bulbar conjunctiva. After removal of all
Email: [email protected]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 215

larvae, three swabs were collected for bacteriological months, depending on changes in the atmosphere. [10]
and mycological culture. Two swabs were inoculated
on bacteriological media such as blood agar, chocolate Man is accidental host, with the eye being point of
agar and Mac Conkey agar. One swab was inoculated on adherence for larvae. In man, the larvae cannot be alive
Sabouraud s dextrose agar and processed according to beyond the early larval stage and are believed to die
standard microbiological procedures.[6] within ten days if not taken out [11] Although the threat
of orbital penetration and future serious consequences
Laboratory findings: seems to be low, it is prudent to get rid of the larvae from
the mucosa of conjunctiva promptly.
On microscopic examination, spindle-shaped
skeleton with multiple segments and intersegmental External ophthalmomyiasis usually presents with
spine bands were seen. The larvae also showed a pair of ocular itching, foreign body sensation and a watery-
sharp dark brown oral hooks and tufts of numerous brown mucopurulent discharge confined to the conjunctiva. [11]
hooks on the anterior margin of each body segment and Draining of conjunctival sac with saline is ineffective
they were identified as Oestrus ovis.[Figure] in cleasing out the larvae. Larvae hold the conjunctiva
firmly with the help of tiny spines on its outer surface
Staphylococcus aureus was isolated from and anterior hooks. Possibilities of misdiagnosis as viral
bacteriological media was found to be methicillin resistant or allergic conjunctivitis is not uncommon. External
Staphylococci and it was sensitive to, chloramphenicol, ophthalmomyiasis typically happens in the summer and
Moxifloxacin and cefazolin. No fungus was isolated autumn which differs from other microbial conjunctivitis,
from Sabouraud dextrose agar even after 14 days. which may occur throughout the year.
The patient improved dramatically after a mechanical A heavy growth of Staphylococcus aureus was
removal of the larvae and a topical application of isolated from conjunctival swab after 24 hours of
antibiotic (Moxifloxacin) –steroid combination therapy. incubation at 37 0 C. Based on this preliminary report
When the patient came for a follow-up after five days, of Staphylococcus aureus, the patient was started on
he was completely relieved of his symptoms of foreign moxifloxacin and the patient recovered completely.
body sensation and excessive watering. Antibiotic susceptibility testing by Kirby Bauer
disk diffusion method also revealed susceptible to
Discussion moxifloxacin. The patient had bacterial infection
Hope was the first person to describe myiasis. [7] following the traumatic episode by the bot fly which
Worldwide, human myiasis is distributed with various could be during the hit by the bot fly or due to the rubbing
species and larger abundance in poor socioeconomic of the eye by the patient.
areas of tropical and semitropical countries. [2] Ocular
involvement happens in less than 5 percent of all cases Conclusion
of human myiasis. [8] The most common cause of A rare case of co infection of external
external ophthalmomyiasis is the larvae of sheep botfly, ophthalmomyiasis due to Oestrus ovis and methicillin
Oestrus ovis Other agents involved in causing myiasis resistant Staphylococcus aureus(MRSA). Early diagnosis
are Rhinoestrus purpureus , Dermatobia. hominis , and prompt initiation of appropriate interventional
Chrysomya. bezziana , Lucilia spp. , and Cuterebra[2] procedure to remove the Oestrus ovis and anti bacterial
Morphologically adult bot fly resembles honeybee, treatment saved an eye.
which is yellow to gray brown, 10– 12 millimeters Source of Funding- Self
long. The gravid fly deposits larvae (Oestrus ovis) in
or around the nostrils of cattle (host). These early stage Conflict of Interest- Nil
larvae (first instar) deposited, adheres to the mucous
membranes within the nasal cavities, then transform Ethical Clearance: Taken from institutional ethical
to second instars and crawl till the sinuses, where they committee.
develop further and mature into third instars, which are
shed out for pupation under the soil [9]. The life cycle of
References
this parasite is variable, from couple of weeks to many 1. Gursel, M., Almemir, O.S., Ozgur, Z., Ataoglu, T.
 216 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A rare case of gingival myiasis caused by Diptera 7. Hope FW: On insects and their larvae occasionally
(Calliphoridae). J Clinic Periodontol. 2002;29:777– found in the human body. Trans R Soc Entomol
780 1840, 2:256-271
2. Fabio Francesconi, Omar Lupi. Myiasis. Clinic 8. Pandey A, Madan M, Asthana AK, Das A, et al.
Microbiol Rev 2012;25:79-104. External ophthalmomyiasis caused by Oestrus ovis:
3. Elliot, R.H., Quoted by Sivaramasubramaniam and a rare case report from India. Korean J Parasitol
Sadanand, Brit. J. Ophthalmol 1968; 52: 64 2009;47:57–9
4. Patel SJ. Extra-ocular myiasis due to the larva of 9. Zumpt P. Myiasis in man and animals in the
Oestrus ovis. East African Med J 1975; 52: 167- Old World. London: Butterworths; 1965.
169. PMid:14272962.
5. Dunbar J, Cooper B, Hodgetts T, Yskandar H, Thiel 10. Hall M, Wall R. Myiasis of Humans and Domestic
PV, Whelan S, et al. Clin Infect Dis 2008;46:124-6. Animals. Adv Parasitol 1995; 35: 257-334.
6. Forbes BA, Sahm DF, Weissfeld AS. Chapter 11. Sreejith R S, Reddy A K, Ganeshpuri S S, Garg
13, Overview of bacterial identification methods P. Oestrus ovis ophthalmomyiasis with keratitis.
and strategies. Bailey and Scott’s diagnostic Indian J Med Microbiol 2010;28:399-402
Microbiology, 12th ed. St.Louis: Mosby; 2007. p.
216-47.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 217

Oral Health Literacy and its Relationship with Level of

Education and Self-Efficacy among Patients Attending a Dental
Rural Outreach Clinic in India

Shatakshi Srivastava1, Shashidhar Acharya2, Deepak Kumar Singhal3, Abhishek Dutta4, Kush Kalra5,
Nishu Singla6
1
Lecturer, Dept. of Public Health Dentistry, MGM Dental College and Hospital, Navi Mumbai, Maharashtra,
India, 2Professor, 3Associate Professor, Dept. of Public Health Dentistry, Manipal College of Dental Sciences,
Manipal , Manipal Academy of Higher Education (MAHE), Karnataka,India, 4Lecturer, Dept. of Oral and
Maxillofacial Surgery, MGM Dental College and Hospital, Navi Mumbai, Maharashtra, India, 5Senior Lecturer,
Dept. of Public Health Dentistry, Santosh Dental College, Santosh University, Ghaziabad, U.P.,
6Associate Professor, Dept. of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal

Academy of Higher Education (MAHE), Karnataka, India

Abstract
Objective:To evaluate the relationship between Oral health literacy (OHL) with the level of education and
self-efficacy among adults (age 18-77 years) patients attending a dental outreach clinic in Udupi Taluk. Basic
research design: A cross-sectional study of adult patients attending a dental outreach clinic by convenience
sampling. Method: Information was obtained about patient’s sociodemographic factors along with the self-
efficacy by using Dental Copings Belief’s scale (DCBS) questionnaire and OHL was assessed by using a
word recognition instrument Rapid Estimate of Adult Literacy in Dentistry (REALD-30).One way ANOVA
and Pearson’s χ2 test were used for analysis. Participants: 200adult patients age range of 18- 77 years who
wanted to seek dental care in a dental outreach clinic. Main outcome measures: Oral health literacy (OHL)
and Self efficacy (DCBS) Results: In this study the OHL was significantly associated with the level of
education of patients.Among the 200 subjects who claimed to be able to read and write English language
andhad completed education till class 10th; more than 50% of the subjects had Low (≤21)OHL scores.Only
12.5% of the total study population had High OHL (≥26) and were clearly able to understand simple dental
terminology. Moderate levels of literacy was recorded in 75.6% in graduate and postgraduates indicating
that even these people partially understood dental terms. There was no significant association between oral
health literacy and self-efficacy.Conclusion:Our study suggests level of education to be a strong indicator
of the OHL in the Indian Population. Further research to develop new instruments to measure the OHL, in
a culturally diverse country like India, which has people of different mother tongues should be encouraged.

Keywords: oral health; health literacy; self- efficacy; community outreach

Introduction developed over several years and the existing literature

The concept of Oral health literacy (OHL) has is ever increasing in this field. Health literacy refers to
the ability of individuals to obtain, understand and act
upon health information and to make appropriate health
Corresponding author: decisions. (1-3) Oral health literacy (OHL) refers to the
Dr. Shatakshi Srivastava: Lecturer, Dept. Of Public degree to which individuals have the capacity to obtain,
Health Dentistry, Mahatma Gandhi Missions Dental process and understand basic oral health information and
College and Hospital, Kamothe, Navi Mumbai, services needed to make appropriate health decisions.(4)
Maharasthra, India -410209 This concept has not yet gained sufficient weightage in
Email id:[email protected] ; Phone regular dental practice.
number: +91- 7045393005
 218 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Oral Health literacy is like a bridge between the dental Scale (DCBS) among adult (age 18-77 years) patients
care provider’s instructions and the comprehension, attending a dental outreach clinic in Udupi Taluk.
thereby abiding of the patient to the same. This role of
OHL makes it important for the dentist to ascertain the Objectives-
level of OHL of the patient before any procedure and then 1) To evaluate the Oral health literacy in adults
treat the patient according to the level of understanding visiting a dental outreach clinic in India by using
of the patient. After identification of the level of OHL word recognition instrument- Rapid Estimate of Adult
attention should be paid by the dentist to communicate Literacy in Dentistry (REALD-30).
with the public and remove literacy-related barriers to
information, decision making, and healthful action. 2) To evaluate the Self-efficacy using Dental
(5) A significant number of patients may have a low Coping Beliefs Scale (DCBS) questionnaire in the same
level of oral health literacy, which possibly interferes subjects.
with their ability to process and understand oral health
information. Providers should identify patients who are 3) To evaluate the relationship between OHL with
having difficulty understanding and using dental health level of education.
information and address their needs. (6) 4) To evaluate the relationship between OHL and
According to Paasche-Orlow and Wolf conceptual self-efficacy.
model of causal pathways between health literacy and Method-
health outcomes the effect of literacy on health outcomes
is mediated by patient-level and extrinsic factors grouped Sample and data collection- A convenience sample
as (1) access to and utilization of health care, (2) provider– of participants (N=200) was recruited from patients
patient interaction, and self-care.(7) Many factors are presenting for an initial consultation to a dental rural
related to OHL but amongst the recent ones focus has clinic in Udupi. Written informed consent was obtained
been given to those that affect behavior because behavior for all study participants. Study Design-A Cross-
is amenable to change. A successful dental practice is sectional questionnaire study. Inclusion Criteria were-
not only related to dental treatment provided, but also to subjects who claimed to be able to read English words,
the patient’s attitude and behavior towards the treatment. subjects more than 18 years of age but younger than
(8) Individual health practices such as oral self-care are 80 years, subjects who had completed education till
based on personal choices.(9) According to the model a minimum of 10th class, subjects without cognitive
proposed by Lee et al., Personal characteristics such impairment, subjects without vision or hearing problems
as self-efficacy mediate and/or modify the impact of and subjects without obvious signs of drug/alcohol
literacy on oral health behaviors.(10) intoxication. Exclusion Criteria: were subjects who
are not able to read English words, subjects less than
Self-efficacy-Perceived self-efficacy is concerned 18 years of age and more than 80 years, subjects who
with people’s beliefs in their capabilities to produce given have completed education less than 10th class, subjects
attainments.(11) Perceived self-efficacy is a judgment of not willing to participate in the study, subjects with
capability to execute given types of performances and psychiatric disorders and subjects with other severe
outcome expectations are judgments about the outcomes systemic illness. Ethical clearance was obtained from
that are likely to flow from such performances. Perceived the Kasturba Hospital Ethics Committee, Manipal before
efficacy has a pivotal role because it affects behavior commencement of the study(IEC 277/2014). Informed
and its impact on other determinants such as goals and consent was obtained from all patients prior to the start
aspirations; outcome and expectations. Self-efficacy of the study. The Oral Health Literacy Assessment was
appraisals reflect the level of difficulty individuals done using REALD-30 which is a word recognition
believe they can surmount. (11) instrument which has 30 dental related words arranged
The aim of the present study was to evaluate the in order of increasing difficulty. (12) The words were read
relationship between Oral health literacy (OHL) by aloud by the subject to the interviewer. The participants
using Rapid Estimate of Adult Literacy in Dentistry were asked not to phonetically deduce the words, but
(REALD-30)with the level of education and self-efficacy rather to skip a word if they did not know it. One point
by using a questionnaire on Dental Coping Beliefs is given to each word pronounced correctly (zero point
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 219

if incorrectly). The REALD-30 score was categorized as Table 1-Distribution of study participants
Low (≤21), Moderate (22 to 25) or High (≥26).(13) according to socio-demographic characteristics

In addition to the above, each patient completed a

Participants (%)
questionnaire regarding Self-efficacy. This questionnaire Variables
N=200
was a part of Dental Coping Beliefs scale (DCBS). (14)
The participants were asked to mark only one response
to each question. Total Self- efficacy was calculated by Male 82 (41%)
Gender
adding each of the responses. It had 9 questions and the
responses were recorded on a Likert scale.The responses Female 118(59%)
were-(1) Strongly agree, (2) Agree, (3) Neither, (4)
Disagree and (5) Strongly disagree. Additionally, socio-
demographic data was included in the questionnaire Mean 38.33
-Age, gender, education, occupation, monthly income. Age (years)
Range 18-77
Data Analysis-Statistical analysis was performed
using SPSS (version 16.0).One way ANOVA was used to
assess the relation between REALD-30(categorized-low, Middle 159(79.5%)
moderate, high)and self-efficacy (continuous variable). Socioeconomic
Pearson’s χ2 test was used to assess association between status
Low 41(20.5%)
education and REALD-30. The level of significance was
set at 0.05.
Table 2- Distribution of REALD-30
Results
The study population consisted of 200 English Frequency Percentage

speaking adults who visited the dental outpatient

High 25 12.5%
clinic. Questionnaire was administered to 200 adults
and the response rate was 100.0%.The mean age of the Moderate 61 30.5%
respondents 38.33 years who were in the age range of
18 to 77 years. Among the respondents 41% were males Low 114 57.0%
and 59% were females. An individual’s completion of
Total 200 100.0%
the entire questionnaire was ensured by checking for
it during the oral health examination. The respondents
were asked to complete the incomplete forms. The Table 3- Distribution of Self efficacy
demographic characteristics of the participants are
presented in Table 1. The distribution of REALD-30 is Median Range
Standard
presented in Table 2 of which 12.5% people have high Deviation
OHL, 30.5% have moderate OHL and 57.0% have low
OHL. Self-efficacy in results have been presented in Total Self
18.00 9-29 3.73
Table 3. The self-efficacy range is 9-29 with a median of efficacy
18.0.The co-relation between REALD and Self efficacy
was analyzed by One way ANOVA and presented in
Table 4.There was no significant association between
OHL and self-efficacy.Pearson’s χ2 test was used to
test for association between Education and REALD has
been presented in Table 5. The OHL was significantly
associated with the level of education of patients. 6.0%
of the participants completed high school education,
33.0%Intermediate/PUC, 58.5% Graduate/Post graduate
and 2.5% Profession/ Honors.
 220 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 4- One way ANOVA- Co-relation between REALD and Self efficacy

N Mean
Standard deviation Sig.
Self-efficacy

High
25 18.520 4.204
REALD
Moderate
61 18.442 3.909
0.983
Low
114 18.377 3.548

Total
200 18.415 3.727

Table 5- Association between Education and REALD

REALD Signi-
High
Total ficance
Moderate Low

Count 0 0 12 12
High school
% 0% 0% 10.5% 6.0%

Intermediate/ Count 6 14 46 66
PUC % 24.0% 23.0% 40.4% 33.0%
Education

Graduate/ Count 17 46 54 117

Post graduate % 68.0% 75.4% 47.4% 58.5%
0.001*
Profession/ Count 2 1 2 5
Honors % 8.0% 1.6% 1.8% 2.5%

Total Count 25 61 114 200

% 100% 100% 100% 100%

Pearson’s Χ2 is taken as 0.001* as significant

Discussion in understanding a patients’ belief either in internal or

external controls and also the ability to which patient
The aim of this study was to evaluate the oral health
perceives himself/herself to be able to perform given
literacy (OHL) and its relationship with self-efficacy
tasks. (14) In the present study, there was no significant
among adult patients attending a dental outreach clinic.
association between oral health literacy and self-efficacy.
To the best of our knowledge this is the second study
The self-efficacy has been assessed using a self-reported
done in India to assess the OHL using REALD-30 as the
questionnaire, thus this finding could be attributed to the
assessment tool and the first study done to look closely
social desirability bias.
into the association between OHL and self-efficacy in
an adult Indian population in an outreach dental clinic. Among the 200 study English speaking subjects
In this study the OHL was significantly associated with who had completed education at least till 10th class, who
the level of education of patients which is similar to the participated in the study OHL scores were very low in
findings of another study on Health Literacy. (15) more than 50% of the subjects (57%-low OHL). These
subjects scored less than 21 which mean these patients are
The dental copings beliefs scale was used to assess
likely to struggle to understand simple dental terminology
self-efficacy. DCBS helps the oral health professional
which is used by the dentists while communicating to the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 221

patients. Only 12.5% of the total study population had costs and disparities. (18) The ‘‘roots of health literacy
High OHL (≥26).This means only a little more than 10% problems have grown as health practitioners and health
of the whole of the study population is actually clearly care system providers expect patients to assume more
able to understand the dental terms used by the dentists. responsibility for self-care at a time when the health
Only moderate levels of literacy was recorded in 75.6% system is increasingly fragmented, complex, specialized,
in graduate and postgraduates indicating that even these and technologically sophisticated”. (19) Thus dentists
people understand only some of the dental terms and not should identify patients who are having difficulty
all. The findings in the present study indicate that even in understanding and using dental health information and
an Indian population with a basic level of education who address their needs.
are able to read and write in English have low levels of
Oral health literacy. Similar findings are reported by M Considering the importance of measuring oral
D’Cruz et al.,2014. (16) health literacy and the numerous instruments available
for the same, it becomes imperative to determine the
Demands for reading, writing, and numeracy skills applicability of the particular instrument to be used in
are intensified due to health-care systems’ complexities, the population under consideration.(15) Thus, for further
advancements in scientific discoveries, and new research in the field of oral health literacy in a culturally
technologies. In this study there was no significant diverse country like India with people of different
association between Oral health literacy and caries mother tongues, other instruments which measure oral
status and periodontal status. This could be attributed health literacy rapidly and also test comprehension of
to the fact that the oral health literacy was taken by a the participants should be developed.
word recognition instrument the REALD-30 which has
several limitations. There is no known conflict of interest for this study.
There was no funding obtained for this study.
This instrument is only a word recognition instrument
and does not take into account whether the individual References
comprehends the dental words. Also, pronunciation of 1. HHS (U.S. Department of Health and Human
words vary in the Indian population due to a difference Services). 2000. Healthy People 2010:
in dialect. It is possible that incorrect pronunciation may Understanding and Improving Health. Washington,
not necessarily mean that meaning of the word is also DC: U.S. Department of Health and Human
not known, more so among individuals with lower levels Services
of education.(17) Therefore, the evaluation of oral health
2. Ratzan SC, Parker RM. Introduction. Selden CR,
literacy via a word recognition instrument like REALD
Zorn M, Ratzan SC, Parker RM, Editors. In: National
may be misleading. Due to these reasons, an association
Library of Medicine Current Bibliographies in
of oral health literacy with DMFT or CPI is difficult to
Medicine: Health Literacy. Vol. NLM Pub. No.
assess.
CBM 2000-1. Bethesda, MD: National Institutes
Newer tools for assessing oral health literacy of Health, U.S. Department of Health and Human
should be developed which test comprehension along Services.
with simple word recognition. Then the level of health 3. Ratzan SC. Health literacy communication for
literacy can be measured accurately and associated with the public good: Health Promotion International,
oral health outcomes like caries status and periodontal Oxford University Press 2001:16 (2), p207-213.
status. 4. National Institute of Dental and Craniofacial
Research. The invisible barrier: literacy and
Conclusion its relationship with oral health. A report of a
Demands for reading, writing, and numeracy workgroup sponsored by the NIDCR, USPHS,
skills are intensified due to health-care systems’ DHHS. J Public Health Dent. 2005; 65: 174-82.
complexities, advancements in scientific discoveries, 5. Rima E. Rudd. Oral health literacy: correcting the
and new technologies. (18) Poor health literacy has mismatch. Journal of Public Health Dentistry 2012;
been described as a “silent epidemic” which needs to 72: S31–S33.
be taken care of by professionals and policy makers in
6. M Jones, J Y. Lee, R. G Rozier. Oral health literacy
order to improve quality of health care delivery, reduce
 222 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

among adult patients seeking dental care. JADA 14. Wolfe GR, Stewart JM et al. Use of Dental Coping
2007; 138 (9): 1199-1208. Beliefs Scale to measure cognitive changes
7. Paasche-Orlow MK, Wolf MS. The causal pathways following oral hygiene interventions. Community
linking health literacy to health outcomes.Am J Dentistry and Oral Epidemiology 1996; 24: 37-41
Health Behav. 2007 Sep-Oct;31 Suppl 1:S19-26. 15. Rathnakar U.P, A Kamath, M Urval, et al .
8. Schou L. The relevance of behavioural sciences in Applicability of the rapid estimate of adult health
dental practice.Int Dent J. 2000;Suppl Creating A literacy in medicine – short form among patients
Successful:324-32. attending a university hospital in southern India.
International J. of Healthcare and Biomedical
9. Hollister MC, Anema MG. Health behavior
Research 2014; 3(1): 196-205
models and oral health: a review.J Dent Hyg. 2004
Summer;78(3):6. 16. A M D’Cruz and M R Aradhya. Health literacy
among Indian adults seeking dental care
10. J Y. Lee, K Divaris, A. D Baker, et al. The
experiences. J Public Health Dent 2014; 74: 195–
Relationship of Oral Health Literacy and Self-
201.
Efficacy with Oral Health Status and Dental
Neglect. Am J of Public Health.2012 May 102(5): 17. J Y Lee, R G Rozier, S Y D Lee, et al. Development
923-929. of a Word Recognition Instrument to Test Health
Literacy in Dentistry: The REALD-30 -A Brief
11. Bandura A. Guide for constructing Self-efficacy
Communication. J Public Health Dent. 2007 ;67
scales, Self-Efficacy Beliefs of Adolescents:
(2):94-98.
Information Age Publishing 2006, p307–337.
18. Bohlman LN, Panzer A, Hamlin B, et al.
12. J Y Lee, R. G Rozier, S Y D Lee, et al . Development
Health literacy: a prescription to end confusion.
of a Word Recognition Instrument to Test Health
Washington: National Academies Press 2004, p1-
Literacy in Dentistry: The REALD-30 -A Brief
25.
Communication. J Public Health Dent 2007; 67
(2):94-98. 19. Parker RM. Health literacy: a challenge for
American patients and their health care providers.
13. Meggan M.H., Caleb L. Corwin, et al. The impact
Health Promot International. 2000; 15(4): 277–83.
of oral health literacy on periodontal health status.
J Public Health Dent 2014; 74: 80-87.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 223

A Study of Relationship between Maternal Height and

Fertility: Indian Concern

A. K. Tiwari1, Shivam Mishra2, Ravi Kant Maurya2

1Associate Professor, Department of Statistics, Institute of Science, Banaras Hindu University, Varanasi-221005
2
Research Scholar, Department of Statistics, Institute of Science, Banaras Hindu University, Varanasi-221005

Abstract
Demographers, as well as public health professionals, have been quite interested to study the relationship
between maternal body size and fertility. In this paper, the relationship between mother height, number of
surviving children and parity is investigated for India and its major states. The mean number of children ever
born is high in shorter mother and mean duration of first birth interval among the taller mothers is less than
the shorter mothers. Taller women tend to have fewer children but more surviving children. The National
Family Health Survey (NFHS) collect the information on fertility, infant and child mortality and the practice
of family planning. For this study authors have used NFHS-4 data.

Key Words: Fertility, maternal height, first birth interval, children ever born, surviving children, parity etc.

Introduction either directly or indirectly. Bongaarts2(1978) refined

Davis and Blake’s fertility framework and identified
Human biologists are concentrated on describing the a smaller set of seven variables and named them
associations between fertility differentials with maternal proximate determinants of fertility; among them, four
shape and assessing the evolutionary implications of determinants were considered most important in terms
these associations. of explaining variations in fertility levels of populations
Fertility is considered one of the most important by Bongaarts3(1982).
factor in the study of population dynamics. It is From the above theories, it has resulted that
determined by a complex set of biological, socio- reproductive success is determined by numerous
economic, and psychological factors. So, social scientists biological, behavioural, ecological, cultural and
and thinkers from different disciplines have made socioeconomic factors. Besides these factors, some
attempts to develop calibrate theories of fertility suited studies suggest that the physical structure of a person
to their disciplinary approaches. For the convenience may also affect fertility behaviour. The anthropometric
of researchers, these theories are grouped under three measure which is used basically to measure growth,
broad categories: biological theories, social or cultural development and health status of an individual is the
theories and economic theories. Biological theories of quantitative body measurement. Anthropometrics
fertility stimulated the concept that human growth is may be considered as a determining factor of fertility.
similar to other living beings. While, social theories tend Outside India, there have been quite a few studies which
to describe fertility in terms of a person’s psychological dealt with the correlation between fertility and physical
attitude, which is determined by the prevalent culture. structure, while in India there is a little literature in this
The socio-economic theories stress the significance of context.
economic factors in the overall process of social change,
which directs the fertility behaviour of a population. To find the impact of physical structure on fertility,
Among many biological, psychological, cultural and early investigations were done by Davenport4(1923) and
socio-economic factors, Davis and Blake1(1956) had Frassetto5(1934); and observed that stockier couples had
identified a set of eleven factors called intermediate larger families than lean couples. Mitton6(1975) observed
variables which affect the process of reproduction significant differential fertility for height among males.
 224 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

He indicated that men who were closer to mean height fertility parameters. The t-independent test is also used to
and weight (in some cases) had higher fertility than compare the selected fertility parameters of shorter and
average. Vetta7(1975) found significant relationships of taller mothers. The surviving ratio has been estimated
fertility with height, weight and ponderal index. to study the relationship between surviving children
and maternal stature. Parity-wise proportion of females
In developed societies, some evidence about the are also given for both groups to answer the question
association of large maternal size with higher fetal survival of whether parity, the number of previous deliveries,
has been found by Bernard8(1952) and Bressler9(1962). differs by mother’s height.
In these studies, it is found that factors linked with tall
statures such as enriched nutritional status and enhanced Findings:
health care facilities, resulting in more successful
pregnancies. Furusho10 (1964) found that short couples Table represents estimated means of selected fertility
had more live births than the tall in Japan, but there was parameters i.e. children ever born, first birth interval,
no significant difference in the number of surviving most recent close birth interval and open birth interval;
children between tall and short. Among Peruvian urban for Indian females who are classified into two groups
poor, Frisancho et al.11(1973) found that short mothers on the basis of their height which are height ≤145.0cm
had a higher proportion of survivors per couple than and height >145.0cm (shown in table). As it can be
tall mothers of similar age. Martorell et al.12(1981) seen in the table, the mean number of children ever
investigated the association between maternal stature, born is high in shorter mother in compare to taller. By
parity, offspring mortality and the number of surviving considering females of all the major states of India, it is
children. Sear et al.13(2004) examined the relationship observed that the mean duration of the first birth interval
between height and reproductive success. among the tall females is less than the short females and
statistically significant (p=0.000). Short females have a
In this study, authors have made an attempt to higher number of children ever born in comparison of
examine the relationship between maternal stature and tall females and it is statistically significant i.e. p=0.041
fertility in India. (shown in table).

Material and Method The study shows that the mean number of surviving
children of shorter females is lower than taller females
The National Family Health Survey (NFHS) in maximum states. It also indicates that taller mothers
is a large-scale, multi-round survey conducted in a had a higher proportion of survivors (Mean number
representative sample of households throughout India. of surviving children/Mean number of children) when
Starting from the first round of this survey (NFHS-1) compared to shorter mothers. The analysis answers
in 1992-93, four rounds of NFHS have been conducted the question of whether one of the most meaningful
in India till now. The recent round of National Family measures of fertility, the number of surviving children
Health Survey (NFHS-4)14 has been conducted in 2015- varies with mother height. The table explains the
16. In this study, data related to fertility measures and proportion of females on each order of births and the
anthropometric measures are taken from NFHS-4. analysis shows that the proportion of females at the
In this study, females of major states of India aged first and second order is greater in taller and it starts
between 15 to 49 years have been considered as the decreasing after second order births. On another side, the
target population. NFHS-4 collected anthropometric proportion of females is more at high parity and it is less
data on the height and weight of women which were in the beginning orders.
used to calculate nutritional status measures. Females
Conclusion & Discussion
are categorized into two groups based on their height
i.e. women having height ≤145.0cm, and having height Over the decades, many public health professionals
>145.0cm. Literature review suggests about a number of and demographers have tested the relationship between
important fertility parameters. Among them, four fertility height and fertility. Many researchers found that
parameters children ever born, first birth interval, most mortality was significantly more for children of shorter
recent close birth interval and open birth interval have women and they also observed a tendency for shorter
been considered for the study. Descriptive statistics have women to have higher parities. Some researchers found
been used to get the estimated mean values of selected no relationship between maternal stature and fertility
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 225

and few researchers found shorter females to have due to deliberate efforts by short females to have more
higher fertility. children to recompense for their child losses. Besides
this, it is also known that after the death of a baby, the
In our study firstly, we studied the fertility parameters cessation of breastfeeding accelerates the return of the
of shorter and taller mothers and found short females menstrual cycle which shortens the intervals between
have more children ever born than tall females as well births (Martorell et al.12,1981). This leads short females
as longer duration of first birth interval. Secondly, we to achieve higher parities.
studied the mean number of surviving children and
calculated survival ratio of children for major states of On the basis of the above analyses, we must
India and it has been observed that survival of children is conclude that there is a relationship of mother’s height
low among short females in comparison of tall females. with fertility parameters, the number of surviving
Earlier works by researchers on different populations children is a function of height and mother height is
show that mortality is greater in children of short mothers related to the proportion of females at different parities.
(Furusho10,1964; Lechtig et al.15,161975,1976). Last, it is The taller mother tends to have fewer children but more
observed that there is a tendency to have higher parities surviving children, the survival of children is lower in
among short females. Survival of children may be caused shorter mothers. The study can be looked in light of the
concern of public health professionals.
Table: Estimates of Fertility Parameters for Indian Females

Females having a height

Fertility Indicators
≤145.0cm >145.0cm
2.00 1.87
Children ever born
(t=1.841, p=0.041*)
30.95 28.01
First birth interval (in months)
(t=7.626, p=0.000**)
37.77 37.73
Most recent close birth interval (in months)
(t=-1.225, p=0.117)
99.84 104.00
Open birth interval (in months)
(t=1.155, p=0.131)
Children survived 1.87 1.75
Proportion of children survived 0.91 0.94
Proportion of females on each birth order
1 0.182 0.198
2 0.285 0.336
3 0.227 0.224
4 0.140 0.122
5 0.079 0.061
6 0.044 0.031
7 0.023 0.015
8 0.021 0.012
Note: t-test is applied by considering all the major states of India.
* p-value is significant at α = 0.05 level of significance.
** p-value is significant at α = 0.01 level of significance.
 226 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Conflict of Interest: Nil. 1952;59:2-16.

9. Bressler JB. Maternal height and the prevalence of
Source of Funding: Datasets access is granted by
stillbirths. Am J Phys Anthrop. 1962;20:515-7.
DHS Program for research work.
10. Furusho T. Relationship between the stature of
Ethical Clearance: Not required as data source is parents and the mortality of their children. Japanese
mentioned above. J Hum Genet. 1964;9:18-34.
11. Frisancho AR, Sanchez J, Pallardel D, Yanez L.
References Adaptive significance of small body size under
1. Davis K, Blake J. Social Structure and fertility: poor socio-economic conditions in Southern Peru.
An analytic framework. Econ Dev Cult Change. Am J Phys Anthrop. 1973;39:255-61.
1956;4(3):211-35. 12. Martorell R, Delgado HL, Delgado H, Valverde
V, Klein RE. Maternal stature, fertility and infant
2. Bongaarts J. A framework for analyzing the
mortality. Hum Biol. 1981;53(3):303-12.
proximate determinants of fertility. Popul Dev Rev.
1978;4(1):105-32. 13. Sear R, Allal N, McGregor IA, Mace R. Height,
marriage and reproductive success in Gambian
3. Bongaarts J. The fertility-inhibiting effects of the
women. Res Econ An. 2004;23:203-24.
intermediate fertility variables. Stud Family Plann.
1982;13(6/7):179-89. 14. International Institute for Population Sciences
(IIPS) and ICF. National Family Health Survey
4. Davenport CB. Body build and its inheritance.
(NFHS-4), 2015-16. Mumbai: IIPS; 2017.
Washington, DC: Cambridge Institution Press;
1923. 15. Lechtig A, Delgado H, Lasky R, Yarbrough C,
Martorell R, Habicht JP, et al. Effect of improved
5. Frassetto F. I principali caratteri anthropologici
nutrition during pregnancy and lactation on
e constitutionalistici studiate i 1450 genitore
development retardation and infant mortality.
prolocici della regione Emiliana. In: Giri C, editors.
In: White PL, Selvey N, editors. Proceedings of
Proceedings of the International Congress for
the Western Hemisphere Nutrition Congress IV;
Studies on Population; 1934; Rome, Italy. Rome:
1974; Bal Harbour, Florida. Acton, Massachusetts:
Rome University Press; 1934. p. 145-220.
Publishing Sciences Group; 1975.
6. Mitton JB. Fertility differentials in modern societies
16. Lechtig A, Delgado H, Yarbrough C, Habicht JP,
resulting in normalizing selection for height. Hum
Martorell R, Klein RE. A simple assessment of
Biol. 1975;49:189-200.
the risk of low birth weight to select women for
7. Vetta A. Fertility, physique and intensity of nutritional intervention. Am J Obstet & Gynecol.
selection. Hum Biol. 1975;47:283-293. 1976;125:25-34.
8. Bernard RM. The shape and size of the female
pelvis. Edin Med J (Trans Edin Obstet Soc).
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 227

Risk Factor Associated with Anthrax Transmission among the

Tribal Communities of Odisha

Sipra Makhija1, Kumar Sumit2, Shah Hossain3

1Post-Graduation in Public Health, 2Assistant Professor, 3Associate Professor, Prasanna School of Public health,
Near KMC greens, Manipal, Udupi

Abstract
Context: Anthrax is a neglected tropical disease caused by Bacillus anthracis. The condition primarily affects
herbivores. Human contacts the natural disease directly or indirectly from animals or their products.

Aims: The purpose of the study was to assess the risk factors associated with the transmission of anthrax.

Settings and Design: A mixed methods study was conducted among the tribal population of Lamtaput block,
Koraput from January to May 2018

Methods and Material: A set of pre-tested and validated structured and unstructured questionnaires were
used in order to conduct the study.

Statistical analysis used: Statistical package for the social sciences(SPSS) version 15.0.

Results: Overall, the respondents heard about anthrax were found to be 62.91 %. 52.98% of respondents
were aware anthrax can affect both humans and animals. The risk factors and risky behaviour were found to
be statistically significant with a p-value of < 0.05. Nevertheless, the qualitative findings suggested the level
of awareness varied among the respondents, and the cause behind transmission was due to consumption
of dead carcasses. The quantitative data showed only 30.464 % of people vaccinated their animals, the
qualitative interviews also proposed that fewer respondents vaccinated their animals, 45.69% of respondents
threw the carcasses in the open air, 52.98 % respondents ate the meat while sharing it with the community
members when an animal died. Food insecurity, poverty, geographical barriers were the reasons cited for
consuming dead carcasses.

Conclusions: The cause of transmission of anthrax in Koraput was dead carcasses consumption, high-risk
behaviour and practices such as eating, selling, or sharing were found to be common among the respondents.
These risk factors are influenced by the low socio-economic status, education level, lack of proper health
education messages and poor veterinary services

Key-words: Anthrax, Awareness, Exposure practises, Risk factors, Tribal communities.

Introduction actual incidence is not known in India1. 18 out of 30

districts in the state have witnessed outbreaks of anthrax
Globally, anthrax accounts for 20,000 to 1,00,000 of
as many as 61 times during the last ten years affecting
human cases where livestock are not vaccinated, whereas
750 people out of that 418 had died2. According to
due to underreporting and geographical distributions the
Department of Animal Husbandry, Odisha, every year
number of anthrax outbreak are reported from Koraput
Corresponding author: district3. Anthrax outbreaks are an annual phenomenon
Dr. Kumar Sumit in Odisha, especially in the region of Koraput4. A
Assistant Professor, Prasanna School of Public health, sizeable portion of Koraput district’s land area is covered
Near KMC greens, Manipal, Udupi with forests; the soil has good moisture which creates
 228 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

favourable condition for anthrax spores to be dormant took informed consent of the interviewee and each
and be activated to give rise to transmission. interview was conducted in the presence and with the
help of grass roots health personnel.
In addition to these eco-environmental factors social
factors plays a vital role in anthrax disease transmission5. Demographic tables were prepared where the
The purpose of this study was to assess the social risk categorical variables were expressed in frequency and
factors associated with the transmission of anthrax in the percentage and the continuous variables. Fisher exact
tribal population of Koraput district of Odisha test and Chi-square test was performed to assess strength
of association of variables the descriptive data was
Material and Method coded and entered and analysed in SPSS version 15.0.
Subjects and Methods: Thematic analysis was used to analyse the qualitative
data, firstly, the data was translated into the English
A mixed method study was conducted in which language, then coding of the data was done, then the code
case, survey was conducted with in-depths and key was translated to the category, and finally the category
informants’ interviews from January 2018 to March was translated into themes
2018 Lamtaput block of Koraput district, Odisha. The
study included males/females aged 18-59 years, medical Findings
workers and veterinary officers, who were willing to Sixty percent of our respondents were in the age
participate in the study. This was done in order to conduct group of 28 to 48, 80% were male and 4% completing
a deeper understanding of the underlying factors which school education. Ninety percent of them were currently
influences the anthrax transmission in the community. married and 80% of them farmers by occupation, an
The study had 2 components additional 10% agricultural labourers. Most of them are
Quantitative questionnaires aware that the anthrax disease is there and it affects both
animals and humans and also that the animals bleed from
Data analysis natural orifices at death. Most of the respondents said
they are not visited by veterinary health personnel and
Koraput districts has 14 blocks, out of which mostly depend on traditional (desi) treatment or that of
Lamtaput is one of the most endemic for anthrax, and quacks for treating their dead animal. Only 30% allowed
frequent outbreaks are reported every year. The block their livestock to be vaccinated against anthrax in the last
is bordered with Boipariguda on the north west and round. Though some people discarded a dead carcass by
Nandapur on the south east, both of them the other two throwing it outside the human habitations, most of them
most endemic anthrax blocks of Koraput. Lamtaput believed there is no harm in consuming them. They
block had a total population of 59873 in 2011 of which justified it with their hunting festivals when they are
46% were tribal7. The block had a livestock population allowed to hunt and eat bush meat. On their own health
of 27088 by the last animal census. We took a sample seeking behaviour, they preferred the village healers or
spread across 12 tribal villages across the length and quacks rather than reach the local health facility, as they
width of the block recruiting a total of 150 households to do not have trust in the health facilities or personnel The
conduct this cross sectional survey to assess social risk perception of the villagers substantively varied from that
factors for anthrax in the area. of the local health care workers, who see the villagers
We used a questionnaire to assess prevalence of stubborn on keeping to their own beliefs and practices
known risk factors that favour anthrax transmission in and not listening to health advice, even when they
animals and humans and supported the same with key reach them. During the survey a few households were
depth interviews to look into the perceptions and beliefs witnessed drying salvaged carcass meat for preservation
determining the presence or absence of these risk factors. for future use.

The administrative permission to conduct the study

was obtained from the Chief district medical officer and
District collectorate. Ethical permission was obtained
from ethical committee of the Kasturba Medical College,
Manipal Academy of Higher Education, Manipal. We
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 229

Table 1: Awareness Related to Anthrax

Variables Category n (%)

Yes 95 (62.91)
Ever heard of anthrax
No 56 (37.09)

Human/Animals/Both 80(52.98)
Awareness about who
can be affected Don’t know 71(47.02)

Yes 52(34.43)
Awareness about vaccination
as prevention
No 99(65.56)

Mass media 96(63.57)

Major sources
of information Personal 55(36.42)

Table 2:Risk factors and Disposal practises

Risk behaviour P value

Risk factors
Eat the meat Throw (open air) Chi-square

Sex
Male 71 52
0.001
Female 18 10 1.592

Occupation
Employed 79 63
0.001
Un-Employed 3 6 1.606

Education

No Schooling 42 44 0.001
1.620

Table 3:Relationship between livestock keeper and loss of cattle due to anthrax

Loss cattle due to anthrax Chi-square P value

Livestock Keeper
Yes No

Yes 100(92.6) 36(83.7) 0.001

1.618

No 8(7.3) 7(16.3)
 230 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 4 : Risk factors and Exposure practises

Risk behaviour
P value
Risk factors
Handling Cooking and others Chi-square

Sex
Male 71 52
0.001
Female 18 10 1.592

Occupation
Employed 80 62
0.001
Non- Employed 6 4 1.625

Education
No schooling 36 47
0.001
Schooling 29 39 1.624

1. Word limit 2500-3000 words, MSWORD Format, single file

2. Please quote references in text by superscripting

Conclusion AN OUTBREAK OF CUTANEOUS ANTHRAX

The study findings showed that general awareness IN TRIBAL AREAS OF VISAKHAPATNAM.
among the communities’ members varied, also the J Evol Med Dent Sci [Internet]. 2016 Aug
vaccination rates were low due to numerous challenges, 4;5(62):4378–81. Available from: https://www.
cultural beliefs, myths and perception which influences jemds.com/data_pdf/G ajay kumar final.pdf
how community treats the dead carcasses. the high-risk 2. Orissa statistics on Anthrax cases and deaths in 10
behaviour and practices such as eating, selling, or sharing years. Available from: http://www.deccanherald.
were found to be common among the respondents. These com/Content/Jun162007/national200706157733.
risk factors are influenced by the low socio-economic asp
status, education level, lack of proper health education 3. Animal-disease-surveillance-bulletin-2014-15
messages and poor veterinary services. odisha.pdf. Cuttack, Odisha: Animal disease
Research Institute, Goo; p. 56.
A backward community that is deprived of awareness
and modern interventions to combat an easy to prevent 4. Turnbull P, Bohm R, Chizyuka G, Fujikura T,
and difficult to cure disease and its transmission suffer Hugh-Jones M, Melling J. Guidelines for the
in isolation because of repeated outbreaks of anthrax that surveillance and control of anthrax in humans and
has become endemic in the region. This calls for a wider animals. Guidel Surveill Control Anthrax Humans
intervention involving non health line departments to Anim. 1993; Fourth edi:76p
stop the transmission cycle of anthrax in Odisha. 5. Chacha I, Arimi S, Thaiya A. Knowledge,
Attitudes, and Practices regarding Anthrax among
Conflict of Interest – Nil Community Members, Health and Veterinary
Workers in Maragua, Kenya. Vol. 10, International
Source of Funding-Nil
Journal of Animal and Veterinary Sciences.
Ethical Clearance – Kasturba Medical College, University of Nairobi; 2016.
Manipal Academy of Higher Education, Manipal 6. Odisha DOCO. District Census Handbook [Internet].
2011 [cited 2018 May 28]. p. 366. Available from:
References http://censusindia.gov.in/2011census/dchb/2129_
1. Kumar G A, B T V N R, Vardhan K R H, Prasad P G. PART_B_DCHB_KORAPUT.pdf
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 231

7. Sitali DC, Mumba C, Skjerve E, Mweemba O, 14. Gombe NT, Nkomo BMM, Chadambuka A,
Kabonesa C, Mwinyi MO, et al. Awareness and Shambira G, Tshimanga M. Risk factors for
attitudes towards anthrax and meat consumption contracting anthrax in Kuwirirana ward, Gokwe
practices among affected communities in Zambia: North, Zimbabwe. Afr Health Sci [Internet].
A mixed methods approach. PLoS Negl Trop Dis 2010;10(2):159–64. Available from: http://
[Internet]. 2017;11(5). Available from: http://dx.doi. www.pubmedcentral.nih.gov/ articlerender.
org/10.1371/journal.pntd.0005580WHO. First fcgi?artid=2956291 &tool=pmcentrez&
WHO report on neglected tropical diseases: working rendertype=abstract
to overcome the global impact of neglected tropical 15. Hotez PJ, Damania A. India’s neglected tropical
diseases. World Heal Organ [Internet]. 2010;1– diseases. Steinmann P, editor. PLoS Negl Trop
184. Available from: http://apps.who.int/iris/ Dis [Internet]. 2018 Mar 22;12(3): e0006038.
bitstream/handle/10665/44440/9789241564090_ Available from: http://dx.plos.org/10.1371/journal.
eng.pdf;jsessionid= F5110D4A42369535E1AE0 pntd.0006038
B55264835B9? sequence=1
16. Chugh TD. Emerging and re-emerging bacterial
8. Opare C, Nsiire A, Awumbilla B, Akanmori BD. diseases in India. Spec issue Emerg re-emerging
Human behavioural factors implicated in outbreaks Infect India [Internet]. 2008;33(4):549–55.
of human anthrax in the Tamale municipality of Available from: http://www.ias.ac.in/jbiosci
northern Ghana. Acta Trop [Internet]. 2000 Jul
17. Dikid T, Jain SK, Sharma A, Kumar A, Narain JP.
21;76(1):49–52. Available from: http://www.ncbi.
Emerging &amp; re-emerging infections in India:
nlm.nih.gov/pubmed/10913766
An overview. Indian J Med Res. 2013;138(July):19–
9. Kracalik IT, Kenu E, Ayamdooh EN, Allegye- 31.
Cudjoe E, Polkuu PN, Frimpong JA, et al. Modeling
18. Wallin A, Luksiene Z, Zagminas K, Surkiene G.
the environmental suitability of anthrax in Ghana
Public health and bioterrorism: renewed threat
and estimating populations at risk: Implications
of anthrax and smallpox. Medicina (Kaunas)
for vaccination and control. PLoS Negl Trop Dis
[Internet]. 2007;43(4):278–84. Available from:
[Internet]. 2017;11(10):1–17. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/17485954
http://dx.doi.org/10.1371/journal.pntd.0005885
19. Pai H-H, Chen W-C, Peng C-F. Cockroaches
10. Food and Agriculture Organization of the United
as potential vectors of nosocomial infections.
Nations. The Control of neglected zoonotic
Infect Control Hosp Epidemiol [Internet].
diseases: a route to poverty alleviation: report
2004;25(11):979–84. Available from: http://www.
of a joint WHO/ DFID-AHP meeting, 20 and 21
ncbi.nlm.nih.gov/pubmed/15566034
September 2005, WHO Headquarters, Geneva, with
the participation of FAO and OIE. Geneva. 2006. 20. Piliavsky A. The criminal tribe in India before
Available from: http://www.oie.int/fileadmin/ the British. Comp Stud Soc Hist [Internet].
Home/eng/Publications_%26_Documentation/ 2015;57(2):323–54. Available from: https://
docs/pdf/bulletin/Bull_2010-4-ENG.pdf www.cambridge.org/core/journals/comparative-
studies-in-society-and-history/article/
11. IDSP. Anthrax Statistics [Internet]. 2010 [cited
criminal-tribe-in-india-before-the-british/
2018 May 19]. Available from: http://idsp.nic.in
E3F6C2797D935E942CE011D0DBBD4FCA
12. Taverne B, Akindes F, Berthe A, Bila B, Caremel
21. Turner WC, Imologhome P, Havarua Z, Kaaya
JF, Desclaux A, et al. Preparing for Ebola
GP, Mfune JKE, Mpofu IDT, et al. Soil ingestion,
outbreaks: Not without the social sciences! Glob
nutrition and the seasonality of anthrax in herbivores
Health Promot. 2015;22(2):5–6.
of etosha national park. Ecosphere. 2013;4(1):1–
13. Chirundu D CA. Behavioural factors associated 19.
with C.Anthrax in Musadzi area of Gokwe North,
22. Thapa NK, Tenzin &nbsp;, Wangdi K, Dorji
Zimbabwe. Cent African Jouranl medeicine
T, Migma &nbsp;, Dorjee J, et al. Investigation
[Internet]. 2009 Feb 15;54(September). Available
and Control of Anthrax Outbreak at the Human–
from: http://www.ajol.info/index.php/cajm/article/
Animal Interface, Bhutan, 2010. Emerg Infect Dis
view/63640
 232 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

[Internet]. 2014 Sep;20(9):1524–6. Available from: Hugh-Jones M, Melling J. Guidelines for the
http://wwwnc.cdc.gov/eid/article/20/9/14-0181_ surveillance and control of anthrax in humans and
article.htm animals. Guidel Surveill Control Anthrax Humans
23. Turnbull P, Bohm R, Chizyuka G, Fujikura T, Anim. 1993; Fourth edi:76p.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 233

Assessment of Risk Factors For Diabetes among Bank

Employees Using Indian Diabetes Risk Score: A Cross
Sectional Study

Smriti1, Anusha Rashmi2, Manjula A3, Kurulkar P.V.4,( Brig) Hemant kumar5
1
PG Tutor, Community medicine , AJIMS&RC, 2Assistant Professor, Community Medicine AJIMS&RC,3 Assistant
Professor, Community Medicine, AJIMS &RC, 4Professor, Community Medicine, AJIMS &RC.,5HOD Professor,
Community Medicine, AJIMS&RC

Abstract
Introduction- Diabetes Is An “Iceberg” Disease And Is One Of The Major Causes Of Premature Illness And
Death Worldwide. From 108 Million In 1980, The Number Of People Living With Diabetes Has Increased
To 422 Million In 2014. In India It Was The 7Th Biggest Cause For Early Death In 2016. There Are Many
Screening Tools Available To Identify The Risk For Diabetes, Of Which Idrs Tool Is One Of Them.

Objective - To Assess Risk Of Diabetes Mellitus Among Selected Bank Employees Using Indian Diabetes
Risk Score.

Methodology- A Cross Sectional Study Was Conducted Over A Period Of 2 Months ( February To March
2019) Among 205 Employees Of 4 Branches Of A Selected Bank. Data Was Collected By Purposive
Sampling Using A Pre-Tested, Semi-Structured Questionnaire And Idrs Scale.clinical Examination And
Grbs Was Carried Out. Chi-Square Test Was Used As Test For Association

Results: Among 205 Respondents, Idrs Score Showed That 61% Belonged To High Risk Category, 25% To
Moderate Risk & 14% Belonged To Low Risk.

Conclusion: Present Study Showed 61% To Be In High Risk Category For Dm; It Also Revealed Significant
Association Between Overweight And High Idrs. Age, Abdominal Obesity In Males, Family History Of
Diabetes And Physical Activity Were Significantly Associated With High Idrs. Early Screening Aids In
Early Diagnosis And Treatment Which Can Reduce The Burden Of Dm.

Keywords: Idrs, Diabetes Mellitus, Bank Employees, Bmi, Grbs

Introduction etiology characterized by chronic hyperglycemia with

disturbances of carbohydrate, fat and protein metabolism
Diabetes Mellitus’ a disease known since ancient
resulting from defects in insulin secretion, insulin action,
times finds its description in vedic literature being
or both.1 Increasing at a rapid rate this disease is posing
described as ‘Madhumeha’ meaning ‘honey-urine’.1
a major public health challenge. A disease finding its
World Health Organization (WHO) defines the term description in Vedic literatures Diabetes mellitus is
diabetes mellitus as- ‘a metabolic disorder of multiple defined by WHO as an unhappening 422 million stand
affected around1,2 the Woorld according to WHO 2016
estimates.2 The Eastern Mediterranean Region and the
Corresponding author: Region of the Americas have highest prevalence (11%
Dr. Anusha Rashmi, for both sexes) and Western Pacific Regions & WHO
Assistant Professor, Community Medicine, AJIMS& European regions (9% for both sexes) have lowest.
RC, Mangalore, Karnataka – 575004
E mail : [email protected]
 234 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

The prevalence that was 2.3% in urban areas in 1. Age: Age was recorded in completed years as
1970’s according to ICMR study has currently risen to revealed by subjects and categorized into 3 groups; age
12-19% in recent years.4,5 The most recent estimates <35 years was given a score of 0, 35- 49 years as 20 and
by ICMR show that there are 66.58 million cases and >=50 years as 30.
2.26 million DALYs loss due to diabetes.6 According to
the Diabetes Atlas 2013 published by the International 2. Waist circumference: Males: Individuals with
Diabetes Federation, the number of people with diabetes waist circumference <90cm were given a score as 0, 90
in India currently is 65.1 Million, which is expected to – 99 cm as 10, and those with >=100 cm as 20. Females:
rise to 142.7 million by 2035 unless urgent preventive Individuals with waist circumference <80cm were given
steps are taken7. The elimination of risk factor, early a score as 0, 80 -89 cm as 10, and those with > 90 cm as
diagnosis and adequate treatment can reduce the risk of 20.
disease. Sedentary lifestyle, work pressure increasing 3. Family history of diabetes: Individuals with
stress amongst individuals are well known factors in no family history of diabetes were given score as 0,
the causation of disease. Since bank employees come those with one diabetic parent as 10 and those with both
under this group, the present study has been conducted diabetic parents as 20.
to assess their risk for diabetes.
4. Physical activity: Individuals were given a
Objective score as 0 if they did leisure time exercise and in addition
To assess risk of Diabetes mellitus among selected had physically demanding work in their occupation;
Bank Employees using Indian Diabetes risk score. individuals who either did exercise or performed
physically demanding work were given score as 20 and
Methodology the individuals who neither did any exercise or who are
leading a sedentary lifestyle were given score as 30.
A cross sectional study was carried out over a period
of 2 month ( February to March 2019) among employees The total scores were added up and the subjects
of 4 branches of Karnataka Bank in Mangalore city, were classified as high risk, moderate
Karnataka.
risk and low risk, based on the IDRS as follows – <
After obtaining the written permission from 30 as low risk, score 30-50 as
managers of respective branches subjects were studied
moderate risk and score 60 and above as high risk.
individually in their leisure time with informed consent.
Employees who were present on the day of visit and 5. GRBS: Cut of 110mg/dl was used as cut of to
who were willing to participate were enrolled for the devide the study subjects into low risk & high risk.11
study. Those with pre existing diabetes (Self-reported)
were excluded. A total of 205 employees were available Statistics:
for the study. Sampling technique was used Purposive
Data was entered in excel. Results presented as
Sampling.
percentages and proportions. Chi-square test was used
A pre-tested, semi-structured questionnaire was as test for Association
used to elicit socio-demographic parameters like age,
sex, marital status, education, occupation, per capita Results
income; IDRS scale 8 having parameters including Age Mean age of the study subjects was 45.45±11.98.
in years, family history, physical activity and abdominal Males 159 (74.6% ) out numbered females 52 (25.4%
circumference was used.8 Examination in the form of ). In our study about 59 (28.8%) were in the age group
BP, PR, Height and Weight, GRBS was tested using of <35, 74 (36.1%) were in the age group of 35-49 yrs
glucometer. BMI was also calculated. and about 72 (35.1%) were aged >=50yrs. Most of the
employees 152 (74.2%) were Professional. By IDRS,
Ethical Clearance was obtained from institutional
most of the subjects, 125 (61%) were having high risk
ethical committee.
for type 2 DM. About 51 (25%) were at moderate risk
Certain definition used in the study10 and 29 (14%) were at low risk of developing type 2 DM.
(Table 2).
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 235

Figure 1: DISTRIBUTION OF IDRS AMONG STUDY SUBJECTS

Figure 2: DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO BMI

Figure 3: DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO GRBS

236 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table.1. Distribution of study subjects in accordance with parameters of IDRS.

IDRS Score Number (%)

Variables
Low risk
Moderate risk High risk Total

< 90 10 (42) 7 (29) 7 (29) 24(100%)

Abdominal
Obesity in Male 90 – 99 7(9) 22( 27) 51(64) 88(100%)
(cm)

>= 100 1(2 ) 9 (18) 39(80) 49(100%)

< 80 7 (46) 4 (27) 4 (27) 15(100%)

Abdominal
Obesity in 80 – 89 4 (21) 5 (26) 10 (53) 19(100%)
Female (cm)

>= 90 0 (0) 4 (23) 14 (77) 18(100%)

< 35 26 (44) 28 (47) 5 (9) 59(100%)

Age
35 – 49 3 (4) 17 (23) 54 (73) 74(100%)
(in years)

>= 50 0 (0) 6 (8) 66 (92) 72(100%)

Exercise+
8 (42) 9(47) 2 (11) 19(100%)
Strenuous Work

Exercise or
Physical activity 18 (16) 29 (25) 67 (59) 114(100%)
Strenuous Work

No exercise & sedentary

3 (4) 13 (18) 56 (78) 72(100%)
work

No Family History 19 (23) 27 (32) 38 (45) 84(100%)

Family
Either parent 9 (11) 22 (26) 54 (63) 85(100%)
History

Both parents 1(3) 2 (5) 33 (92) 37(100%)

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 237

Table 2: Association between IDRS and Clinico- Social-Factors

Variable IDRS Score (%)

P value
Low risk Moderate risk High risk

Male 18(62%) 38 (74.5%) 97(77.6%) 0.223

Female 11(38%) 13(25.5%) 28(22.4%)
Sex
Total 29(100%) 51(100%) 125(100%)

Underweight 2 (7% ) 5 (10%) 10(8%) 0.083

Normal 10 (35%) 8 (16 %) 19 (15%)
BMI
Overweight 8 (28%) 7 (14%) 21(17%)
Obese 9 (30%) 31 (60%) 75 (60%)
Total 29(100%) 51(100%) 125(100%)
<90 10 (55.55%) 7(18%) 7 (7%) 0.000

Abdominal 90 -99 7(39.88%) 22(58%) 51(53%)

Obesity in Male (cm) >100 1(5.55%) 9 (24%) 39(40%)
Total 18(100%) 38(100%) 97(100%)
<80 7 (64%) 4 (31%) 4 (14%) 0.26
Abdominal 80- 89 4 (36%) 5 (38%) 10 (36%)
Obesity in
>90 0 (0%) 4 (31%) 14 (50%)
Female (cm)
Total 11(100%) 13(100%) 28(100%)
<35 26 (90%) 28 (55%) 5 (4%) 0.000

Age 35-49 3 (10%) 17 (33%) 54 (43%)

(in years) >50 0 (0%) 6 (12%) 66 (53%)
Total 29(100%) 51(100%) 125(100%)

Exercise+
8 (28%) 9(18%) 2 (2%) 0.000
Strenuous Work

Exercise or
18 (62%) 29 (57%) 67 (54%)
Physical activity Strenuous Work

No exercise &
3 (10%) 13 (25%) 56 (44%)
sedentary work

Total 29(100%) 51(100%) 125(100%)

No Family
19 (66%) 27 (53%) 38 (30%) 0.000
History
Family
History Either parent 9 (31%) 22 (43%) 54 (43%)
Both parents 1(3%) 2 (4%) 33 (27%)
Total 29(100%) 51(100%) 125(100%)

<110 16 (55%) 21(41%) 48(38%) 0.255

GRBS >110 13 (45%) 30(59%) 77(62%)
Total 29(100%) 51(100%) 125(100%)
 238 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Discussion history showed a higher risk for diabetes. In our study,

120 individuals had a GRBS reading of > 110 mg/dl.
There is a clear association between increasing
Acoording to Reshma S Patil etal18 study showed that
age and greater diabetes prevalence. Among 205
those individuals having GRBS of more than equal to
respondents, IDRS score was found to reveal high risk
110mg/dl have recommended oral glucose tolerance test
in the age group >35 years (96.34%) and in patients
to detect status of diabetes in future. A GRBS of >/=110
with high BMI (56%). Overall, 61% of the patients had
mg/dl is showed to have a 68 (49%) out of 140 high
high risk of Diabetes. Higher the age group more was
risk participants had GRBS of >=110mg/dl. In our stud
the risk score. The National Institute for Health and
showed of the 120 individuals who had a GRBS reading
Care Excellence (NICE) states that being older than 40
of more than 110 mg/ dl 59% of them were belonged to
years, or older than 25 years for some black and minority
moderate risk and 62% were in high risk group based
ethnic groups, is an important risk factor for developing
on IDRS. Though not significantly associated it can be
type 2 diabetes.12
taken as ameasure for risk scoring for diabetes.
An increase in waist circumference is seen as an
important risk factor for developing diabetes with a Conclusion
gender based difference where in men are seen to have IDRS is a simple and cost-effective tool to screen
a higher risk with a waist circumference of 94 – 102 cm and assess people at high risk for DM. The present study
and Women are at higher risk if the waist circumference brought out 61% of Bank employees to be at high risk &
is 80 – 88cm.13 In our study, majority of male 52 (24 %) also revealed significant association between BMI and a
and females 14 (6 %) were seen in group 2 i.e., males high risk score of DM. Due to sedentary nature of work
(90-99cm) and females (>90) and these showed to have for most bank employees, they are at risk of developings
a higher risk for diabetes though it was significant only a disease like diabetes. Our study found 61% of the
in males(p = 0.00). This could be because of the risk study population at high risk for DM using IDRS. IDRS
jobs that most have at Banks which invariably lessens can be used as a baseline screening tool to assess the risk
physical activity.Over the past 4 decades, a huge number of individuals and take measures accordingly. Our study
of the working population has shifted from manual labor found presence of 61 % of subjects at high risk and 25 %
associated with agriculture sector to physically less at moderate risk of type 2 DM.
demanding office jobs.14 It has been observed in other
studies that prevalence of diabetes is 3 times higher in Early screening aids in early diagnosis and treatment
individuals with light physical activity compared to which can reduce the burden of DM.
those doing heavy physical activity.14 In our study 57%
Limitations of Study
of individuals involved in exercise or strenuous work
belonged to moderate risk and 54% in high risk group Sample size was small for want of time. Blood
which was also significant (p = 0.00). Strenuous work Glucose levels of subjects at high risk were not assessed
may have added to stress factor contributing to higher because of cost factor.
risk . Similarly, 25% and 44% ofindividuals following a
sedentary pattern showed to have moderate and high risk Acknowledgement: We are grateful for all the
scores respectively.Genetic susceptibitlity and common subjects involved in the study for their co-operation
environmental factors including cultural background are in completing this project. We are thankful for Bank
factors that determine the family history for a diseases manager & employees for conducting study. A follow of
specially so in diabetes.15 The disease risk increases to patient for FBS & PPBS for future purpose of diabetes
40% when a 1st degree relative has history of diabetes.15 screening.
In our study, 85 (41.5% %) subjects had positive family
Source of Funding- Nil
history of type 2 DM in one parent, 33 (16 %) had positive
history in both parents of whom 125 (61 %) were in high Conflict of Interest – No
risk group, 51 (25 %) of them were in moderate risk
group and 29 (14 %) were in low risk group and these Ethical Clearance- Taken from Institutional ethics
factors were significantly (p = 0.00) associated with committee
higher risks according to IDRS. In a similar study by
Raja Subramanian et al16 it was seen those with family
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 239

References 11. Shah SK,Msaikaka NN,Burman C, Snehlata

AC,Ramachandran A. High prevalence of type 2
1. Amos AF et al: The rising global burden of diabetes
diabetes in Urban population in northeastern India.
and its complications: Estimates and projections to
Int J Diab Dev Ctries.1999;19:144-6
the year 2010: Diabet Med 1997, (Suppl. 5): S1-
S85 12. Sharma R. Online interactive calculator for realtime
update of the Prasad’s social classification for 2015.
2. WHO (2016), Diabetes Fact Sheet No. 312, June
Available at http://prasadscaleupdate.weebly.com/.
2016
Accessed December 31st, 2016.
3. WHO (2011), Global Status Report on Non-
13. Mohan V, Sandeep S, Deepa R, Shah B , Varghese
communicable Diseases,2010.
C. Epidemiolog of type 2 diabetes: Indian scenario,
4. Ahuja MM, Sivaji L, Garg VK, Mitroo P. Indian J Med Res 125, March 2007;217-30.
Prevalence of diabetes in northern India (Delhi
14. Mohan V, Deepa R, Deepa M, Somannavar S,
area) Horn Metab Res. 1974;4:321.
Datta M. A simplified Indian Diabetes Risk Score
5. Gupta OP, Joshi MH, Dave SK. Prevalence of for screening for undiagnosed diabetic subjects.
diabetes in India. Adv Metab Disord. 1978;9:147– JAPI.2005;53:760.
65
15. Bener A, Darwish S, Al-Hamaq AO, Yousafzai
6. ICMR. Assessment of burden of non-communicable MT, Nasralla EA. The potential impact of family
diseases. ICMR New Delhi 2004 history of metabolic syndrome and risk of type 2
7. Whiting DR, Guariguata L, Weil C, Shaw J, IDF DM: In a highly endogamous population.Indian J
Diabetes Atlas: Global estimates of the prevalence Endocr Metab 2014;18:202-9.
of diabetes for 2011 and 2030 Diabetes Res Clin Pr 16. Subramani R, Umadevi, Shankar U, Stephen,
2011; 94(3):311-21. Karthik ,Seshadhri et al,Assessment of Risk of
8. Abdullah A, Peeters A, de Courten M, et al. The Type 2 Diabetes Mellitus Among Rural Population
magnitude of association between overweight and in Tamilnadu by using Indian Diabetic Risk Score,
obesity and the risk of diabetes: A meta-analysis Middle-East J.Sci.Res,21(1), 2014:224.
of prospective cohort studies. Diabetes Research & 17. Patil RS, Gothankar JS. Assessment of risk of type
Clinical Practice, 2010;89(3):309-19. 2 diabetes using the Indian Diabetes Risk Score
9. Sharma R. Online interactive calculator for realtime in an urban slum of Pune, Maharashtra, India: A
update of the Prasad’s social classification for 2015. cross-sectional study. WHO South-East Asia J
Available at Public Health 2016;5(1):53–61.
10. Preventing type 2 diabetes: population and
communitylevel interventions. Available at: https://
www.nice.org.uk/guidance/ph38/chapter/2-public-
health-need-andpractice accessed November 6th,
2015.
 240 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Emotion dysregulation in patients with major depressive

disorder and borderline personality disorder

Snehalata Choudhury1, Surjeet Sahoo2, Soumya Ranjan Dash3

1Clinical Psychologist, 2Professor and Head, 3Senior Resident, Department of Psychiatry, IMS & SUM hospital,
Siksha O Anusandhan University, K8, Kalinga Nagar, Bhubaneswar-751003, Odisha, India

Abstract
Emotional dysregulation is a central topic of interest in many clinical studies. It plays a vital role in making
or breaking interpersonal and interpersonal relationships in clinical populations as well as healthy controls.
This study seeks to investigate the nature, intensity and extensity patterns of emotional regulation in patients
diagnosed as major depression (N: 254) and borderline personality disorder (N: 69). By using a one-shot
cross sectional purposive sample survey design, this hospital-based study targeted a random sample of
subjects from both gender between 18-30 years. Following clinical interviews and diagnosis as per the
chosen inclusion and exclusion criteria, participants were recruited based on ICD-10 criteria and after they
secured a minimum cut-off score on McLean’s Screening Instrument for Borderline Personality Disorder
and Hamilton Depression Rating Scale. The selected participants were administered Difficulties in Emotion
Regulation Scale and Cognitive Emotion Regulation Questionnaire. Results show significantly high scores
on emotion regulation in patients with borderline personality disorder than major depressive disorder
(p:<0.05). These differences are maintained across all domains except for cognition mediated areas like
‘awareness’, ‘self-blame’, ‘acceptance’, ‘rumination’, and ‘positive refocusing’. Associated variables like
genderand marital status appear to influence only some aspects of non-cognitive emotional dysregulation.
The findings are discussed along with their implications for therapy in the context of cultural factors unique
to Indian settings.

Key Words: Emotional dysregulation, Major Depression, Borderline Personality Disorder, Self-Blame,
Rumination

Introduction used strategy out of six strategies (problem solving,

reappraisal, acceptance, suppression,avoidanceand
Emotional dysregulation is a term used in mental
rumination) was seen for rumination. Avoidance,
health settings to refer to emotional responses that are
problem solving and suppression were used with
poorly modulated. It may manifest as anger outbursts,
medium frequency where as reappraisal and acceptance
acts of aggression or destructiveness against self or
used least. 1
others, and can result in a breakdown of interpersonal
relationships. Emotional dysregulation is implicated It is shown that individuals having major depressive
as being at the core of major depressive disorder and disorder less differentiated emotional experiences than
borderline personality disorder. It is shown that in healthy controls but only for unhelpful emotions.2
psychiatry disorders including anxiety, depression, eating Further, emotion regulation difficulties in female patients
disorderand substance-related disorders most commonly with major depressive disorder are found to be greater
in comparison to normal healthy controls 3. Although
Corresponding Author there is extensive research exploring the relationships
Surjeet Sahoo, Professor and Head, Department between these processes and depression, the research on
of Psychiatry, IMS & SUM hospital, Siksha O other unhelpful emotions is sparse.
Anusandhan University, K8, Kalinga Nagar,
Based on self-report measures, investigators have
Bhubaneswar-751003, Odisha, India.
identified a triad of emotional functioning-emotion
Mail id- [email protected]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 241

dysregulation, distress tolerance, and experiential Self report questionnaires such as MSI-BPD and
avoidance in young adult out patients with borderline HAM-D were used to screen borderline personality
personality disorder 4. Emotional reactivity to social disorder and measure depressive disorder patients 9,10
rejection and negative evaluation in patients with . Difficulties in Emotion Regulation Scale was used to
borderline personality disorder was found to be higher measure difficulties in emotion regulation difficulties in
than in comparable healthy controls 5. Taking these facts the following six domains of emotion regulationNon-
in to account, our aim is to identify emotion dysregulation acceptance, Goals, Impulse, Awareness, Strategies
in major depressive disorder and borderline personality and Clarity. 11 Similarly cognitive emotion regulation
disorder, and compare emotion dysregulation in major questionnaire was used to measure cognitive emotion
depressive disorder and borderline personality disorder. regulation difficulties in nine dimensions present in
Also we investigate emotion dysregulation in major the scale are self blame, blaming others, acceptance,
depressive disorder and borderline personality disorder refocus on planning, positive refocusing, rumination,
in relation to key socio-demographic correlates like positive reappraisal, putting into perspective and
gender, marital status, and occupation. catastrophizing.11

Material and Method Results

The clinical samples were recruited based on the (i) Emotion regulation in major depressive
6
Diagnostic Criteria for Research-10 . 323 participants disorder and borderline personality disorder:
with the age range of 18-30 were recruited out of
which 69 borderline personality disorder and 254 Results of comparative overall scores on emotion
major depressive disorder. Those scored 7 are more on dysregulation in persons with major depressive
MSI-BPD7 and HAM-D were included in the study.8 disorder and borderline personality disordershow gross
Patients with intellectual disability, psychosis, bipolar difficulties in emotion regulation for both the clinical
disorder, substance dependence or abuse disorder and populations. If the patients with borderline personality
presence of any serious physical disease, head injury and disorder (N: 69; Mean: 103.48; SD: 7.72) score in
neurological disorder. Personal details were collected ‘moderate-severe’ range of norms on DERS, the sample
using a socio-demographic data sheet. There were with major depressive disorder do not lag much behind
statements on assuring confidentiality, leaving choice (N: 254; Mean: 93.67; SD: 8.60). The same is true for
of participation to the respondents, and acknowledging the trends on cognitive emotion regulation between the
ones willingness or otherwise to participate in the study. two groups.

Table 1: Distribution of Mean Scores and SD across Tests & Conditions

BPD MD
Tools Items Score Probability
(N: 69) (N: 254)

36-180 103.48 93.67 t: 8.5809;

DERS 36
(7.72) (8.60) Df: 321; p: 0.0001

100.99 95.70 t: 5.1670;

CERQ 36 36-180
(7.32) (7.60) Df: 321; p: 0.0001

(KEY: BPD: Borderline Personality Disorder; MD: Major Depression)

(ii) Domain-wise profiles in emotion regulation personality disorder consistently score high across all
between major depressive disorder and borderline areas except ‘non-acceptance’ (N: 69; Mean Score:
personality disorder 16.28; SD: 2.44) wherein those diagnosed as major
depressive disorder score relatively lower (N: 254; Mean
Wherein a domain-wise analysis of score profiles
Score: 15.15; SD: 1.87).
is undertaken on DERS, the patients with borderline
 242 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 2 : Distribution of Mean Scores and SD across Domains on DERS

NA G ID A S C Total
Sample N Probability→
(6) (5) (6) (6) (8) (5) (36)

16.28 14.93 20.26 15.14 24.03 13.35 103.48

BPD 69 <0.001; VHS;
(2.44) (2.20) (4.22) (1.82) (2.89) (1.79) (7.72)

15.15 14.67 15.88 14.97 20.21 12.90 93.67

MD 254 <0.001; VHS;
(1.87) (2.18) (3.60) (2.20) (2.31) (1.86) (8.60)

Probability↓ <0.001 <0.001 <0.001 >0.05 <0.001 <0.001

VHS VHS VHS NS VHS VHS

[Key: NA: Non-Acceptance; G: Goals; ID: Impulsive Difficulty; A: Awareness; S: Strategies; C: Clarity][Number of
items under each domain is given in parenthesis]

Domain-wise comparative analysis of scores on CERQ between the two clinical groups (Table 3) shows that
the predominant aspects of cognition involved in emotion regulation that are affected is acceptance, rumination,
self-blame, positive reinforcing and refocusing on planning, which are all mostly on the higher side for patients with
borderline personality disorder than for those with major depressive disorder.

Table 3: Distribution of Mean and SD Scores across Domains on CERQ

BPD MD
Scales Items Probability →
(N: 69) (N: 254)

t: 1.90;
Self-blame 4 14.26 (2.54) 13.69 (2.13)
p: 0.05; S;

t: 3.94;
Acceptance 4 16.94 (2.39) 15.98 (1.61)
p: 0.001; VHS;

t: 7.60;
Rumination 4 13.41 (1.95) 11.44 (1.89)
p: 0.001; VHS;

t: 9.69;
Positive Refocusing 4 13.65 (2.68) 10.66 (2.14)
p:0.000; VHS;

9.46 9.96 t: 2.25;

Refocusing on Planning 4
(1.82) (1.55) p: 0.03; S;

8.84 t: 1.32;
Positive reappraisal 4 8.58 (1.631)
(1.38) p: 0.19; NS;

8.30 8.36 t: 0.27;

Put into perspective 4
(1.49) (1.55) p:0.78; NS;
9.22 9.33 t: 0.43;
Catastrophizing 4
(1.93) (1.96) p: 0.67; NS;
7.49 7.61 t: 0.596;
Other-blame 4
(1.72) (1.36) p: 0.55; NS
Probability↓
(KEY: BPD: Borderline Personality Disorder; MD: Major Depression)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 243

(iii) Distribution of profiles in emotion regulation the married respondents with major depressive disorder
between major depressive disorder and borderline show significantly less elevation of scores on the domains
personality disorder in relation to key socio-demographic of catastrophizing only (p: > 0.05). This means that
variables married clients with major depressive disorder maybe
receiving sufficient supports to buffer such attribution
Gender wise differences within each clinical tendencies to cope with their predicament.
condition (p: <0.001). The males with borderline
personality disorder score significantly high on the Discussion
domain of ‘Impulsive Difficulty’ (N: 54; Mean: 20.77;
SD: 4.20) than the females in the same group (N: 15; Depression is found to be greatly associated with
Mean: 18.40; SD: 3.88) (p: <0.001). A similar trend is difficulties in cognitive control and, especially, with
seen also for the patients with major depressive disorder difficulties in inhibiting the processing of unhelpful
(p: <0.001). material. Evidence appears to favour greater rumination
in borderline personality disorder with also a different
Analysis of scores across domains on CERQ between course or illness trajectory and treatment pathway as
the two clinical populations based on gender variable compared to major depressive disorder. It is noted
shows no statistically significant differences except that major depressive disorder can co-occur with
for ‘Other-blame’ condition. There are statistically borderline personality disorder. Many patients with
significant differences in all the domains on DERS borderline personality disorder often present depressive
for major depressive disorder as well as borderline symptoms. It is postulated that depressed individuals
personality disorderin relation to three categories of the are characterized by emotional inertia, while individuals
occupational variable (p: <0.001). with borderline personality disorder are characterised
by emotional instability. Both groups have been found
On the CERQ, there is a clear pattern of nil significant using more maladaptive affect regulation strategies than
differences across its nine different scales for patients healthy controls 12. The essential findings in the present
with borderline personality disorder as compared to study related to high scores on emotion regulation
significant differences at least with respect to a few for patients with borderline personality disorder than
sub-scales for those with major depressive disorder in those with major depressive disorder especially in
relation to occupational variable. Thus, respondents with cognitive related domains ‘self-blame,’ ‘acceptance,’
major depressive disorder show significant elevation ‘rumination,’ ‘positive refocusing,’ and to a lesser extent
of emotion regulation scores on domains like positive on ‘refocusing on planning’ has critical implications for
reappraisal, catastrophizing, positive refocusing, treatment.
refocusing on planning and other-blame tendencies for
this variable (p: < 0.05). This means that clients with Both the clinical conditions appear to be equally
major depressive disorder still hold tendencies to think affected for emotion dysregulation in the domains of
of pleasant things or experiences, or think of how best to ‘putting into perspective’,‘positive reappraisal,’other-
cope with the situation. blameand ‘catastrophizing’,respectively. Similar trend
are reported in previous studies 13,14,15 . Also, patients
The next series of test wise domain analysis was with borderline personality disorder are found to have
undertaken for the binomial marital variable: married poor social problem-solving skills that may disturb their
vs. unmarried. There are statistically major differences emotion regulation 16 The high borderline personality
for distribution of mean scores across all domains on disorder individuals demonstrated greater increase in
DERS for both groups of sample with major depressive unhelpful emotions, shame and ager in response to the
disorder as well as borderline personality disorder in social rejection/ compared with the annoying arithmetic
relation to marital variable (p: < 0.001). On the CERQ, task 17 .
the distribution of scores across domains shows nil
significant differences across all its nine different scales Gender is most frequently discussed variable for
for patients with borderline personality disorder as emotion dysregulation in clinical conditions. Despite this
compared to significant differences in all except one sub lay conviction, empirical evidence on gender differences
scale of catastrophizing sub-scales for those with major in emotional responding is mixed. A limitation of these
depressive disorder in relation to marital variable. Thus, studies is that they are all based on self-reports and is
 244 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

vulnerable to the effects of gender stereotypes. Future Buschkuehl M, Barrett LF, Ellsworth PC, Demiralp
studies must distinguish emotional reactivity and emotion M, Hernandez-Garcia L, Deldin PJ, Gotlib IH.
regulation. There is also a cultural dimension to emotion Feeling blue or turquoise? Emotional differentiation
regulation that is emerging in this study. Collectivistic in major depressive disorder. Psychological
cultures as in India, may recommend less expression science. 2012 Nov;23(11):1410-6.
of emotions for fear of upsetting social harmony 18,19. 3. Brockmeyer T, Bents H, Holtforth MG, Pfeiffer
Occupation has not emerged as a critical variable for N, Herzog W, Friederich HC. Specific emotion
emotion regulation in major depressive disorder and regulation impairments in major depression and
borderline personality disorderin this study. Being anorexia nervosa. Psychiatry research. 2012 Dec
in relation or marriages in which one or both partners 30;200(2-3):550-3.
have borderline personality disorder can be tumultuous,
4. Berking M, Wirtz CM, Svaldi J, Hofmann
conflict-laden, and dysfunctional. It is likely to be an
SG. Emotion regulation predicts symptoms of
everyday challenge for persons with major depressive
depression over five years. Behaviour research and
disorder and borderline personality disorder to deal with
therapy. 2014 Jun 1;57:13-20.
negative emotions at work. However, more research is
required to conclude emphatically on this variable of 5. Iverson KM, Follette VM, Pistorello J, Fruzzetti
emotion regulation in these clinical conditions. AE. An investigation of experiential avoidance,
emotion dysregulation, and distress tolerance in
Conclusion young adult outpatients with borderline personality
disorder symptoms. Personality Disorders: Theory,
In conclusion, this study sought to inquire the Research, and Treatment. 2012 Oct;3(4):415.
nature, intensity and extensity patterns of emotion
6. Chapman AL, Walters KN, Gordon KL. Emotional
regulation in patients diagnosed as major depressive
reactivity to social rejection and negative evaluation
disorder and borderline personality disorder. By using
among persons with borderline personality
a one-shot cross sectional purposive sample survey
features. Journal of Personality Disorders. 2014
design, this hospital-based study targeting a random
Oct;28(5):720-33.
sample of subjects from both gender between 18-30
years has significantly high scores on emotion regulation 7. Zanarini MC, Vujanovic AA, Parachini EA,
in both the clinical populations with marked differences Boulanger JL, Frankenburg FR, Hennen J. A
across specific cognition mediated domains and in screening measure for BPD: The McLean screening
relation to associated variables like gender and marital instrument for borderline personality disorder
status appear to influence only some aspects of non- (MSI-BPD). Journal of personality disorders. 2003
cognitive emotional dysregulation. These findings have Dec 1;17(6):568-73.
implications for therapy in the context of cultural factors 8. Hedlund JL, Vieweg BW. The Hamilton rating
unique to Indian settings. scale for depression: a comprehensive review.
Journal of Operational Psychiatry. 1979;10(2):149-
Conflict of Interest statement: Nil 65.
Ethical clearance- Taken from IMS and SUM 9. Hamilton M. The Hamilton rating scale for
hospital, Siksha O Anusandhan University, K8, Kalinga depression. In Assessment of depression 1986 (pp.
Nagar, Bhubaneswar-751003, Odisha, India. ethical 143-152). Springer, Berlin, Heidelberg.
committee 10. Gratz KL, Roemer L. Multidimensional assessment
of emotion regulation and dysregulation:
Source of Funding- Self
Development, factor structure, and initial
validation of the difficulties in emotion regulation
References
scale. Journal of psychopathology and behavioral
1. Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion- assessment. 2004 Mar 1;26(1):41-54.
regulation strategies across psychopathology: A 11. Garnefski N, Kraaij V, Spinhoven P. Negative life
meta-analytic review. Clinical psychology review. events, cognitive emotion regulation and emotional
2010 Mar 1;30(2):217-37. problems. Personality and Individual differences.
2. Demiralp E, Thompson RJ, Mata J, Jaeggi SM, 2001 Jun 1;30(8):1311-27.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 245

12. Schulze L, Bürkner PC, Bohländer J, Zetsche role of emotion differentiation in the relationship
U. Cognitive control and daily affect regulation between borderline personality and urges for
in major depression and borderline personality maladaptive behaviors. Journal of psychopathology
disorder: protocol for an experimental ambulatory and behavioral assessment. 2014 Dec 1;36(4):616-
assessment study in Berlin, Germany. BMJ open. 25.
2018 Oct 17. Chapman AL, Dixon-Gordon KL, Butler SM,
13. Diedrich A, Grant M, Hofmann SG, Hiller W, Walters KN. Emotional reactivity to social rejection
Berking M. Self-compassion as an emotion versus a frustration induction among persons
regulation strategy in major depressive disorder. with borderline personality features. Personality
Behaviour research and therapy. 2014 Jul 1;58:43- Disorders: Theory, Research, and Treatment. 2015
51. Jan;6(1):88.
14. Lei H, Zhang X, Cai L, Wang Y, Bai M, Zhu 18. Ford BQ, Shall cross AJ, Mauss IB, Floerke
X. Cognitive emotion regulation strategies in VA, Gruber J. Desperately seeking happiness:
outpatients with major depressive disorder. Valuing happiness is associated with symptoms
Psychiatry research. 2014 Aug 15;218(1-2):87-92. and diagnosis of depression. Journal of social and
15. Krieger T, Altenstein D, Baettig I, Doerig N, clinical psychology. 2014 Dec;33(10):890-905.
Holtforth MG. Self-compassion in depression: 19. Kwon H, Yoon KL, Joormann J, Kwon JH. Cultural
Associations with depressive symptoms, and gender differences in emotion regulation:
rumination, and avoidance in depressed outpatients. Relation to depression. Cognition & Emotion. 2013
Behavior therapy. 2013 Sep 1;44(3):501-13. Aug 1;27(5):769-82.
16. Dixon-Gordon KL, Chapman AL, Weiss NH,
Rosenthal MZ. A preliminary examination of the
 246 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A Study on Stress Management and Health Impacts on Women

Employees of it Sectors in Chennai City

Snigdha Preethi R.V1, M. Valliappan2

1ResearchScholar , Department of Management Studies, Sathyabama Institute of Science and Technology,
Chennai, 2Professor, Department of Management Studies, Jeppiaar Engineering College, Chennai

Abstract
Women are playing diverse roles in the family and in the work place. Women experience stress and many
health impacts in both sides from psychological tension and physical harassment at workplaces, apart
from the common job stress. Information Technology (IT) companies is one of the significant employee
generating industry in the worldwide condition where the people are participating. In these companies
women advanced into the corporate workforce, however without need of full improvement of their abilities
and ascend for authority positions because of stress. Globalization of economy have constrained our IT
workforce to concern more in winning the ability individual and India’s informed IT proficient women
are a noteworthy resource that should never again be underestimated and under-used. This paper depends
on discoveries from research studies on Indian Information Technology Industry. It gives a diagram of the
difficulties and stress observed by women who are working in IT companies associations. Here discussion is
about what changes are required to manage stress among women and what is being done to get the prescribed
procedures for Information Technology industry in India. The present paper features the adapting systems
that can be chosen to additionally precede corporate journey to gender inclusion and the development of
women in the society.

Keywords: Stress management, IT companies, women, economy, health, employees

Introduction However, this study is about women stress with

unique focus on the work stress in IT companies.
In the recent years the developments in the areas of
Numerous individuals think they comprehend stress, but
communication, power and software developments is
actuality stress is perplexing and frequently misjudged.
constantly increasing in India. Information technology
Our Information Technology industry has a name for it
industry has already established itself becoming a
‘Burn out stress disorder’, which is seen usually among
popular across the globe. In today‘s context the word
women working in IT companies. Technological and
stress we often listen everywhere in this globalized
administrative changes in the IT companies in India
world, stress are often described as feelings of being
made a sharp and genuinely sudden increment in the
under too much physical, emotional and mental resulting
interest for female laborers (Vijayakumar Bharathi,
into tension.
2015)1 Therefore stress among women employees in
Stress at work place is common aspect. Now a day Information Technology industry is a contemporary
jobs are more associated with stress. The working persons issue to talk about and to hit upon on explanation of this
come under stress and suffer from its consequences. In issue.
reality the stress is faced by everyone in everyday life.
Some people have high tolerance for stress and succeed Women Employees
well in the expression of numerous stressors in the In the modern world, women no longer wait behind
environment. Stress is a wide phenomenon as it appears in terms of career. The IT has been noticed that one of
to exist in human beings, animals and even in metals. the industry, which has witnessed high development for
women and helped them more. Though, still now women
are expected to do multi tasking. The Nature has given
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 247

women too much supremacy but, the law gives them too offers an opportunity for one to gain something.
little as there is no detach in support of women to fill Eustress implies useful stress-either mental, physical or
the gap during their intrinsic responsibilities. Women biochemical, radiological. Eustress is frequently seen as
themselves support the idea of men as a pioneer which an inspiration since in its nonappearance the individual.
cannot be broken by the women to make a position in the Positive stress gives the sprit to accomplish and actuates
male-dominating corporate world. us to succeed are achieve the following dimension
of vocation openings and to get more money related
Women in India is changing the view of them in the advantages, these positive stress helps women.
society, from just a housewife to CEO of an organization,
she not only has acquired skills and abilities to being an Negative Stress
ideal housewife but being at same time competition with
life partner. Now, women are transforming themselves Stress influences individual physiologically and
with their dream career and this is the new transmission typically and it is connected to a few medical issues, the
of women but, women are suffering from numerous procedure of physiological stress reaction begins from
symptoms of stress those who are working. They have the minute the body understands the stressor, viewed by
to fulfill the various demands at both workplace and the sending of signs to the cerebrum, and to the particular
home. Today, to create a balance with occupational life thoughtful and hormonal reactions to take out, decrease
as well as their personal life at home with their children or adapt to the stress Sympathetic Response things to go
maximum married couples are working at equal level to immediately with stress and the synapse is discharged
live a stable life. But it is very difficult for the women as by the nerve endings and is sent to the SNS Enhance the
she has to perform various tasks right from a cooking, as quality of your skeletal muscles.
a tutor to their children, a housemaid who take care and Nature of stress
fulfill requirements of the home. So, a working woman
is highly stressed and restless. The main cause of stress among the work force has
become part of human life, due to development, whether
Health impact it is supposed as a negative or positive experience.
Anxiety and depression are types of health impact There various reasons for stress in workplace conditions
that affects a mental status of a person. It can affect are associated with the work pressure, physical and
thoughts, feelings, behavior, and overall health. Normal mental-illness. Some of stresses are identified as Job
feelings fall along a range from lower level to higher related stress and they are workload, organizational
level. It is regular to react to suffering in life with sorrow and physical work environment, long working hours,
and obscurity. But when these feelings create impact on a culture and politics of the organization, the restrictions
person from performing their everyday activities and the compulsory on behavior, etc. Relationship related stress
reality of a person’s life, they are considered indications which is identified outside the workplace. Change in
of Health impact (Eleni Kampanellou, 2016)2. living conditions also plays important role in creating
stress (Schneiderman et al, 2016)3. Stress linked with the
Type of stress home and workplace interface and it includes conflicts
of allegiance, life style and life crisis.
Stress has often been misunderstood to be negative
but, some people recognize the significance and REVIEW OF LITERATURE
effectiveness of positive stress. In daily life stress is
everywhere and definitely unavoidable. So it is required Sudha Tiwari (2015)4 stated that the stress
to differentiate between positive stress and negative originates from two sources, namely organization and
stress. Negative stress causes many physical and the family. The factors recognized for the stress include
psychological problems. There are four main category anxiety about the replacement and insecurity, future of
of stress namely eustress, distress, hyper stress and hypo their children and financial inference. The percentages
stress. of women being affected by these in two companies are
equivalent. The stress can be managed by maintaining
Positive Stress balance between the proficient and the individual
responsibility.
Stress is said to be positive when the circumstance
 248 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Thirumaleswari (2013)5 has conducted a study on Research Methodology

job stress among employees of IT industries in Chennai.
Details regarding the research design, data collection
She has found that employee becomes stressed when
questionnaire, sampling plan, area of the study and
they are allotted with unachievable targets and are
statistical tools used have also been given. Finally, the
unable to manage the given situation. The researcher
limitations of the study have also been briefed.
acknowledged few steps for effectively handling stress.
The result from the study stated that the employees Research Design
should to be avoided by providing overload of work;
proper rewards should be giving for their excellent The research design is purely and simply the
performances of the employee. framework or plan for a study that guides the collection
and analysis of the data. The research design indicates
Janani (2016)6 stated in her study that the stress the methods of research that is the method of gathering
refers to a physical function that is mainly caused by information and the method of sampling study is
some form of emotional or psychological, it could be descriptive in nature.
a mild depression, work-related pressure and even
tremendous behavior qualities that can produce severe Sampling Plan
stress. However, these problems are considered to run in
The sampling plan is to be decided about the
families and workplaces. Working women suffers from
sampling unit, sample size and sampling method.
stress issues; it may also be at a risk of making tragedy
in their family, work and their life. Sampling Method
Rao N (2017)7 conducted a study on the effect of For this study, the samples were drawn using
stress on women health. Results show that working random sample method.
women are facing higher level of stress than that of the
non- working women. It has been determined that stress Statistical Tools Applied for the present paper
level of working women were higher when compared
The following tools and techniques have been used
to non- working women and that there was a significant
for the analysis of the data.
difference between women’s working status and their
stress level. Working women had higher level of stress i. One- way ANOVA
than unemployed women.
ii. Chi-square
Chaudhari et al. (2014)8 studied that raise in stress
levels are found in female health care professionals in the iii. SEM (Structural Equation Modeling)
India due to shortage of manpower, lack of infrastructure,
ANALYSIS OF THE DATA
extended working hours and inadequate remuneration
for their work. Enthusiastic relaxation exercises had The data collected through questionnaires have
decreased not only the stress levels but also increased been tabulated. By using the above mentioned statistical
the quality of their life and most important patient care. tools, the data have been analyzed. Interpretations
have been drawn based on the analysis. The findings
OBJECTIVES
and observations are the result and outcome of the
• To study stress management among women interpretations made during the course of analysis.
employees of IT industries in Chennai.
ONE WAY ANOVA
• To study the effects of stress on women
H01There is no significant difference between age
employees.
with respect to perception about Work Performance,
• To analyze the level of stress and health impact Occupational stress, Organizational stress, Behavioral
experienced by women employees. stress and Stress management.

• To provide suggestions for the women

employees to overcome stress.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 249

Table 1: One Way ANOVA

Sum of Squares df Mean Square F Sig.

Between Groups 28.902 4 7.225

.469 .758
Work Performance Within Groups 3016.571 196
15.391

Total 3045.473 200

Between Groups 53.345 4 13.336

1.148 .335
Occupational stress Within Groups 2277.023 196
11.617

Total 2330.368 200

Between Groups 34.181 4 8.545

1.222 .303
Within Groups 1370.416 196
Organizational stress 6.992

Total 1404.597 200

Between Groups 32.534 4 8.133

.747 .561
Behavioral stress Within Groups 2132.750 196
10.881

Total 2165.284 200

Between Groups 56.259 4 14.065

Stress management Within Groups 1834.637 196 1.503 .203

9.360
Total 1890.896 200

Between Groups 99.393 4 24.848

Health Impact Within Groups 2406.696 196 2.024 .093

12.279
Total 2506.090 200

**Significant at 0.05% level

Analysis: It can be seen from Table 1.1 that Performance, Occupational stress, Organizational stress,
the p-value is significant at 0.05% level for Stress Behavioral stress and Stress management
management of women employee in IT companies.
Therefore, the null hypothesis is rejected in such cases. CHI-SQUARE

Discussion: There is no significant difference Association between age and experience

between age with respect to perception about Work
 250 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 2: Chi-Square

Statistical
Value df Asymp. Sig. (2-sided)
Inference

Pearson Chi-Square 796.351a 16 .000

X 2=796.351a
Likelihood Ratio 610.141 16 .000 Df = 16
P= .000 <0.05
*Significant at 5%
Linear-by-Linear
199.315 1 .000 level
Association

N of Valid Cases 201

*Significant at 5% level

Analysis Number of variables in your model: 8

Since the P value is lesser than our chosen Number of observed variables: 6
Significance at =0.05, we can reject the null hypothesis,
and conclude that there is an association age and Number of unobserved variables: 2
experience.
Number of exogenous variables: 6
Discussion: Number of endogenous variables: 2
There is no significant association between age and
experience in relation to the variables such as Work
Performance, Occupational stress, Organizational stress,
Behavioral stress and Stress management.

Structural Equation Modeling

Observed, endogenous variables

Work Performance
Figure 1: SEM Path Analysis
Stress management Model Fit Indices Summary: The important fit
indices are presented in the Table below.
Observed, exogenous variables
Table 3: Major Model Fit Indices Summary
Occupational stress

Health impact Acceptable

Research Model
Parameters values for Good
Values
Organizational stress Fit

Behavioral stress GFI >0.9 0.932

Unobserved, exogenous variables AGFI >0.9 0.900

e2 CFI >0.9 0.958

RMSEA <0.06 0.027

e1
RMR <0.02 0.008
Variable counts (Group number 1)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 251

Source: Primary Data, SPSS AMOS output, Haier et various professional and family factors, prominent of
al. (2009); Hooper et al. (2008); Steiger (2007); Hu and which being relocation and uncertainty, anxiety about
Bentler (1999). the future of their children and financial implications.
Job-related stress is a major issue for working women.
Interpretation: Women are being the mainly affected by stress therefore
The Goodness of Fit Index (GFI) value was 0.932, their stress management is essential for both family and
Adjusted Goodness of Fit Index (AGFI) value was 0.900 work life. Companies have to understand the needs of the
and Comparative Fit Index (CFI) value was 0.958. All women employees and they have to provide relaxation
these values are (greater than 0.9) indicating a very techniques and counseling sessions and to provide
good fit. It was found that Root Mean Score Error of good opportunities for their career development. The
Approximation (RMSEA) value was 0.027 (lesser than development of an independent woman’s health program
0.06) and Root Mean Square Residual (RMR) value was that takes a life-course approach to improving their
0.008 (lesser than 0.02). access to healthcare is needed to enable management
of all issues that affect women’s health. This requires
Findings behavioral change communication in the health system
to primary-level health workers and through them to the
• The respondents are only women employees communities. Any people with stress cannot precede
from IT companies in Chennai city their work life balance properly. The human life and
• The majority of the respondents are employed stress common and nobody are free from stress. It is
and below the age of 30 not that only people with higher position will have only
stressed even the low position people also has stress.
• The result is showing that the stress management If our attitude is positive and its outcome will be also
and health impact playing a significant role in work positive. It is also found that in case of IT companies the
performance of working women. level of stress is high.

• It is observed from the study that the women Ethical Clearance: This research was approved
employee of IT perceive high level of stress by Head of the Department of Management
Studies, Sathyabama Institute of Science and
Suggestions
Technology, Chennai. The research was reviewed and
• Though the stress is common for everyone, the discussed under the guidance of Research Supervisor
solution for managing stress should be done. Hence, it of Department of Management Studies, Jeppiaar
is suggested that expert can be appointed to identify the Engineering College, and Chennai.
problems faced by the women employees working in the
Source of Funding: The research was self funded.
IT companies which could help in managing such stress.
This research obtained no specific grant from any
• Proper practice relaxation techniques like funding agency in the public, commercial, or not-for-
meditation and yoga should be implemented and profit companies.
awareness should to be created in every IT companies to
reduce the level of stress Conflict of Interest: There is no potential conflict
of interest reported in light of the current research.
• It is further suggested that promotions based
time bound also be introduced and which will help the References
employees to get promotion occasionally.
1. Vijayakumar Bharathi. Work Life Balance of
• The stress can be managed by keeping a fine Women Employees in the Information Technology
balance between work life and family life. It is advisable Industry. Asian Journal of Management Research. 2015;
to avoid unnecessary concern about the work-place 5(3):323-343.
anxiety there itself before coming home.
2. Eleni Kampanellou. The health impacts of the
CONCLUSION contemporary manufacturing and service sectors on
men and women. Longitudinal and Life Course Studies.
Women working in the IT sectors feel stress due to
 252 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

2016; 7(4):1-10. 6. Janani. A Study On Stress Management Among

Women Employees In The Information Technology
3. Schneiderman N, Ironson G, Siegel S. STRESS Companies, Coimbatore City, Tamil Nadu.
AND HEALTH: Psychological, Behavioral, and International Journal of Management Research.
Biological Determinants. Annu Rev Clin Psychol 2016; 6(1):53.
2005. 2016; 1(1):607-628.
7. Rao N. An Impact of Stress on Women Employees
4. Tiwari S. Women, Work and Stress Management- with Reference to Selected Bpo’s Visakhaptnam.
A Comparative Study of Education and Finance International journal of scientific research and
Companiess. International Journal of Commerce, management. 2017; 5(7):6211-6214.
Business and Management. 2015; 4(3):19-28.
8. Chaudhari et al. Stress and Health at the
5. Thirumaleswari. A study on job stress among Workplace-A Review of the Literature. Journal of
employees of software Industries in chennai. Business Studies Quarterly. 2014; 6(3):12.
International Research Journal of Business and
Management. 2013; 3(1):25.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 253

Superbrain Yoga Enhances Well-Being among School Students

Srikanth N Jois 1,K. Nagendra Prasad2, Lancy D’Souza3

1ResearchHead, World Pranic Healing Foundation, India, Research Centre, Mysore, India, 2Senior Research
Consultant, World Pranic Healing Foundation, India, Research Centre, Mysore, India, 3Associate Professor,
Maharaja’s College, University of Mysore, Mysore, Karnataka, India

Abstract
Background: Superbrain Yoga (SBY) boosts pranic energy in the brain. It is based on ear acupuncture and
the movement of subtle energy in the body.

Aim: The aim of this study is to improve the well-being of school students by practicing SBY.

Setting and Design: The study involves 1,945 school students from Mysore district, India. SBY was practiced
by the students for a period of three months thought by their teachers.

Method: Responses with a questionnaire from the students and their teacher were collected and examined. The
questionnaire was on health, relationship with their family and friends, time consciousness, communication
skills and activeness of students.

Statistical Analysis: The data collected were analyzed with Chi-square test and contingency coefficient
analysis.

Results: Responses of the students were analyzed and they reported that their health has often improved by
78%, sometimes improved (16.3%) and rarely improved (5.6%). Similarly, responses in the relationship
with family and friends were found to be drastically improved (81.3%), moderately improved (14.6%) and
hardly improved (4.1%). Both the results were found to be significant (p<0.001). Teachers also reported that
students improved in their time consciousness, communication skills, and activeness.

Conclusion: SBY has improved the overall well-being of school students.

Keywords: Brain, family, health, prana, school, yoga

Introduction (SBY) is a yogic exercise that cleanses and energies the

The human brain being more powerful and chakras needed for the brain to function efficiently. The
sophisticated, it becomes essential to maximise its chakras are actually the main acupuncture points. SBY
potential for better work output and holistic wellbeing. is done by squeezing earlobes with forefinger and thumb
Many techniques to optimize brain wellness are described in a specific position followed by fourteen squats with
in literature. Among them Yoga is most popular. Yoga controlled breathing technique. By doing this, the ear
changes the physiology of the body through breathing produces the necessary energy or prana connection to
techniques, physical postures (asanas), and cognitive the right and the left brain. This causes the left and right
control (relaxation and meditation).[1,2] Superbrain Yoga brain to become activated and energized.[3]

Crown chakra is located at the crown of the head

and has the task of controlling and energizing the brain.
Corresponding author: The sex chakra is located in the coccyx area. It controls
Srikanth N Jois the energy of the gonads and gives them energy. Basic
Tel No: 0821-2340673 chakra is a dynamic activity center. This is the center of
Email: [email protected] action and operation. If basic chakra is imbalanced, it
 254 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

will be very overactive and could lead to several health for a period of three months. Daily before the school
complications for humans. By doing SBY energy is began, teachers guided students to practice SBY except
transferred from the lower centers to the upper centers on Sundays and hoildays.
mainly the crown centre, which control the pineal gland
and overall brain health. Hence, SBY could enhance IIIrd phase
the Pranic energy in the brain. This technique was Teachers and students responses were collected
practiced and developed long ago by Indian rishis to with a questionnaire and analysed after completion of
increase the intelligence of people.[4] Earlier studies second phase.
showed when school childrens practiced SBY it could
help in enhancing concentration, confidence,[5] memory, Superbrain Yoga procedure
selective attention,[6] academic performance and
visuospatial ability [7]. When SBY is practiced for one Stand facing the east, Connect the tongue to the
minute, Alfa wave activity in the brain is increased.[8] It roof of your mouth i.e..palate; Press the right earlobe
also helps children with Attention Deficit Hyperactivity by the thumb and index finger of the left hand and
Disorder (ADHD).[9] SBY is easy to learn technique, left earlobe by the thumb and index finger of the right
cheap and could be practiced daily by school students hand; The right hand should overlap the left hand;
to improve their overall performance. The present study While sitting, simultaneously inhale and while standing,
aims to find the effectiveness of SBY on well-being of simultaneously exhale; Repeat the last step for 14 times.
[3]
school students.
Tools employed for the study
Method
Two questionnaires were used as tools in the present
Sample
study.
Thirty eight teachers from many schools in Mysore
• Superbrain Yoga Questionnaire for school
district, India randomly participated in this study.
teachers.
They were trained about SBY technique. Among them
997 were girls and 948 were boys totalling to 1,945 in • Superbrain Yoga Questionnaire for students.
number, with their average age of 12.5 yrs. The subjects
(teachers and students) were informed about the purpose Permission
and method of the study and their consent was obtained.
Permission to conduct this study was obtained from
They were guaranteed that they could withdraw from the
Deputy Director of Public Instructions office (DDPI)
study at any time.
and from District AYUSH Officer, to conduct the study.
Study Design
Statistical methods applied
Cross sectional study design was used.
The data collected have been analyzed under Chi-
Phases of the study Square test and Contingency Coefficient analysis and
the results obtained have been tabulated and interpreted.
The study was performed in three phases.
Results and Discussion
Ist phase
Improvement in overall health
A workshop was performed for the selected school
teachers about SBY as hypothesised by Master Choa Table I denoted that 78 % of the students have
Kok Sui. They were provided with SBY trainers manual, opined that they have often felt an improvement in their
which contained detailed information about SBY and its overall health after the practice of SBY. Only 16.3 %
procedure of them felt that sometimes they observed improvement
and 5.6 % felt that practicing SBY has helped them
IInd phase rarely in improving their health. Chi-square test revealed
These teachers in turn trained their students who a significant difference in student’s health after SBY (X2
participated in this study about SBY and was practiced = 1783.528, P < .001). Among 78 % of the students who
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 255

have experienced significant improvement in their health Teachers feedback

93.8 % of them are studying in the lower grade (1st to 5th
standard), 71 % in the middle grade (6th to 8th standard) To study the impact of SBY on students, 14 teachers
and only 66.3 % in the higher grades (9- 10th standard) were randomly selected and given a questionnaire.
and the results were found to be signifncant (P<0.001). There were 11 male and 3 female teachers within age 30
to 55 yrs. Data from teachers were elicited questioned
Relationship with friends and family members through a questionnaire regarding the effects of SBY on
student’s time consciousness, discipline, communication
Both urban and rural area students have found to have skills, memory and activeness of students. It is very
experienced improvement in relation to their family and encouraging to know that 92.9 % of the teachers opined
friends. Practice of SBY has helped the students from that they have observed improvement in the time
urban areas to improve the relationship with their friends consciousness among students after the practice of SBY
and family members by 85.1 % than the rural students and it was found to be significant. As shown in Table III,
(78.1 %) and the resuts were significant (P<0.001). a majority of the teacher’s (85.7 %) of them observed a
The effect of SBY is the same for both boys and girls better discipline in students after the practice of SBY.
of all age group (Table II). Chi-square test revealed a Majority of the teachers (71.4 %) have opined that
significant difference in student’s relationship after SBY they have noticed signs of memory enhancement of the
practice (X2 = 2049.247, P < .001). students after the practice of SBY.

Table 1. Frequency and percentage of students who have experienced improvement in overall health
related to gender, class and locality and results of test statistics

Gender Class Locality

Responses Total
Boys Girls 1-5 6-8 9- 10 Urban Rural

f 49 60 12 48 49 48 61 109
Rarely
% 5.2 6.0 1.7 7.0 8.8 5.3 5.8 5.6

f 137 181 32 148 138 157 161 318

Sometimes
% 14.5 18.2 4.5 21.6 24.9 17.4 15.4 16.3

f 761 756 662 488 368 695 823 1518

Often
% 80.4 75.8 93.8 71.3 66.3 77.2 78.8 78.0

f 947 997 706 684 555 900 1045 1945

Total
% 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

CC = .055 CC =.279 CC =.029, X2=1783.528

Test Statistics
P = .051 P < .001 P = .451 P < .001
 256 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 2. Frequency and percentage of improvement of student’s relationship with friends and family members
related to gender, class and locality and results of test statistics

Gender Class Locality

Responses Total
Boys Girls 1-5 6-8 9- 10 Urban Rural

f 41 38 8 39 32 27 52 79
Hardly improved
% 4.3 3.8 1.1 5.7 5.8 3.0 5.0 4.1

f 126 158 19 123 142 107 177 284

Moderately improved
% 13.3 15.8 2.7 18.0 25.6 11.9 16.9 14.6

f 780 801 679 522 381 766 816 1581

Drastically improved
% 82.4 80.3 96.2 76.3 68.6 85.1 78.1 81.3

f 947 997 706 684 555 900 1045 1944

Total
% 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

CC =.037 CC =.288 CC =.090 X2=2049.274

Test Statistics
P = .257 P < .001 P < .001 p < .001

Table 3. Frequency and percentage of teacher’s feedback about students behaviour after regular practice
of SBY for 3 months and results of test statistics

Teachers Opinion Rarely Sometimes Most of the times Statistics

f 0 1 13
More time conscious X2= 10.286 p<.001
% 0 7.1 92.9

f 0 2 12
Discipline of students X2= 7.143 p= .008
% 0 14.3 85.7

f 0 1 13
Communication skills of students X2= 10.286 p<.001
% 0 7.1 92.9

f 0 4 10
Memory enhancement X2= 2.571 p= .109
% 0 28.6 71.4

f 0 1 13
Activeness of students X2= 10.286 p<.001
% 0 7.1 92.9
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 257

Discussion Conflict of Interests: All the authors reports no

conflict of interests
The relationship of students with their family and
friends have improved along with the physical health Funding: World Pranic Healing Foundation, India
indicating overall improvement among students after funded the study.
the practice of SBY. SBY being practiced on a regular
basis becomes a physical activity contributing towards Ethical Clearance: Permission to conduct this
the brain wellness of the child. Examinations of SBY study was obtained from Deputy Director of Public
practitioners with EEG and Brain Maps show that their Instructions office (DDPI) and from District AYUSH
brain are fully synchronized and balanced. Even the Officer, to conduct the study.
Alpha waves activity is increased over Frontal, Parietal
and Occipital regions of the brain.[8] Elevations in alpha References
wave activity have been associated with an increased 1. Rocha KKF, Riberio AM, Rocha KCF, Sousa MBC,
perception of calmness, memory enhancement and pain Albuqerque FS, Riberio S, Silva RH. Improvement
reduction. Aplha waves are also known to strengethen in physiological and psychological parameters
the immune system, which makes the person healthy.[10] after 6 months of yoga practice. Consciousness and
Yoga claims to relax the sympathetic nervous system by Cognition, 2012, 21, 843-850.
activating parasympathetic–limbic pathways that relax 2. Sharma KD (2002). Yoga and naturopathy: The true
body and mind.[11] This helps to enhance children’s science of healing. Indian Journal of Traditional
performance at school. According to studies of Wheeler Knowledge, 2002, 1, 22-24.
& Wilkin, [12] yoga improves focus, concentration
3. Sui CK. Superbrain Yoga. Institute for Inner studies
and learning readiness as well as enhances health and
Publication Foundation, India Pvt Ltd., Bengaluru
fitness. A positive correlation with yoga in improving
India. 2013.
physiological and pychological performance of healthy
subjects was studied by Mariappan and Subramanium. 4. Sui CK. Pranic Psychotherapy, 2 Indian edition,
[13] By performing Yoga, children reported that they Institute of Inner studies publishing foundation
felt calmer, could sleep better, less panicky and more India Private Ltd., India. 2015.
relaxed.[14] Child self-esteem showed significant 5. Jois SN, Lancy D. The effectiveness of Superbrain
improvements in children’s confidence, social abilities Yoga on concentration, memory and confidence
and involvement. Child–parent relationship quality also in school children’s. Indian Journal of Traditional
improved.[15] Knowledge, 2018, 17, 741-744.
6. Jois SN, Lancy D, Moulya A. Beneficial effects
Earlier studies on SBY revealed that it is a very
of Superbrain Yoga on short term memory and
simple exercise, being performed in less than two minutes
selective attention of students. Indian Journal of
can transform and help the students to remain active
Traditional Knowledge, 2017, 16, S35-S39
mentally and intellectually.[16] SBY can play an efficient
role in the enhancement of mental activity among 7. Jois SN, D’Souza L, Moulya R. Effectiveness
college-going adolescence.[17] It exercises the brain and of Superbrain Yoga on Short-term Memory,
balances energy in the left and right hemisphere of the Visuospatial Ability and Academic Performance of
brain. This balance of energy in the brain contributes Students, Indian Journal of Public Health Research
to the enhancement of well-being of a person. SBY and Development, 2018, 9, 183-187.
is an technique that needs no special technology and 8. Ramesh, D. Superbrain Yoga–A Research study: In
equipment, no particular time and place to practice as a Prana World, 2007. 18.
result, the independence of the practicioner is preserved. 9. Farahani PV, Hekmatpou D, Khonsari AH,
Gholami M. Effectiveness of superbrain yoga for
Conclusion children with hyperactivity disorder, Prespectives
SBY helps in increasing their health and enhanced in Psychiatric Care, 2019, 55, 140-146
relationship with family and friends of students. Schools 10. Desai R, Tailor A, Bhatt T. Effect of yoga on
can implement SBY regularly to students to improve brain waves and structural activation. A review.
their well-beign. Complementary Therapies in Clinical Practice,
 258 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

2015, 21, 112-118. Rhythms, 2006, 4, 207-214.

11. Gothe NP, Keswani RK, McAuley E. Yoga practice 15. Harrison LJ, Manocha R, Rubia K. Sahaja Yoga
improves executive function by attenuating stress Meditattion as a family treatment programme
levels. Biological Psychology, 2016, 121, 109-116. for children with attention deficit-hyperactivity
12. Wheeler A, Wilkin L. A study of the impact of yoga disorder. Clinical Child Psychology and Psychiatry,
asana on perceived stress, heart rate, and breathing 2004, 9, 479-497.
rate. International Journal of Yoga Therapy, 2007, 16. Singh P. Management of Mathematics Anxiety
17, 57-63. through Behaviour Technology, Superbrain Yoga
13. Mariappan, R., Subramanian, M.R. Experimental and Varmalogy in Ninth Standard Students, The
investigation of cognitive impact of yoga meditation International Journal of Indian Psychology, 2016,
on physical and mental health parameters using 3, 163-169.
electro encephalogram, Springer Briefs in Applied 17. Kumar P, Singh V. Application of Superbrain
Sciences and Technology, 2019, 129-139 Yoga For Academic Anxiety Management in
14. Sulekha S, Thennarasu K, Vedamurthachar A, Raju Adolescence, International Journal of Science and
TR, Kutty BM. Evaluation of sleep architecture Consciousness, 2017, 3, 72 –77.
in practitioners of Sudarshan Kriya yoga and
Vipassana meditation, Sleep and Biological
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 259

Impact of Kinship on the Chosen Autosomal Anomalies in

Sivagangai, Tamil Nadu, India

Subalakshmi T1, Jepa Chandra Mohan2

1Research Department of Zoology, 2Assistant Professor, Research Department of Zoology, Raja Doraisingam
Government Art College, Sivagangai, Tamilnadu, India

Abstract
Significance of study: Prevalence of consanguinity and their impact on the autosomal recessive anomalies
such as diabetes mellitus, hearing impairments, epilepsy, limb defect and eye defect among Sivagangai
population was studied. The present investigation provides a new plat form for pinpointing out the genetic
causes leading to congenital autosomal recessive disorder, so that in future newer gene therapy approaches
can be developed to treat such anomalies. In our study, an attempt has been made to evaluate the association
of the most common causes of autosomal recessive impairment among heterogeneous Sivagangai population.

Objective: To determine the effect of endogamy on the hereditary anomalies of Sivagangai population.

Study design: Human health survey.

Method: The impacts of kinship against autosomal recessive disorder among the selected population of
Sivagangai were studied. In this study, 2376 families were taken for assessment by face-to-face interviewed
in the local language according to the standard procedures.

Result: Consanguineous marriage was significantly higher in current generations (29.62%) than the previous
generations (37.94%). The occurrences of abnormality were higher among inter breeding populations
(67.34%) than non consanguineous population (32.65%). The highest Odd ratio was recorded in epilepsy,
followed by hearing impairment, limb defect and eye defects, while, the lowest value was observed in
diabetic population. The highest P value, odd ratio and 95% Class Interval recorded were 0.001, 26.48
and 18.63-37.63 respectively. The highest degree of consanguinity reported in the study was 2nd degree in
epilepsy.

Conclusion: The present study showed that the hereditary anomalies were higher among cognate population
than out breeding population. The children of such con sanguineous couples have higher risk of expressing
recessive gene disorders.

Keyword: Endogamy, Lethality, epilepsy, hearing impairment, limb defect, diabetics and eye defect.

Introduction practiced for hundreds of years in many communities

throughout the world1. Historically, the prevalence of
Kinship refers to the culturally defined relationships
consanguineous marriages is very high in south India.
between two people who share a common ancestor
However, marriages between biological relatives are
or blood. Consanguineous marriages have been
quiet common not only in developed countries but also
Correspondance Author: in developing countries. More than one billion peoples
Dr. Jepa Chandra Mohan, around world are consanguineous 2 and 3. In India, cognate
Ph.D., Assistant Professor, Research Department of marriage is a customary practice in some communities.
Zoology, Raja Doraisingam Government Art College, They won’t prefer non-consanguineous marriage
Sivagangai, Tamilnadu, India, Pin -630561. because of their cultural differences between families.
Contact no: 9443692675 email- [email protected] This is based on either matrilineal or patrilineal. The
 260 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

endogamous population increases the level of autosomal in convulsion, unconsciousness and shaking. Some of
recessive homozygosity, which leads to biological them are caused by single gene defect and many of them
unfitness of population. This phenomenon is known as were caused by multiple gene defect. Epilepsy is usually
inbreeding depression4. The children of consanguineous treated by medication and in some cases by surgery,
unions have the highest chance for expression of devices or dietary changes.
single-gene disorders inherited from their recessive
parents. The risk of autosonal anomalies increases with Limb Defect
degree of genetic relationship between the parents. In Congenital Limb defect is the most common
the present study, an attempt has been made to assess complex disorders among human population. This
the prevalence of consanguinity and their impact on disorder occurs during the specification of upper or
the autosomal recessive anomalies such as diabetes lower limb development. This defect is a common
mellitus, hearing impairments, epilepsy, limb defect and congenital disorder next to cardiac anomalies. The
eye defect among Sivagangai population. The present impact of congenital limb malformations are reduction
investigation provides a new plat form for pinpointing of limb size, direction of bone angle, polydactyly and
out the genetic causes leading to congenital autosomal syndactyly. These are genetic syndromes produced by
recessive disorder, so that in future newer gene therapy number of point mutations during cell fate determination
approaches can be developed to treat such anomalies. and regulation during embryogenesis.
Autosomal recessive defect selected for the present Eye Defect
study
The development of eye is specified through a
Diabetes mellitus complex program during the embryonic development.
It is a type of heterogenous metabolic disorder Any anomalies in this specification of eye cause profound
causes high blood sugar level for a prolong period of life. defects in the eye. The most common congenital inborn
Hence it is called as hyperglycemia. It is due to either the errors in eyes are anophthalmia, microphthalmia,
disinfection of beta cells of pancreases to secrete insulin coloboma, aniridia and optic nerve hypoplasia.
or irresponsiveness of body cells to insulin hormone. The other minor defects are myopia, hypermetropia,
Based on this, diabetes can be classified into Type 1 and presbyopia, astigmatism and cataract.
Type 2 diabetes.Type1 diabets is caused by insufficient Ear defect
production of insulin by pancreas and also called as
Insulin dependent diabetes mellitus (IDDM) or juvenile The ear defect is a problem in recognizing different
diabetes. Type 2 is caused by insulin resistance power types of sound from the birth. It is a hereditary disorder
of the cells in our body and also known as non-insulin due to the loss of certain factors in the uterus during
dependent diabetes mellitus (NIDDM) or adult onset development. More than 50% of the ear defect is caused
diabetes. Any defective 3 genes for type I and 20 genes by genetic factors. The hearing loss is an autosomal
for II diabetes are responsible for these anomalies. These dominant or autosomal recessive or X-linked pattern of
genes are localized in 2,3,4,5,6,7,8,10,11,12,13,15,17,1 inheritance. Approximately, about 5% of the population
9, and 20th chromosomes5. has some sort of such ear malformation. The frequently
encountered congenital ear problems are protruding ear
Epilepsy and external ear microtia.
It is a clinically heterogeneous neurological disorder, The characteristics of nonsyndromic hearing loss
commonly called as seizures. Seizures are caused by vary among the different types.Hearing loss can affect
a disturbance in the electrical activity of the brain. one ear (unilateral) or both ears (bilateral). Degrees of
Thus the nerve cell produce excessive and abnormal hearing loss range from mild (difficulty understanding
activity at the cortex region of the brain. Epilepsy may soft speech) to profound (inability to hear even very loud
occur as a result of genetic disorder and acquired brain noises). The term “deafness” is often used to describe
injury such as a trauma or stroke. During a seizure, a severeto-profound hearing loss. Hearing loss can be
person experiences abnormal behaviour, symptoms and stable, or it may be progressive, becoming more severe
sensations leads to the loss of consciousness. There as a person gets older. Particular types of nonsyndromic
are various types of seizures, but all are not involve
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 261

hearing loss show distinctive patterns of hearing loss. children. For the current generation, cases of
For example, the loss may be more pronounced at high, respondent’s offspring offspring of consanguineous
middle, or low tones. Most forms of nonsyndromic union and non-consanguineous union were experimental
hearing loss are described as sensorineural, which means and control respectively. Chi-square test was used to
they are associated with a permanent loss of hearing ascertain the associated between two or more categorical
caused by damage to structures in the inner ear. The variables. Since the sample size was small (2x2 tables),
inner ear processes sound and sends the information to the Fisher exact test (two-tailed) was applied. Mantel-
the brain in the form of electrical nerve impulses. Less Haenszel method was used to calculate Relative risk
commonly, nonsyndromic hearing loss is described as and confidence level at 95% interval. All statistics test
conductive, meaning it results from changes in the middle were two-sided and p<0.05 was considered statistically
ear. The middle ear contains three tiny bones that help significant.
transfer sound from the eardrum to the inner ear. Some
forms of nonsyndromic hearing loss, particularly a type Result
called DFNX2, involve changes in both the inner ear and The 2376 families were selected for the cross
the middle ear. This combination is called mixed hearing sectional studied. A total of 704 consanguineous
loss. Depending on the type, nonsyndromic hearing loss (29.62%) and 1672 non consanguineous (70.38%) union
can become apparent at any time from infancy to old age. in parental generation were observed. The maternal grand
Hearing loss that is present before a child learns to speak parents of 916 were consanguineous and 1460 non -
is classified as prelingual or congenital. Hearing loss that consanguineous and the paternal grand parents were 887
occurs after the development of speech is classified as consanguineous and 1489 non-consanguineous (Figure
postlingual.5 1). The overall prevalence of consanguinity among
parents was 29.62% and grandparental generation was
Methodology 37.94%. This showed that th econsanguinity was higher
The present study was a cross sectional based among the grandparent generation than the current
population investigation, carried out in Sivagangai thaluk, generation.
which have many native populations. A total number
of 2376 families were investigated. These families Figure 2 depicts various types of abnormalities
were selected by simple random sampling. The details among the consanguineous and non consanguineous
about their subjects in terms of history, clinical features, population. The highest number of anomalies were
consanguinity, disorder and pregnancy outcomes in the recorded among consanguineous population. The
present generation as well as the previous generation by total number of abnormalities among consanguineous
face-to-face interview in the local language according population was 67.34%. The maximum number of
to the standard procedure6 and 7. The maximum care degree of consanguinity recorded in 2nd degree.
was taken to avoid any wrong interpretation by the The P value, odd ratio and 95% CI for diabetes
respondents. Information was collected through personal mellitus were 0.02, 8.75 and 6.34-12.09 respectively,
visit to the selected families. The collected data were for hearing impairment were 0.0006, 22.53 and 15.17-
then processed to get the prevalence of consanguinity 33.47, epilepsy were 0.001, 26.48 and 18.63-37.63
and defects. The types of disorder were then classified. respectively. In the case of Limb defects and eye defects,
Odds ratios were calculated based on the influence the P value, odd ratio and 95% CI were 0.0108, 18.24
of endogamy on autosomal recessive anomalies status and 10.99-30.26, and 0.319, 14.44 and 9.53-21.87
in the current generation as well as the respondent’s respectively (Table1).
262 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table1: Odd ratio and P value of consanguineous and non-consanguineous population.

Consanguineous Non consanguineous

Odd 95%
Confidence P value
Affected Affected Ratio Interval
% %
individuals individuals

Diabetes 96 60 64 40 8.75 6.34-12.09 0.02

Hearing
120 78.94 32 21.06 22.53 15.17-33.47 0.0006
impairment

Epilepsy 168 60 112 40 26.48 18.63-37.63 0.001

Limb 64 80 16 20 18.24 10.99-30.26 0.010

Eye 80 71.42 32 28.58 14.44 9.53-21.87 0.319

Figure 1: Prevalance of consanguineous and non consanguineous marriages

C: Consanguineous NC: Non Consanguineous

Figure 2: Degrees of endogamy in current generation and parental generation

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 263

Discussion intrauterine destruction of normal embryonic tissues.

It can also occur with various syndromes in offspring.
Consanguinity is a couple of biologically blood
Teratogenic agents (eg, thalidomide, vitamin A) are
related individuals of second cousins or more closer
known causes of hypoplastic or absent limbs. The other
to one another8. It promotes family stability with
congenital limb anomaly is amniotic band-related limb
significant social and economic advantages9 and 10.
deficiency, which loose strands of amnion entangle
Kuntla et al., (2013)11 estimated that the prevalence
or fuse with fetal tissue. Hereditary hearing loss is an
of consanguineous marriage among Indian population
autosomal recessive or X-linked recessive as well as
was 38.2%. In this study, consanguineous marriage was
by mitochondrial inheritance. The defective genes
higher among grand parents generation (37.94%) than
cause syndromic or non-syndromic with dominant or
the current generation (29.62%). Among the selected
recessive genes hereditary hearing loss. The syndromic
population, 704 couples were consanguineous and 1672
hearing loss is a hearing impairment associated with
were non-consanguineous of current generation, where
specific traits. The dominant deafness is caused by only
as 916 and 1460 of maternal grandparents and 887 and
one faulty gene from the mother or father with hearing
1489 of paternal grand parents were consanguineous
impairment. The recessive deafness is because of faulty
non-consanguineous respectively. The calculated P value
gene from both the mother and father. There are more
was statistically significant. The highest Odd ratio was
than 200 forms of such syndromic hereditary hearing
recorded in epilepsy, followed by hearing impairment,
impairment. The human eye is programmed by a complex
limb defect and eye defects, while, the lowest value was
system of specification during embryonic development.
observe eye defectd in diabetic population. The highest
The common congenital eye malformations are
degree of consanguinity reported in the study was 2nd
anophthalmia, microphthalmia, coloboma, aniridia, and
degree. The reported marriages were first cousin type.
optic nerve hypoplasia. The eye is completely developed
According to the study of Roychoudhury (1976)12 and
in the first trimester of pregnancy. Many genes have
Badaruddoza (1998)13 that the frequency of first cousin
been found to have a role in this complicated process.
marriages in different parts of South India varied from 5
Any alternation in these genes due to point mutations
to 57 %. The intra familial marriages have the possibilities
can cause abnormal development in eyes.
of transmitting recessive identical lethal genes from
parents to offspring. Such lethal genes cause number Considering the above, the practice of consanguinity
of anomalies in children. Congenital malformations should be avoided by educating the public about the
are the major reasons for prenatal mortality during adverse effect of blood related marriages. The present
gestation in developing countries like India 14 and 15. In investigation provides a new plat form for providing
the present study, the prevalence of abnormalities were proper health care to public regarding the transmission
higher in consanguineous population (64.5%) than the of lethal endogamic disorders.
non consanguineous population (34.5%). The studies
of Verma et al. (1992)16 and Becker et al (2015)17 Author statement section
had recorded the significant number of congenital
Ethical approval – Ethical approval is not required
malformations among the children of consanguineous
for this study, because we had not used any experimental
couples than the non-consanguineous one. The babies
samples (Blood/ saliva) from the individuals. Before
born with congenital anomalies were found to be 3.4
sampling, consent certificate had been received from
times more from consanguineous parents than non-
each individual. We collected data by individual face to
consanguineous. In the present investigation, the risk
face interview.
of deleterious anomalies was found to be statistically
significant. Funding agencies-Nil
Diabetics are a most common defect in India. It may Competing Interest- None declared
be heritable. It may be due to insufficient secretion of
insulin by pancreas. Epilepsy is also called as seizure. Reference
It is due to any disturbance in the electrical activity of
1. Jaber L, Shohat M, Halpern GJ. Demographic
brain. The limb defect is a type of autosomal dominant or
characteristics of the Israeli Arab community in
autosomal recessive or x-linked anomalies. These genetic
concentration with consanguinity. Isr J Med Sci.
defects are caused by primary intrauterine inhibition or
 264 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

1996; 32: 1286-1289. 10. Hussain R. Community perceptions of reasons

2. Modell B, Darr A. Science and society: genetic for preference for consanguineous marriages in
counselling and customary consanguineous Pakistan. J Biosoc Sci. 1999; 31(4): 449–61.
marriage. Nat Rev Genet.2002; 3: 225–229. 11. Kuntla S, Goli S, Sekher TV, Doshi RP.
3. Bittles AH, Black ML. Evolution in health and Consanguineous marriages and their effects on
medicine Sackler colloquium: consanguinity, pregnancy outcomes in India. Int J Sociol Soc
human evolution, and complex diseases. Proc Natl Policy.2013; 33 (7/8): 437–52.
Acad Sci U S A.2010; 107: 1779–1786. 12. Roychoudhury AK. Incidence of inbreeding in
4. Fareed M, Afzal M. Evidence of inbreeding different states of India. Demogr India.1976; 5 (1–
depression on height, weight, and body mass index: 2): 108–19.
a population-based child cohort study. Am J Hum 13. Badaruddoza Afzal M, Ali M. Inbreeding effects
Biol.2014; 26 (6): 784–95. on the incidence of congenital disorders and fetal
5. https://ghr.nlm.nih.gov/ growth and development at birth in north India.
Indian Pediatr.1988; 35(11):1110–3.
6. Maheswari K, Lalita Wadhwa. Role of
consanguinity in paediatric neurological 14. Mohanty C, Mishra OP, Das, B.K., Bhatia, B.D. &
disorders. International Journal of Contemporary Singh G. Congenital malformations in newborns:
Pediatrics.2016;3(3):939-942. A study of 10,874 consecutive births. J Anat Soc
India. 1989; 38: 101-111.
7. Omar Ali Nafi. Maternal age and consanguinity
as risk factors for mental retardation among 15. Singh M. Hospital-based data on perinatal and
children in south Jordan. European Scientific neonatal mortality in India. Indian Pediatr.1986;
Journal.2018;9:1857-7431. 23:579-584.
8. Bittles H. A community genetics perspective 16. Verma IC, Prema A, Puri RK. Health effects of
on consanguineous marriage. Community consanguinity in Pondicherry. Indian Pediatr. 1992;
Genet.2008;11:324-330. 29 (6):685–91.
9. Bittles AH. The role and significance of 17. Becker R, Keller T, Wegner RD, Neitzel H, Stumm
consanguinity as a demographic variable. Popul M, Knoll U, et al. Consanguinity and pregnancy
Dev Rev. 1994; 20(3): 561–84. outcomes in a multi‐ethnic, metropolitan European
population. Prenat Diagn. 2015; 35(1):81–89.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 265

Preliminary Phytochemical Screening and FTIR analysis of an

Indian Medicinal Herb: Paederia foetida (Prasarini)

Subhashree Satapathy1, Gurudutta Pattnaik2

1M.Phil Scholar, School of Pharmacy and Life Sciences, Centurion University, Jatni, Bhubaneswar 752050,
Odisha, India. 2Principal, School of Pharmacy and Life Sciences, Centurion University Jatni, Bhubaneswar,
Odisha, India

Abstract
Aim: To carry out the preliminary qualitative phytochemical screening of leaf extract of an Indian herb. P.
foetida and Fourier Transform Infra-red Spectroscopy (FTIR) analysis of the extract containing the highest
number of phytochemicals.

Method: The leaf extracts were prepared using, water, methanol, ethyl acetate and acetone. Several in vitro
phytochemical analyses were carried to check for the presence various secondary metabolites. FTIR analysis
of all the 4 extracts were carried out of the for identifying organic secondary metabolites.

Results: Ethyl acetate extract was found to be positive for most of the qualitative phytochemical screening
test containing almost all the phytochemicals. The FTIR analysis revealed, that the leaf-extracts of P.
foetida had phytochemicals of different functional groups such as alkanes, aromatic compounds, aldehydes,
saturated fatty acids, alcohols, carboxylic acids, esters, ethers and alkyl halides

Conclusion: The study concluded that, the Indian herb P. foetida is rich secondary metabolites and it can
be used in the production alternative and complementary drugs, that can be against various human diseases.

Keywords: Medicinal plants; Paederia foetida; Phytochemical screening; FTIR analysis; Secondary
metabolites

Introduction becoming ineffective, e.g. antibiotics. Hence, medicinal

plants are the best alternative to solve the worldwide
Medicinal plants refer to plants having medicinal
problems arising due to synthetic drugs.3
or therapeutic values. These medicinal plants are a
rich resource of biochemicals which can be used in Treatment with medicinal plants is an ancient
development of natural drugs against several health process, as old as human origin itself. The relationship
ailments. They are also a rich source of nutrition, hence between mankind and their search for drugs is recorded
can be used as preventive too.1 Plants their by-products and documented in all civilization, across the world.
are also used in various daily use products such toothpaste 4 Knowledge of medicinal plants and their usage is
and oils. The use of complementary alternative medicine an outcome of years of research and trials by various
has become quite popular across various societies of the ancient health care workers to modern day doctors and
world.2 However, the modern health care system is still researchers. Modern day science has also approved
heavily dependent on chemical based drugs, which has and accepted plant based drugs.5 The knowledge of the
mild to severe side effects and some of them are slowly development of ideas related to the usage of medicinal
plants with awareness has increased the ability of
Corresponding author:
pharmacists and physicians to respond to the challenges
Subhashree Satapathy,
that have emerged with the spreading of professional
M. Phil Scholar, School of Pharmacy and Life Sciences,
services in facilitation of man’s life.6
Centurion University, Jatni, Bhubaneswar 752050,
Odisha, India. Email: [email protected]
 266 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Paederia foetida is an Indian edible herb that has 20% w/v solution of α-napthol in ethanol were added
traditionally been used against gastrointestinal and male to it. Further, 1 ml of concentrated H2SO4 was added.
infertility problems. P. foetida is a promising antioxidant, Appearance of red-purple ring at the interface of the two
anti-inflammatory antimicrobial, anthelmintic and layers indicated the occurrence of carbohydrates.
anticancer agent.7, 8 Its efficacy encourages the need of
proper scientific evaluation so that it can be considered 2. Fehling’s Test: An aliquot of 2 ml each solvent
for development of new drugs. Some studies also extract was dissolved in about 2 ml of distilled water and
validate in erotogenic and aphrodisiac properties.9 filtered. An equal amount of Fehling’s solution A and B
The medicinal properties are majorly due to presence was added to the filtrate and the contents were boiled.
of phytochemicals present in this herb, which acts in Advent of brick red precipitates indicated the presence
combinations or in solitary mode against various human of reducing sugars.
ailments.7,8 Hence, this study was conducted to know the Test for Cardiac glycosides
phytochemicals present in the 4 solvent extracts of the
plant and further the best extract is was subjected FTIR 1. Keller killiani’s test (Cardiac glycosides): In
analysis for the identification of different functional a mixture of glacial acetic acid, one drop 5% FeCl3,
groups in each extract of P. foetida leaves. concentrated H2SO4, 2ml of each extract were added.
Further at the junction of the 2-layer Reddish brown
Material and Method colour was observed & bluish green colour were
Processing of plant material observed at the upper layer of the mixture.

Fresh young leaves of P. foetida plant were collected 2. Raymond’s test: Few drops of test solution
from the Chandaka forest region, Bhubaneswar, Odisha. were mixed with hot methanol alkali Further violet
The fresh leaves were washed properly, shed-dried and colour precipitation was observed.
powdered and were stored in airtight polybags for future Test for Anthraquinones
use.
1. Modified Borntrager’ Test: To 5ml extract,
Extraction 5 ml 5% FeCl3 & 5ml dilute HCL was added and the
A total of 15-gram sample of powdered leaf samples mixture was heated for 5min. in boiling water bath.
was taken and extraction was carried out with the help of Further it was cooled, and benzene was added to the
a Soxhlet apparatus by using different solvent like ethyl mixture. Organic layer was separated, Equal volume of
acetate, acetone, methanol and water on their polarity dilute Ammonia was added to observe ammonia layer
basis. After extraction, the extracts were concentrated shows pinkish red colour, which indicated the presence
using a rotary-evaporator. The final crude extracts were of anthraquinones.11
stored in a glass air tight container at 4°C until further Test for Saponin
use.
1. Foam test: Plant extracts were thoroughly mixed
Primary screening of phytochemicals with distilled water and stirred well. The formation of
Test for Alkaloids foam indicated the presence of saponins.

1. Mayer’s test: To 5 ml of each extract 0.5 ml Test for Coumarins

of Mayer’s reagent were added separately and it was 1. The moistened dry leaf powder in test tube was
observed for precipitation. covered with filter paper pre-soaked in dilute NaOH. The
2. Dragendroff’s Reagent: 0.5 ml of tube was heated in water bath. After some time, filter
Dragendroff’s reagent was added separately to each paper was exposed to Ultraviolet light. The formation
filtrate and observed for orange yellow precipitation.11 light yellowish-green florescence was observed, which
indicated the presences of coumarins
Test for Carbohydrates
Test for Proteins
1. Molisch’s Test: An aliquot of 3 ml of each
extract was dissolved in ethanol and two drops of a 1. Biuret test: To 3 ml leaf extract, 1 ml of 4%
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 267

NaOH and few drops of 1% CuSO4 solution was added. Total phenolics content
Further the formation of violet or pink colour indicated
the presence of proteins. The total phenolic content was evaluated using
Folin–Ciocalteu reagent, a method described by
2. Million’s test: To 3ml leaf extract, 5 ml of Alhakmani et al in 2013.12
millions reagent was added, and it was heated in boiling
water bath, Appearance of brick red and pink colours Total flavonoid content
indicated the presence of proteins. An aliquot of 0.5 ml of sample solution was
3. Xanthoprotein test: To 3ml of leaf extract, 1 mixed with 0.1 ml of 10% aluminium nitrate, 0.1 ml of
ml conc.H2SO4 was added. white precipitation indicated 1mol.L-1 potassium acetate and 4.3 ml of 80% methanol.
the presence of proteins. The mixture was thoroughly mixed and was incubated
at room temperature. The absorbance was measured at
Test for Amino acids 415nm. Quercetin was used as standard compound for
the quantification of flavonoids content. Results were
1. Ninhydrin test: To 3 ml test solution 3 drops expressed in milligram of Quercetin equivalents per
5% ninhydrin solution was added and the mixture was gram of dried extract. 13
heated in a boiling water bath for 10 min to observe
the Purple or bluish colour change, which indicated the FTIR analysis
presence of amino acids.
FTIR technique was used for the identification of
Test for Steroids different functional groups in each extract of P. foetida
leaves as described in Sravan et al 2015. The infrared
1. Salkwoski reaction: To 2ml of extract, 2ml of spectroscopy spectrum (IR) was obtained using FTIR
chloroform and 2 ml con. HCL was added. Appearance Shimadzu Japan 14
of red colour in the chloroform layer and greenish yellow
fluorescence colour in acid layers indicated the presence Results
of steroids.
Methanol extract of P. foetida leaves was recorded
Test for Flavonoids for the presence of a maximum number of polar
compounds in the crude drug followed by the aqueous
1. Addition of lead acetate: Small quantity of extract (Table 1).
extract was added to the lead acetate; yellow colour
precipitate indicated the presence of flavonoids. Table 1. Extractive values of P. foetida leaves

2. Addition of Sulphuric acid: By addition of Solvent Used Extractive Value (% wt/wt)

sulphuric acid (66%-80%) to extract yellow colour was
observed, which indicated the presence of flavonoids Ethyl acetate 5.160 ± 0.32

3. Addition of Sodium hydroxide: Addition of Acetone 11.133 ± 0.4

increasing amount of sodium hydroxide to the extract
Methanol 46.306 ± 0.26
showed colorations and decoloured by adding acid,
indicated the presence of flavonoids. 11 Water 22.00 ± 0.12

Test for Fat and Oil Preliminary phytochemical screening of P.

1. Solubility test: Extracts were mixed with the foetida leaf extracts
ether, benzene, and chloroform totally mixing of extract In the ethyl acetate extract, carbohydrate, glycosides,
shows the presence of oil in the extracts, stains on filter alkaloids, tannins & phenolic compounds, flavonoids
paper shows the presence of the oil in the extracts. and amino acids were present as recorded (Table 2). Out
2. Addition of CuSO4 and NaOH: Addition of of which, carbohydrate is richly present in the extract.
the CuSO4 and NaOH in extract shows the clear blue Other phytochemicals are present moderately. Steroid
coloration.11 content was found very low. Carbohydrates, glycosides,
alkaloids, tannins & phenolic compounds, flavonoids,
 268 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

proteins and amino acids were present in the acetone (Table 3, Figure 2).
extract. Among of all these phytochemicals, carbohydrate
is abundantly present. Others were moderately present. Table 3. Flavonoid content in different solvent
However, proteins, amino acids and steroids content was extracts
low. Lastly methanol and aqueous extract show similar
results. High amount of carbohydrates, glycosides, Extracts flavonoid content (mg QUE/gm)
alkaloids, tannins & phenolic compounds, flavonoids
presence was recorded. The preliminary phytochemical Ethyl acetate 35.44118
screening of P. foetida leaves concluded that, that there
was a high number of polar compounds present in the Acetone 25.58824
crude extract.
Methanol 44.55882
Determination of total phenolic content
Aqueous 43.08824
The anti-oxidative effectiveness of this plant has
been reported due to presence of phenolic compounds.
Acetone extract had the highest phenolic content
(789.70mg GAE/gm), followed by methanol, aqueous
and ethyl acetate (Table 2, Figure 1)

Table 2. Phenolic content in different solvent

extracts

Extracts Phenolics content (mg GAE/gm)

Ethyl acetate 449.1176

Acetone 789.7059 Figure 2. Standard Curve of Quercetin

FTIR Analysis
Methanol 652.647
The FTIR spectral analysis was utilised to identify
the functional group of the active ingredients based on
Aqueous 533.529
peak value in the vicinity of infrared radiation. The results
of FTIR peak values and functional groups of aqueous
extract are represented in the graph. IR spectrum shows
strong absorption peaks at 2850.79cm-1(weak band),
1724.36cm-1 (wide), 1600.91cm-1 (sharp), 1444.68cm-
1(weak), 1049.27cm-1(wide), 831.39cm-1(sharp), which

corresponds to the presence of small amount of alkanes

(C-H stretch band), aldehydes, saturated aliphatic or
α-β-unsaturated esters, aromatics (C-C stretch ring),
aromatics, alcohols, carboxylic acids, esters, ethers ( wide
), alkyl halides respectively. Methanolic extracts showed
peak values 2918.29cm-1(sharp), 2850.79cm-1(weak),
1724.36cm-1(sharp), 1600.91cm-1(wide), 819.74cm-
Figure 1. Standard Curve of Gallic acid 1(small) which could be attributed to the existence of
Determination of total flavonoid content functional groups alkane(medium), small amount of
alkanes, aldehydes and saturated fatty acids(c=o stretch),
Flavonoids are a large group of ubiquitous molecules aromatics, aromatics respectively. The graph (Figure 3),
and possess antioxidant activities. Methanol extract shows that the peak data of acetone and ethyl-acetate
contained highest flavonoid content (44.558 mg QUE/ extract are quite same with the methanolic extract. Both,
gm), followed by aqueous, ethyl acetate and acetone
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 269

ethyl acetate and acetone extracts showed peak values constituents are chemical methods of evaluation. The
2850.79cm-1(strong band), 1724.36cm-1(strong), phytochemical evaluation helps in establishing chemical
1600.91cm-1(strong), 1444.68(sharp), 1049.27cm- profile of crude drugs.19 The purity of crude drugs is
1(small),831.39cm-1(sharp),which corresponds to the ascertained by quantitative estimation of the active
presence of alkanes, aldehydes and saturated fatty acids, chemical constituents present in them. The method may
aromatics, alcohols, carboxylic acids, esters, ethers and be useful in determining single active constituents or the
alkyl halides, respectively. group of related constituents present in the same drug. 20

Conclusion
Ethyl acetate extract was found to be positive for
most of the qualitative phytochemical screening test
containing almost all the phytochemicals. The FTIR
analysis revealed, that the extracts of P. foetida leaves
had phytochemicals of different functional groups such
as alkanes, aromatic compounds, aldehydes, saturated
fatty acids, alcohols, carboxylic acids, esters, ethers
Figure 3: Transmittance of P. foetida leaf extracts by [FTIR]. and alkyl halides. The study concluded that, P. foetida
is rich secondary metabolites and it can be used in the
Discussion production alternative and complementary drugs.
As part of the traditional therapy, population of
Conflict of Interest: None.
different regions of the world use medicinal plants.
Not only whole plant but also some specific parts Funding: None
(such as leaves, bark, etc.) of the plant are used as the
herbal therapy.15 As a part of traditional use, leaves Ethical Permission: Not required.
of P. foetida is used for the treatment of many human
ailments in Indian and other countries. It was confirmed References
preliminary phytochemical screening that both methanol 1. Sedighi M, Bahmani M, Asgary S, et al. A
and ethyl acetate extract of P. foetida possess some review of plant-based compounds and medicinal plants
compounds like alkaloid, tannin, flavonoids, steroids, effective on atherosclerosis. J Res Med Sci 2017; 22:30.
saponin etc. which may be responsible for amelioration
of diarrhoea.16 2. Cragg GM, Newman DJ. Natural products: a
continuing source of novel drug leads. Biochim Biophys
Chemical diversity in natural product is an advantage Acta 2013;1830(6):3670–3695.
for human civilization and they are a rich source of
new pharmaceuticals, cosmetics, agrochemicals and 3. Pan SY, Zhou SF, Gao SH, et al. New
other economically important chemicals. Therapeutic perspectives on how to discover drugs from herbal
potentials of plant-based drugs ranges from simple medicines: CAM’s outstanding contribution to modern
parts of plants, to simple extracts to isolated active therapeutics. Evid Based Complement Alternat Med
constituents.17 Plants may be considered as biosynthetic 2013; 2013:627375.
laboratories in which various kinds of organic compounds
4. Chen SL, Yu H, Luo HM, et al. Conservation
are synthesized such as carbohydrates, proteins, lipids,
and sustainable use of medicinal plants: problems,
flavonoids, glycosides, alkaloids, volatile oils, and
progress and prospects. Chin Med 2016; 11:37.
tannins etc., which exert a physiological effect and
are utilized as biologically active components by man 5. Shirbeigi L, Mohebbi M, Karami S, et al. The
since time immemorial.18,19 The therapeutic value role of nutrition and edible medicinal plants in the
of any plant drug, however, depends on the nature of treatment of chronic wounds based on the principles of
chemical constituents present in it and is referred to as Iranian traditional medicine. Iran J Med Sci 2016;41(3):
active principle. Phytochemical screening comprises S72.
of different chemical tests and chemical assay. The
isolation, purification and identification of active 6. Kujawska M, Hilgert NI, Keller HA, Gil G.
 270 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Medicinal plant diversity and inter-cultural 14. Sravan SK, Manoj P, Giridhar P. Fourier transform
interactions between indigenous guarani, infrared spectroscopy (FTIR) analysis, chlorophyll
criollos and polish migrants in the subtropics of content and antioxidant properties of native and
Argentina. PLoS One 2017;12(1): e0169373. defatted foliage of green leafy vegetables. J Food
7. Wang L, Jiang Y, Han T, et al. A phytochemical, Sci Technol 2015;52(12):8131–8139.
pharmacological and clinical profile of Paederia 15. Harrison AM, Heritier F, Childs BG, et al.
foetida and P. scandens. Nat Prod Commun 2014; Systematic review of the use of phytochemicals for
9(6):879-86. management of pain in cancer therapy. Biomed Res
8. Kumar V, Anwar F, Ahmed D, et al. Paederia Int. 2015; 2015:506327
foetida Linn. leaf extract: an antihyperlipidemic, 16. Billah MM, Hassan MR, Nawrin K, Habib MR.
antihyperglycaemic and antioxidant activity. BMC Evaluation of Analgesic and Sedative-anxiolytic
Complement Altern Med 2014; 14:76. Potential of Paderia foetida leaf extract. Am J
9. Osman H, Rahim AA, Isa NM, Bakhir NM. Biomed Sci2015; 7(2): 98-104
Antioxidant activity and phenolic content 17. Altemimi A, Lakhssassi N, Baharlouei A, et
of Paederia foetida and Syzygium aqueum. al. Phytochemicals: extraction, isolation, and
Molecules 2009; 14(3):970-8. identification of bioactive compounds from plant
10. Das S, Kanodia L, Mukherjee A, Hakim A. Effect extracts. Plants (Basel) 2017;6(4):42.
of ethanolic extract of leaves of Paederia foetida 18. Scarpa ES, Ninfali P. Phytochemicals as innovative
Linn. on acetic acid induced colitis in albino therapeutic tools against cancer stem cells. Int J
rats. Indian J Pharmacol 2013;45(5):453–457. Mol Sci 2015;16(7):15727–15742.
11. Doss A. Preliminary phytochemical screening 19. Yoo S, Kim K, Nam H, Lee D. Discovering health
of some Indian medicinal plants. Anc Sci Life. benefits of phytochemicals with integrated analysis
2009;29(2):12–16. of the molecular network, chemical properties
12. Alhakmani F, Kumar S, Khan SA. Estimation of and ethnopharmacological evidence. Nutrients
total phenolic-content, in-vitro antioxidant and 2018;10(8):1042.
anti-inflammatory activity of flowers of Moringa 20. Sasidharan S, Chen Y, Saravanan D, et al.
oleifera. Asian Pac J Trop Biomed 2013;3(8):623– Extraction, isolation and characterization of
627. bioactive compounds from plants’ extracts. Afr J
13. Chandra S, Khan S, Avula B, et al. Assessment of Tradit Complement Altern Med 2010;8(1):1–10.
total phenolic and flavonoid content, antioxidant
properties, and yield of aeroponically and
conventionally grown leafy vegetables and
fruit crops: a comparative study. Evid Based
Complement Alternat Med 2014; 2014:253875.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 271

Clinical and biochemical profile of Indians with type 2 Diabetes

Mellitus: A Study from a Tertiary Care Hospital in
Greater Noida

Suresh Babu1, Payal Jain2, Saurabh Srivastava3, Parwinder Kour4, HM Kansal5

1
Senior Consultant, 2Associate Professor, 3Professor, Department of Medicine, Government Institute of Medical
Sciences, Greater Noida,Gautam BuddhNagar,UP, 4GDMO, 15th battalion, ITBP, Udhampur, 5Ex Professor,
Department of Medicine, SMS&R, Sharda University, Greater Noida

Abstract
Objective: To study the clinical and biochemical profile of newly detected type 2 diabetes mellitus patients
from a tertiary care hospital in Greater Noida,Gautam Buddh Nagar.

Method: At total of 100 newly diagnosed type 2 diabetes mellitus patients presenting in the Department
of Medicine were included and studied. A detailed clinical history, examination and investigations were
recorded.The presence of microvascular and macrovascular complications of diabetes mellitus was assessed
using this clinical and laboratory data.

Results: There were 52 males and 48 females. Maximum patients belonged to fourth decade and upper-
lower socioeconomic status.20% patients had obesity and 50% people were overweight. Polyuria was the
chief presenting complaint in 51% cases with polydipsia,weight loss and weakness being the other common
symptoms. 62 % of the diabetics had hypertension. Increased cholesterol was reported in 44% and 53
%patients had altered triglyceride. The prevalence of neuropathy, retinopathy and nephropathy was 33%,
28% and21 % respectively.

Conclusion:Type 2 diabetes mellitus patients present with comorbidities and complications frequently.
Significant proportion of patients in this study had poor glycemic control as well as microvascular
complications at the very time of diagnosis.A vast majority were overweight with high waist circumference.
Commonest observed comorbidities with diabetes were that of hypertensionand dyslipidemia.

Keywords:type 2 diabetes mellitus,Neuropathy, Retinopathy, Nephropathy.

Introduction 2 diabetes mellitus).Raised blood glucose, a common

effect of uncontrolled diabetes, may lead to serious
Diabetes Mellitus is a chronic, progressive disease
damage to the heart, blood vessels, eyes, kidneys and
characterized by elevated levels of blood glucose. It
nerves. Eventually, diabetics are further affected by
is a non-communicable disease due to either genetic
various diseases including obesity, hypertension,
or acquired deficiency in production of insulin (type
microangiopathy and metabolic syndrome.
1 diabetes mellitus)or a lack of action of insulin (type
Diabetes is the cardinal cause of death globally
with an estimated 3.7 million deaths in 2012. This
Corresponding author:
number includes 1.5 million deaths as direct cause, and
Payal Jain
an additional 2.2 million deaths from cardiovascular
Associate Professor, Department of Medicine,
diseases, chronic kidney disease, and tuberculosis due
Government Institute of Medical Sciences
to hyperglycemia. After 50 years of age, middle income
Greater Noida,Gautam BuddhNagar,UP
countries have the highest proportion of deaths attributed
email: [email protected]
to diabetes.The prevalence of diabetes mellitus is on
 272 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

rise, particularly in developing countries.It has been of hypertension and other co-morbid conditions was
predicted that India along with China will harbour more assessed from case records.Socio-economic status of the
than 75%of global diabetic load by 2025.1,2 study subjects was divided according to Kuppuswamy
classification.4 The American Heart Association criteria
The starting point of management in diabetes was referred to define and diagnose hypertension.5
is an early diagnosis – the longer a person suffers
with undiagnosed and untreated diabetes, the worse Anthropometric data measured using standardized
their outcomes are meant to be. The disease may go procedures was recorded from case sheets. Results of
undiagnosed for several years, until complications have clinicaland biochemical tests, such as urinalysis (first-
already arisen. To facilitate early diagnosis and suggest morning sample for micro-albuminuria), complete
lifestyle modifications to curb the onward progression of haemogram, plasma glucose, glycosylated haemoglobin
the disease,it is vital to describe and understand the clinical (HbA1c), renal function tests, and lipid levels including
and biochemical profile of diabetes population. Hence total cholesterol (TC), triglycerides (TG), and high-
the current research was carried out with an objective to density lipoprotein-cholesterol (HDL) levels and Low-
study the socio-demographic and biochemical profile of density lipoprotein-cholesterol (LDL-C) were recorded
diabetes patients attending diabetes clinic in a tertiary from the case records andanalysed.Dyslipidemia
care hospital in GautambudhNagar,Greater Noida,Uttar was defined when one of the following was present:
Pradesh. Triglyceride (TG) concentration more than 150 mg/dl
or Cholesterol concentration more than 200 mg/dl or
Materials and Method HDL cholesterol less than 50 mg/dl in females and less
This retrospective study was carried out in the than 40 mg/dl in males or LDL more than 100 mg/dl.
department of Medicine, Government Institute of This classification was conforming to ATP III (Adult
Medical Sciences,Gautam budh Nagar. Case records of Treatment Panel III) guidelines.6
100 newly diagnosed type 2 diabetes mellitus patients of The nervous system examination at the time of
both genders were enrolled randomly for the study. initial evaluation for touch, pain, vibration and reflexes
Inclusion criteria was recorded from thecase sheets and analysed. 128 Hz
tuning fork was used to examine vibration sense and 10
The American Diabetes Association criteria were g monofilament for light touch perception in diabetic
used for selecting the newly diagnosed type-2 diabetes clinic.
mellitus patients. i.e. a fasting plasma glucose (FPG)
level of >7.0 mmol/L or ≥126 mg/dL after a minimum Records of fundus examination for assessment
12-hour fasting, or two-hour post glucose level (oral of retinawere interpreted and 24hour urinary albumin
glucose tolerance test) of >11.1 mmol/L or ≥200 mg/dL estimationdone was used to diagnose nephropathy.
on more than one occasion, with symptoms of diabetes. Coronary artery disease (CAD) was reported on the
basis of electrocardiograph (ECG) changes, treadmill
Exclusion criteria test and echocardiography reports. Patient was
reported to be having stroke if supported byclinical
The case records of patients having the following history, examination,and non-contrast CT scan. Data
features were excluded from this study of peripheral arterial disease,which was diagnosed by
1. Type-1 Diabetes mellitus or established diabetes history of claudication, absence of pulses or Doppler
mellitus on treatment for more than 6 months. study wherever required,was recorded and analysed.

2. Patients with pregnancy/ gestational diabetes. Data Analysis: Data were compiled, tabulated
and analysedby using standard appropriate statistical
Case records of the patients from diabetic clinic of technique, which includes numbers and percentages.
our hospital having thorough work up and comprehensive The mean and standard deviation was obtained for
case history including details of age, presenting summarizing the quantitative variables.
complaints, diet, smoking, alcohol consumption,
physical activity, socioeconomic statuswere included. Results
The findings ofgeneral physical examination,history In this study, data of 100 patients with newly
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 273

diagnosed type 2 diabetes mellitus who presented in Variables Number of patients(%)

diabetes clinic of our hospital were studied.Out of these
cases, 58 were females and 42 were male.Maximum BMI
≤ 18.5 (Underweight) 2(2)
incident cases wereseen in the fifth decade of life with
18.5 - 22.9 (Normal) 28 (28)
a mean age of subjects being 54.6 years.The maximum
23 - 24.9 (Overweight) 50 (50)
number of patients,around 35% belonged to upper- lower
≥ 25 (Obese) 20(20)
socioeconomic status.The education status showed that
majority of subjects in our study,around 68%,were either Waist circumference
had no formal education or educated only upto primary Female(58) >80 cm 50(82.7)
Male (42) >90 cm 20(47.6)
level (table 1).

Table 1: Demographic variables of the Patients Table 3:Biochemical profile of study subjects

Gender Number of patients(%) Number of

Variables
patients(%)
Male 42(42)
Glycaemic status (HbA1c%)
Female 58(58) <7 (good control) 3(3)
7-8 (sub-optimal control) 19(19)
Age (years) 8-9 (sub-optimal control) 34(34)
>9 (uncontrolled) 44(44)
≤ 35 2(2)

36-50 29(29)
Microalbuminuria 21(21)

51-65 49(49) Hypercholesterolemia

44(44)
(>200mg/dl)
>65 20(20)
Hypertriglyceridemia
Socioeconomic status 53(53)
(>150mg/dl)
Upper 6(6)
High density lipoprotein
Upper middle 10(10) 39(39)
cholesterol(<35mg/dl)
Lower middle 25(25)

Upper lower 35(35) Low density lipoprotein

33(33)
cholesterol(>130mg/dl)
Lower 24(24)

Education level Normal Blood pressure 38(38)

No formal education 28(28) High blood pressure 62(62)

Primary 40(40)
44%of the patients had uncontrolled diabetes with a
Secondary 27(27)
high glycated haemoglobin greater than 9%. In our study
Tertiary 5(5) 44 patients had increased cholesterol and 53 patients had
hypertriglyceridemia. 62% were hypertensive and 38
It was observed that BMI was significantly high,with %were normotensive among diabetics (table 3).
50% patients being overweight and 20% obese.70%
Mostcommon presenting symptom in our study was
patients had high waist circumference (table 2)
polyuria(51%),with polydipsia(32%),weight loss (35%)
Table 2: BMI and Waist circumferenceof the and weakness (38%)being other common ones.Among
study subjects microvascular complications,neuropathy,retinopathy
and nephropathy was reported in 33%,21% and 28% of
our subjects respectively. The prevalence of coronary
 274 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

artery disease,peripheral vascular disease and stroke was Maximum number of patients in our study were
found to be 13%,6% and 3% respectively(table 4). from low socio-economic status. This may be due to
a greater number of poor people in the vicinity of our
Table 4:Presenting symptoms and complications. institute where study was conducted. The demographic
profile of the study participants can be explained by the
Presenting symptoms Number of patients(%)
fact that the hospital where this study was conducted
Polyuria 51(51) is a government hospital. In a study Mudhaliar MR et
al,similar results were reported.10
polydipsia 32(32)

polyphagia 18(18) With regard to gender, while our study had 58%
females as compared to 42% of males, a study from
Weight loss 35(35) Gujarat found males to be 62% of the total.11
Paresthesias 16(16)
In our study majority of the patients were either
Weakness 38(38) educated upto primary or had no formal education while
few studies observe a high literacy rate with illiterates
Blurred vision 15(15)
forming a mere one percent in their study.11
Skin manifestation 8(8)
In the present study, the majority (70%) of the
Urinary tract infection 16(16) subjects were either overweight or obese. This is
Altered sleep 10(10) consistent with the findings of various other studies.11,12
Ideal normal BMI was observed in only 28% patients
Microvascular complications which could be because of poor awareness about weight
Neuropathy 33(33) management as a measure to control diabetes. The was
similar to a study in Brazil where normal BMI has been
Nephropathy 21(21)
reported in 24% patients.12
Retinopathy 28(28)
Another noteworthy finding in our study was that
Macrovascular complications diabetic females overpower males in the proportion of
Coronary heart disease 13(13)
being having high BMI with a higher waist circumference
seen in almost 50%of females. High mean of BMI in
Peripheral artery disease 6(6) females though being significantly low weight and short
Stroke 3(3) statured when compared to the males could be explained
from a sedentary lifestyle of females. A high proportion
of abnormal waist circumference and a high mean of
Discussion
BMI in the female subjects forecasts higher insulin
The prevalence of diabetes mellitus is on a resistance in them due to decreased insulin sensitivity.14
rise,particularly in developing world.In near future,India
shall become the diabetes capital of the world. Our main The main presenting symptom in our study was
concern through this study was to assess the profile of polyuria. Similar presentation of a classic symptom in
diabetic patients in this part of Uttar Pradesh so that we newly diagnosed diabetics was reported in few other
can prevent or decrease the burden of complications by studies.15
early diagnosis and intervention.
In the present study, only 3% of the subjects had
In this study maximum incident cases of diabetes good glycaemic control while 44% had uncontrolled
mellitus occurred in fifth decade,followed by diabetes. This was similar to a study from Gujarat who
fourthdecade.The risk of developing diabetes, especially reported only 7% of their participants with controlled
type 2 diabetes mellitus, greatly increases with age, diabetes whereas 41% with uncontrolled diabetes.[11]
where the most affected age group is that of 40–59 A Swedish study reported that 34% of type 2 diabetes
years.7 This finding is in accordance with other Indian subjects had good glycaemic control.16 Again a few
studies which also report the highest incidence in fourth other studies reported good control of glycemia in more
and early fifth decade.8,9 than 30%.17,18
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 275

Awareness and intervention programs targeting the profile of the diabetic patients attending our hospital
measures at glycemic control among diabetics are the comprises mainly of lower socioeconomic class and
need of hour. Our study showed around 62% diabetic has poor literacy rate.Therefore, educating the masses
patients to be hypertensive. Basavegowda M et al from with increased awareness about the disease and its
urban slums of city of Mysore also showed the prevalence management is of prime importance.More population-
of hypertension to be around 65% in diabetics.19 Some based studies on a larger scale are required further to
showed almost 50%hypertension prevelance in diabetic increase our understanding and better identification of
population.11 the magnitude of the problem.

The lipid profile was significantly deranged in our Ethical Clearance- Taken from Ethical committee
diabetic study subjects. The most prevalent form of of Government Institute of Medical Sciences.
dyslipidemia in this study was Hypertriglyceridemia
which was seen in 53% of diabetics. The pattern of Source of Funding- Self
dyslipidemia in our study more or less matched the Conflict of Interest - Nil
typical diabetic dylipidemia,that is high TG and low
HDL as reported in many studies.22 References
Our study reported a high prevalence of 1. World Health Organization. Globalreporton
microvascular complications with retinopathy (21%), diabetes. Geneva: World Health Organization;2016.
peripheral neuropathy (33%) and nephropathy (28%). 2. Wild S, Roglic G, Green A, Sicree R, King H.
This was similar to a study from cenral India which Global prevalence of diabetes: estimates for the
showed a prevalence of retinopathy (26%),peripheral year 2000 and projections for 2030. Diabetes Care,
neuropathy (26%) and nephropathy (22%).9 Another 2004; 27:1047-1053.
study from south India also reported a high prevalence
3. American Diabetes Associa on. Standards of
of retinopathy.20 The diabetics with retinopathy had poor
medical care in diabetes–2008. Diabetes Care
glycemic control, a significantly high fasting plasma
2008;31 Suppl1:S12-54.
glucose and were mostly dyslipidemic. These findings
were in accordance with other studies from India.9,20 A 4. Mishra D, Singh HP. Kuppuswamy’s
close prevalence of nephropathy to retinopathy might socioeconomic status scale- A revision. Indian J
be used in the prediction of a high-risk of concomitant Pediatr., 2003;70:273-74.
diabetic neuropathy in patients with retinopathy,though 5. Whelton PK, Carey RM, Aronow WS, et al.2017
some earlier studies did not show this pattern. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/
ASH/ASPC/NMA/PCNA guideline for the
The prevalence of coronary artery disease,peripheral prevention, detection, evaluation, and management
vascular disease and stroke in our study was found to be of high blood pressure in adults: a report of the
13%,6% and 3% respectively. A similar study in South American College of Cardiology/American Heart
India on new onset type 2 diabetics showed prevalence Association Task Force on Clinical Practice
of coronary artery disease(25%), peripheral vascular Guidelines.Hypertension. 2018; 71:e13–e115
disease (11%) and stroke (8%).23 These results suggest
6. Third Report of the National Cholesterol Education
that complications in diabetes mellitus begin before
Program (NCEP) (2002) Expert Panel on Detection,
overt hyperglycemia is seen.
Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III)
Conclusion
final report. Circulation 106: 3143-421
Most of the patients were not obese in our study 7. Shaw JE, Sicree RA, Zimmet PZ (2010). Global
but were overweight and had high waist circumference. estimates of the prevalence of diabetes for 2010 and
Hypertension was the commonest observed comorbidity. 2030. Diabetes Res Clin Pract, 87(1): 4–14.
Significant percentage of our patients had microvascular
8. Shukla V, Karoli R,Chandra A.A Study of Newly
complications at the time of diagnosis of diabetes
Diagnosed Type 2 Diabetes Mellitus Patients from
mellitus.Hence blood sugars and lipid profile should be
Rural Areas. J Assoc Physicians India.2014; 62:
aggressively managed early in the course of disease to
682684.
prevent life threatening complications. The demographic
 276 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

9. Singh S, Singh AP, Multani MK, Purohit A. practices among diabetic patients in the United
Clinical and biochemical profile of Indians with Arab Emirates. Rev Diabet Stud 2008;5:110-5.
type 2 diabetes mellitus: A problem lurking for 18. Al-Maskari F, El-Sadig M. Prevalence of risk factors
India. Trop J Med Res 2014;17:91-98. for diabetic foot complications. BMC Fam Pract
10. Mudhaliar MR et al. Association between 2007;8:59.
socioeconomic status and diabetes in rural 19. Basavegowda M, Shankarappa KH, Channabasappa
settings of India. International Journal of Green AN, Marulaiah SK, Hathur B. Magnitude and
Pharmacy.2017;11:S144-S148. pattern of hypertension among diabetics; risk
11. Patel M, Patel I, Patel Y, Rathi S. A Hospital-based prediction for stroke and myocardial infarction. J
Observational Study of Type 2 Diabetic Subjects Mahatma Gandhi Inst Med Sci 2014;19:51-4.
from Gujarat, India. J Health PopulNutr 2011; 20. Narendran V, John RK, Raghuram A, Ravindran
29(3): 265-272 RD, Nirmalan PK, Thulasirajet RD, et al. Diabe
12. Lieberman LS. Dietary, evolutionary, and c re nopathy among self-reported diabe cs in
modernizing influences on the prevalence of type 2 southern India: A popula on based assessment. Br J
diabetes. Annu Rev Nutr 2003;23:345-77. Ophthalmol 2002;86:1014-8.
13. Gomes M B, Giandella D, Faria M. Prevalence of 21. John L, Ganesh A, John G, Raju JM, Kirubakaran
Type 2 Diabetic patients within the [16] targets MG, Shastry JC. Clinical profile of Indian non-
of care guidelines in daily clinical practice: A insulin-dependent diabetics with nephropathy and
multicentre study in Brazil. Rev Diabetic Studies. renal failure. Diabetes Res Clin Pract 1989;7:47-
2006; 3: 82-87. 50.
14. Henriksson J. Influence of exercise on insulin 22. Hammoudeh AJ, Haddad J, Al-Mousa E. Is
sensitivity. J Cardiovasc Risk 1995;2:303-9. dyslipidemia in Middle Eastern patients with type
15. Bhaskar ME et al. Presenting Features of Diabetes 2 diabetes mellitus different from that in the west?
Mellitus. Indian J Community Med. 2010; 35(4): The Jordan hyperlipidemia and related targets study
523–525. (JoHARTS-3). Clin Diabetes 2006;5:128-31.
16. Holmström IM, Rosenqvist U. Misunderstandings 23. Deepa D V, Kiran B R, Gadwalkar Srikant
about illness and treatment among patients with R. Macrovascular and microvascular [22]
type 2 diabetes. J Adv Nurs 2005;49:146-54. complication in newly diagnosed Type 2 Diabetes
Mellitus. Indian J Clin Pract. 2014; 25 (7): 644-48.
17. Al-Kaabi J, Al-Maskari F, Saadi H, Afandi B,
Parkar H, Nagelkerke N. Assessment of dietary
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 277

Effect of Proprioceptive Neuromuscular Facilitation (PNF)

Pattern on Respiratory Parameters in Chronic Bronchitis

Sushma Singh1, Javid H. Sagar2, G. Varadharajulu3

1MPTh (Cardio-pulmonary), 2Professor/ Unit Head (Cardio-pulmonary), 3Dean/ Professor/ HOD, Krishna College
of Physiotherapy, Krishna Institute of Medical Science Deemed to be University, Karad, Maharashtra, India

Aim: To study the effect of PNF pattern on respiratory parameters in chronic bronchitis.

Objectives: To find the effect of PNF pattern on respiratory parameters and to compare the effects of pursed
lip breathing and PNF pattern in chronic bronchitis.

Materials and Method: 60 patients were included according to inclusion and exclusion criteria by
consecutive random sampling and were divided into two groups, group A (Conventional-PLB) and group
B (D1 & D2 flexion and extension) - with 30 patients in each group. The treatment was given for 2 weeks
thrice a day. After 2 weeks effect of interventions were assessed by taking Respiratory Rate (R.R), Oxygen
Saturation (SpO2) and FEV1/FVC.

Results:. There was significant difference in R.R, SpO2 and FEV1/FVC seen with PNF pattern exercises.
The intra group comparison showed significant improvement in R.R, SpO2 and FEV1/FVC. The inter group
comparison showed no significant improvement in SpO2 and FEV1/FVC except R.R

Conclusion: PNF pattern has shown significant improvement in SpO2, R.R and FEV1/FVC

Key words: Chronic Bronchitis, PNF, PLB, PFT.

Introduction The common characteristic of the disease is

obstruction to airflow out of the lungs which leads to
Chronic bronchitis is a term that describes
poor gas exchange and difficulty in breathing. [2]
inflammation of the bronchial tubes (i.e. bronchi and
smaller branches termed bronchioles) that results in Symptoms include dyspnea, cough with mucus
excessive secretions of mucus into the tubes, which (sputum) production, wheezing are generally seen. [15]
leads to tissue swelling that can narrow or close off Other features are: constriction in the chest, tachypnoea,
bronchial tubes. tachycardia, adventitial breath sounds, accessory
muscles becomes active, thick and stringy mucus.
One of the major disease includes COPD, the
significance of which is difficult to overestimate. The other causes are long term exposure to irritating
According to the GOLD (2013), guidelines states that gases or particulate matter, respiratory infection and
chronic bronchitis is a completely independent disease most often from cigarette smoke.
but one which can precede the development of airflow
limitation as well as cause or aggravate the persistent The pathological foundation for chronic bronchitis
airflow limitation. The primary risk factor for majority is due to the over production of mucus in response to the
of patients is smoking. [1] inflammatory signals, this is known as mucus metaplasia.
The overproduction and hypersecretion is due to the
Chronic bronchitis is defined as a productive presence of goblet cells and reduced elimination of
cough that lasts for three months for at least two mucus.
consecutive years. Most people with chronic bronchitis
have chronic obstructive pulmonary disease (COPD). The mechanisms responsible for mucus metaplasia
[1,2] is associated with the function of the T cells, this
mechanism is still poorly understood but it is believed to
 278 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

be linked to end production of the cells called as Th2 cells Pursed lip breathing is used as a conventional
which are inflammatory cells while the cellular response treatment in chronic bronchitis which showed
is thought to be attributed to the Th1 inflammatory cells, improvement on respiratory parameters and also in
cytokine substance is produced by both the cells that reducing dyspnea. [10]
have an influence on mucus production associated with
chronic bronchitis. [2] PNF i.e. D1 and D2 flexion and extension used as an
advance technique which has also some improvement.
Airflow obstruction is caused due to mucus
metaplasia through several mechanisms and they causes PNF pattern and methods of treatment were used
luminal occlusion, thickening of the epithelial layer to obtain the maximum quantity of activity, which can
which intrudes on the airway lumen and the mucus alters be achieved at each voluntary effort and the maximum
the airway surface tension. [2] possible number of repetition of the activity to facilitate
the response.
Due to this, the airway has high tendency for
collapse and also decreases the capacity for airflow and In the development of PNF techniques, greater
exchange of gas. [2] emphasis was placed on the application of maximal
resistance throughout the range of motion, using many
Mucus hypersecretion is one of the risk which is combinations of motion that were related to primitive
associated with cigarette smoking, viral infections, patterns and the employment of postural and righting
bacterial infections or inflammatory cell activation. reflexes.

When combined with poor ciliary function, distal In the modern field, the advanced physiotherapy
airway occlusion, ineffective cough, respiratory muscle techniques of PNF are being applied as a means of
weakness and reduced peak expiratory flow rate clearing stimulating response and strengthening muscles related
secretions becomes difficult and requires high energy to respiration.
expenditure. [2]
PNF mobility exercise aims in improving the
Chronic bronchitis is a condition in which an pulmonary functions and the mobility of chest wall,
obstructive ventilation disturbance of the respiratory trunk and shoulder. [11]
passages evokes a feeling of shortness of breath.
Respiratory rate, oxygen saturation, chest mobility, As D1 and D2 flexion extension involves movement
expiration are all affected. [2] of shoulder which improves chest mobility and also
shows improvement in chest expansion and mobilizing
Furthermore, the amount of air exhaled during secretions.
initial one second (FEV1) is reduced and is reduced to a
greater degree than the entire Forced Vital Capacity and This study is basically done to find the effects of
FEV1/FVC ratio is affected. [10] PNF pattern on respiratory parameters and also to
compare the effects of PLB and PNF as there are very
PFT is used to measure the lung volumes and few literatures available on it. This technique is rarely
capacities which shows decreased FEV1/FVC ratio . It used in hospital setup so after the study, based on the
is an investigation tool for monitoring of patients with findings we can prescribe the more effective treatment
respiratory pathology. It also provides information about to the patients for prevention of chronic bronchitis
large and small airways, the pulmonary parenchyma and complications and symptoms and thus enhance the
the size and integrity of the pulmonary capillary bed. [10] patient’s recovery which can also improve the quality
of life.
As this is progressive condition and can worsen the
quality of life, the physiotherapy plays an important role Method
for promoting good health by reducing breathlessness,
improves chest mobility by various breathing exercises. Study type: Experimental study

Breathing exercise and other ventilatory techniques Study design: pre test or post test
also have a vital role in influencing the rate, depth and Sample size: 60 (30 + 30)
distribution of ventilation. [10]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 279

Place of study: Krishna Hospital, Karad By using consecutive random sampling method the
participants were divided into two groups.
Criterion for Study
Group A and Group B and was named as
Inclusion criteria: Conventional and Experimental group. PLB exercise
• Both male and female was given as a conventional exercise and PNF was given
to the experimental group.
• Patient diagnosed with chronic bronchitis
The intervention was given for 2 weeks and thrice a
• Patients with reduced chest wall movements day for both the groups.
and reduced air entry
Pre test and post test evaluation was taken, which
• Haemodynamically stable patients who are includes: R.R, SpO2 and FEV1/FVC
willing to participate in the study.
Intervention :
Exclusion criteria
GROUP A : PLB was given in this group. Patient
• Any recent thoracic surgeries and abdominal was positioned in semi fowler position with relaxed
surgeries shoulders and slowed expiration was done by pursing
the lips. It was performed 10 times and was given for 2
• Any musculoskeletal abnormalities limiting the weeks thrice a day.
shoulder girdle functions.
GROUP B : In this group, PNF pattern was given: D1
• Neuromuscular weakness of upper limb flexion and D1 extension, D2 flexion and D2 extension.
• Patients with grade IV dyspnea (according to It was performed with 10 repetitions for 2 weeks thrice a
MMRC grading). day. After two weeks of session post test and statistical
analysis was done.
Procedure
Outcome Measure
The subjects who were admitted in wards and those
falling in inclusion criteria were selected. Each subject • SpO2 / R.R
was screened as per inclusion and exclusion criteria and • PFT: FEV1/FVC
was informed about the study and a written consent was
taken from them.
Results
Table 1: Comparison of pre and post R.R, SpO2 and FEV1/FVC within the group

MEAN ± SD MEDIAN P VALUE t VALUE df

GROUP A
17.7±3.800 17.000
PRE R.R
0.0004 3.096 29
GROUP A
19.6±2.527 19.500
POST R.R

GROUP A
94.76±2.775 95.000
PRE SpO2
<0.0001 8.515 29
GROUP A
96.76±2.046 97.000
POST SpO2
GROUP A
75.38±4.457 76.000
PRE FEV1/FVC
<0.0001 13.868 29
GROUP A
80.33±4.221 81.000
POST FEV1/FVC
280 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 2: Comparison of pre and post R.R, SpO2 and FEV1/FVC within the group

P t
MEAN ± SD MEDIAN df
VALUE VALUE

GROUP B 16.9±2.528 14.000

PRE R.R

<0.0001 14.715 29
GROUP B 17.46±2.374 18.000
POST R.R

GROUP B 95.000
94.73±2.559
PRE SpO2

<0.0001 7.909 29
GROUP B
POST SpO2 96.96±1.86 96.500

GROUP B 75.63±4.214 78.000

PRE FEV1/FVC

10.912 29
GROUP B <0.0001
81.5±3.288
POST FEV1/FVC 81.500

Table 3: Comparison of pre and post R.R, SpO2 between the group

GROUP A & P t
MEAN ± SD MEDIAN df
GROUP B VALUE VALUE

17.7 ± 3.800 17.000

PRE
R.R
0.931 4.160 58
15.4 ± 2.528 14.000
PRE

19.6±2.527 19.500
POST
R.R
0.0013 3.370 58
17.46±2.374 18.000
POST

94.76±2.775 95.000
PRE
SpO2
0.9616 0.0483 58
94.73±2.559 95.000
PRE

96.76±2.046 97.000
POST
SpO2
0.693 0.395 58
96.96±1.866 96.500
POST
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 281

Table 4: Comparison of pre and post FEV1/FVC between the group

PRE 75±4.457 76.00

FEV1/FVC
0.573 0.565 58
PRE 75.63±4.214 78.00

POST 80.33±4.221 81.00

FEV1/FVC
0.237 1.194 58
POST 81.5±3.288 81.50

Statistics selected on the basis of inclusion and exclusion criteria.

The outcomes were assessed at the 1st day prior to In this, the efficacy of D1 and D2 flexion and extension
treatment and at the end of 2nd week post treatment. Inter pattern on respiratory rate, oxygen saturation and FEV1/
group analysis was done by unpaired ‘t’ test and intra FVC were investigated. They were investigated using
group analysis was done by using paired ‘t’ test. The Pulmonary Function Test. The intervention was given
inter and intra group analysis was done by using Instat 3. for 2 weeks thrice a day.

Discussion After the intervention statistical analysis was done

where; Respiratory Rate, SpO2 and FEV1/FVC ratio of
Chronic Bronchitis is common but a variable
pre and post were compared by paired ‘t’ test of within
phenomenon on COPD with numerous clinical
the groups. Whereas, the comparison between the groups
consequences and reduced lung function with increase
were also done by comparing pre and post R.R, SpO2,
in airflow obstruction[1]
FEV1/FVC of group A with group B by unpaired ‘t’ test.
The therapeutic role of PNF pattern based on
Post intervention it was found that there was
stretch-reflex theory in altering pulmonary functions.
significant improvement within the group A and group
E.Dean, Donna Frownfelter stated that ventilation has
B and in comparison of both the groups there was no
been improved, chest wall muscles are being maximally
significant improvement may be because the shoulder
stretched and ribs are naturally opening up in butterfly
movement didn’t had effect on improving lung volumes
technique where the inspiration with trunk extension,
and capacity and thus FEV1/FVC ratio and oxygen
shoulder flexion, abduction and external rotation (D2
saturation was not improved.
flexion) and the expiration with trunk flexion, shoulder
extension, adduction and internal rotation (D2 extension) And also, during intervention patient had difficulty
. [4] in performing shoulder flexion and extension repeatedly
due to dyspnoea where some of the participants were
Vanessa Resqueti stated that pursed lip breathing is
performing trick movements.
used conventionally which has been showed in reducing
the dyspnoea and has greater effect on improving Therefore, various dyspnoea relieving techniques
pulmonary function. [10] were given to the patient like pursed lip breathing,
forward leaning position and rest which helped in
The main objective of the study was to find the
relieving dyspnea.
effect of PNF on improving the pulmonary function in
chronic bronchitis. It was difficult to treat dyspnoea in grade 3 patients,
as some patients were non –co-operative and some didn’t
In the present study, the sample size was 60 and they
do exercises independently once the therapist is taught
were divided into two groups: group A (conventional
how to do the exercise and instructed to do number of
group) and group B (experimental group) which consisted
times in a day, which hampered the results of the study
of 30 participants in each group. The participants were
 282 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

and recovery in the patients. Neuromuscular Facilitation pattern has shown significant
improvement in SpO2, R.R and FEV1/FVC.
But there was significant improvement in respiratory
rate post intervention may be due to chest wall muscles The present study provided the evidence to support
are being maximally stretched and the inspiration that both the techniques are effective on SpO2, R.R and
with trunk extension, shoulder flexion, abduction and FEV1/FVC individually in chronic bronchitis patients.
external rotation (D2 flexion) and the expiration with
trunk flexion, shoulder extension, adduction and internal However, the techniques when compared with each
rotation (D2 extension). other were equally effective and there were no significant
difference between each other but had shown significant
As the intercostals muscle and diaphragm contains improvement in R.R.is study
sensory muscle spindles that respond to elongation. A
signal is sent to spinal cord and anterior horn cells. These Conflict of interest: Short intervention duration as
neurons signal make more muscle fibers to contract patients did not stay in wards for more than 2 weeks.
(recruitment) and thus increase the strength. Stretching Funding: This study was funded by Krishna
the ribs and diaphragm activate the stretch reflex and Institute of Medical Science Deemed to be University,
help the patients to take a deep breath which helps in Karad.
improving the quality of breathing and thus improves
the respiratory rate. Ethical Clearance: The study was approved by the
institutional ethics committee of KIMSDU.
Few studies like D.Anandhi, P.Deekshitha - PNF
shows an immediate improvement in FVC and IC thus References
shows an enhanced lung function among collegiate
students. 1. Victor kim etal “Concise clinical review of chronic
bronchitis and chronic obstructive pulmonary
Leandro Ferracini - concluded that pursed lip disease” Am J Crit Care Med. 2013 Feb; 187(3):
breathing reduces dynamic hyperinflation and improves 228-237.
exercise tolerance, breathing pattern and arterial 2. Galina L. Ignatova etal “Features of chronic
oxygenation at submaximal intensity exercise. bronchitis in different age groups” International
journal of biomedicine 2014;4(1): 15-18
Gopi Parth Mehta - shows significant improvement
in chest expansion and pulmonary function test such 3. Seo K,etal “The effects on the pulmonary function
as forced expiratory volume and forced vital capacity of normal adults proprioceptive neuromuscular
than only active assisted exercise program for elderly facilitation respiration pattern exercise” Journal of
subjects. physical therapy science. 2014;26(10):1579-82
4. Frownfelter DL, Ed Dean EW “Principles and
After comparing with the above study, PNF exercise practice of cardiopulmonary physical therapy”
has important role on pulmonary function as the Mosby incorporated; 1996.
therapeutic role of PNF pattern is based on stretch reflex
5. Marek SM, etal “ Acute effects of static and
theory in altering pulmonary functions with D1 and D2
proprioceptive neuromuscular facilitation stretching
extension it showed improvement in oxygen saturation,
on the muscle strength and power output” J Athl
respiratory rate and FEV1/FVC ratio.
Train. 2005, Apr-Jun; 40(2): 94-103.
But in comparison it had no significant improvement 6. Bernard – Narbonne F etal “effectiveness of chest
except respiratory rate which may be due to short physiotherapy in ventilated children with acute
intervention duration and small sample size may be bronchiolitis” Arch Pediatr. 2003:10:1043-1047.
responsible for the baseline differences that appeared to 7. Mackenzie CFal et “Cardio respiratory function
exist in the groups for PLB and PNF. before and after chest physiotherapy in mechanically
ventilated patients with posttraumatic respiratory
Conclusion failure” Crit Care Med. 1985:13:483-6
Based on the statistical presentation, analysis and 8. Schmidt RW “The effect of airflow and oral
interpretation it can be concluded that Proprioceptive pressure on the mechanics of breathing in patients
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 283

with asthma and emphysema.” Am Rev Respir Dis 11. D.Anandhi, P etal “Immediate effect of
1964;90:564-71 proprioceptive neuromuscular facilitation(PNF)
9. Breslin EH etal “Abdominal muscle recritment of respiratory muscles on pulmonary function
during pursed lips breathing in COPD” Am J Respir ig collegiate students” International Journal of
Crit Care Med 1996;153:A128 Pharma Bio Sci 2017 october; 8(4): (B) 508-512
10. Leandro Ferracini Cabral, etal “Pursed lip 12. Seemungal TAetal.” Time course and recover of
breathing improves exercise tolerance in COPD: A exacerbations in patients with chronic obsturctive
randomized crossover study” Eur J Phys Rehabil pulmonary disease” Am J Respir Crit Care Med
Med 2015; 51(1): 79-88. 2000;161:1608-1613
 284 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Impact Of Thera-Pep And Forced Expiratory Technique In

Chronic Bronchitis Patients.

Sushmita Goswami1, Javid H Sagar2, G. Varadharajulu3

1MPTh (Cardio-pulmonary), 2Professor/ Unit Head, 3Dean/ Professor/ HOD, Krishna College of Physiotherapy,
Krishna Institute of Medical Science Deemed to be University, Karad, Maharashtra, India.

Aim: To study the impact of Thera-Pep and Forced Expiratory Technique in Chronic Bronchitis patients.

Objectives: To find the effect of Thera-pep device in mobilizing secretion. To find the effect of forced
expiratory technique in mobilizing secretion and To compare the effect of Thera-pep and forced expiratory
technique in chronic bronchitis patients.

Materials and Method: 54 patients were included according to inclusion and exclusion criteria, were
randomized by chit method into two groups. Group A (Forced Expiratory technique with coughing) and
Group B (Thera-PEP device with coughing) - with 27 patients in each group. All the patients were assessed
with Six Minute Walk Test (6MWT) and Peak Expiratory Flow Rate (PEFR). The treatment was given for
twice a day for 6 days a week for 2 weeks. After 2 weeks, effect of interventions were assessed by 6MWT
and PEFR.

Results: There was no significant difference in 6MWT and PEFR score in comparison of both experimental
and conventional intervention. The inter group values of 6MWT and PEFR showed significant improvement
in chronic bronchitis patients. The intra group values of 6MWT and PEFR showed no significant improvement
in comparison of the techniques in chronic bronchitis patients.

Conclusion: Both the techniques are effective on removal and mobilizing of secretion individually in
chronic bronchitis patients. However, the techniques when compared with each other were equally effective
and there was no significant difference between each other.

Key words: FET, 6MWT, Chronic Bronchitis, PEFR, Thera-PEP device.

Introduction The symptoms includes coughing up mucus, wheezing,

shortness of breath, and chest discomfort.[3] Bronchitis
Chronic obstructive pulmonary disease (COPD) is
is classified into two types: acute bronchitis and chronic
an illness which progresses in severity and needs lifelong
bronchitis.[3] Chronic bronchitis (CB) is very common
treatment.[1] The signs and symptoms are observed over
but changeable phenomenon in chronic obstructive
40 years of age and in 10% of general population.[1] There
pulmonary disease (COPD).[4] Chronic bronchitis is
occurs partial reversible flow restriction in the airways
defined as a productive cough lasting for minimum
in pulmonary pathology.[2] Patient condition and disease
of three months or more per year and consistent for
prognosis depends on the severity of pathology and
at least two years.[4] It affects about a third of patients
physiological changes, intensity of symptoms(chronic
with COPD, but also occurs in individuals with normal
cough, sputum production, resting dyspnea and reduced
lung function, with prevalence estimates varying widely
working capacity), presence of non-pulmonary general
both in population based studies (2.6-16%) and among
pathologies ( body mass loss and dysfunction of the
COPD patients (7.4-53%).[5] Cigarette smoking is the
musculoskeletal system with nutritional abnormalities)
most probable cause, with many other factors such
and co-morbid factors (osteoporosis, bone fractures,
as air pollution and genetics playing a smaller role.
diabetes, chronic anemia, cardiovascular diseases, [5] The conventional treatments used include cessation
depression).[2] Inflammation of large and medium sized
of smoking, vaccinations, rehabilitation, and
airway bronchi in the lungs is known as bronchitis.[2]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 285

inhaled bronchodilators and steroids via nebulizers. Method

Also long-term oxygen therapy or lung transplantation
Study type: Experimental study
may help in prognosis of the condition.[6] Positive
expiratory pressure Thera-Pep device allows the entry Study design: Comparative
of air to peripheral airways via collateral airways which
creates pressure air to go behind the secretions. This Sample size: 54 (27+ 27)
will move the secretion towards the larger airways and
Place of study: Krishna Hospital , Karad
expel out easily to prevent collapse of alveoli.[6] It is a
portable device with easy to use technique so that patient Criterion for Study
with Cystic Fibrosis (CF), lung diseases with secretory
problems, atelectasis, and patients recovering from Inclusion criteria:
surgery can use for mobilizing their secretions.[7] Forced
1. Confirmed patient diagnosis of chronic
Expiratory Technique (FET) with correct procedure and
bronchitis.
learning, this technique is most practiced and effective
airway clearance technique.[7] This technique can be 2. Male and female patients.
used as an individual technique or with different airway
clearance techniques for mobilizing secretions.[8] It 3. Patients who can complete stage I of Bruce
can be used as a stand-alone technique and also can be protocol.
included in any airway clearance routine.[8] Huff is also
4. Patients Haemodynamically stable and who are
known as forced expiratory technique with breathing
willing to participate in my study.
control and mobilizes the secretions from lower to
upper airways and expectorates them through mouth by Exclusion criteria:
coughing out.[9] FET is effective than coughing as it is less
painful, less tiring, and creates less intracranial pressure 1. Patients who are in ICU with mechanical
inside skull.[9] Peak expiratory flow rate is the outcome ventillatory support.
measurement tool used to evaluate the maximum flow
2. Unconscious, uncooperative patients.
rate generated during forceful exhalation starting from
full lung inflation.[10] It depends on the voluntary effort 3. Patients having grade IV dyspnea.
and muscular strength of the patient reflecting large
airway flow.[10] The 6mwt is a submaximal exercise test 4. Patients having other respiratory complications
used to evaluate the functional capacity of the patient. It secondary to chronic bronchitis.
measures the distance walked over a span of 6 minutes
5. Bedridden patients.
with various cardiopulmonary responses in the body.
[10] It measures the response to therapy and prognosis of
6. Recent facial, skull surgery or trauma.
various cardiopulmonary conditions.[10]
Procedure
This study examined the effect of Thera-PEP device
in mobilizing secretion in chronic bronchitis patients. By using random sampling method the participants
We also investigated the effect of Forced Expiratory had been divided into 2 groups by chit method; Group A,
Technique in mobilizing secretion in chronic bronchitis Group B. subjects with confirmed diagnosis of Chronic
patients. As Chronic Bronchitis is a very common Bronchitis with secretions and who are able to complete
condition with progressive worsening of its symptoms. stage I of Bruce Protocol had been assessed by 6MWT
It needs effective treatment to control the symptoms and and PEFR.
its complications which hampers the quality of life of the The intervention had been given for Twice a day for
patient. Easy and beneficial technique may be effective 2 weeks and treatment was given 6 times a week.
in improving the quality and functional life of the patient.
Therefore comparison of both the techniques has been Intervention protocol for group A and group B
done and given to patients respectively to check for the
improvement in the functional capacity and quality of GROUP A: Forced expiratory technique with
life of patient. coughing:
 286 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Before starting the session, the technique and its to patient’s condition. Sterilisation process after the use
physiology with diagrams which will help the patient of Thera-PEP device was done in autoclave machine.
to understand the need for monitoring the expiratory
force were taught to the patient. Technique was taught Outcome Measure:
in sitting position. Technique involved using 1 or 2 huffs 1. Peak Expiratory Flow Rate(PEFR):
from middle to low lung volumes, with the glottis open,
followed by a period of relaxed-controlled diaphragmatic Peak Expiratory Flow Rate is the maximum flow
breathing with slow deep breaths. The patient then rate generated during a forceful exhalation, starting from
breathes quietly, at their own pace, for as long as is full lung inflation. PEFR primarily reflects large airway
required and then coughing followed by huffing were flow and depends on the voluntary effort and muscular
performed. The session was carried out for (15-20 mins). strength of the patient. It is a portable flow gauge device
(PFM). The PEFR measurement depends significantly on
Group B: Thera-pep and coughing: patient effort and technique. Clear instructions, accurate
Patient is seated in upright or sitting position. The demonstrations, and frequent review of technique are
patient was instructed to slowly inspire to vital capacity essential. The position of patient while measuring PEFR
and then hold the breath for about 3 seconds and then is seated upright on chair.
slowly exhales through the mouthpiece with the fixed 2. Six Minute Walk Test (6MWT):
orifice resister that creates an expiratory pressure
resistance between 10–20 cm H2O. The resistance can 6MWT is a simple evaluative tool to asses functional
be increased or decreased according to the patient’s exercise capacity that is the capacity of the individual
condition. Then the patient performs slow deep to perform activities of daily living. 6MWT is a self
breathing which was repeated anywhere from 10 to paced test, which depends on various external factors
20 times. Then a “cough“ technique was done to clear like energy expenditure, encouragement of the therapist
secretions that have been mobilized from larger airways and motivation. It varies with age, gender, body weight,
to central airways. Rest intervals for relaxation and height. The patient is instructed to walk 60m yard (i.e;
breathing control for about 1–2 minutes were provided. 30 m each lap) for 6 minutes without any symptoms or
Full expiration was explained to be avoided. Treatment episodes of breathlessness. 6 MWT measures the heart
session was given for about 15–20 minutes and this rate, respiratory rate, oxygen saturation, blood pressure
therapy duration and frequency were adjusted according and distance walked before and after the treatment.

Results
Table 1: Comparison of PRE and POST intervention showing Mean, Median, p Value of PEFR and
6MWT of Group A and Group B respectively.

MEAN ± SD MEDIAN p VALUE t VALUE dF

PRE 145.185 ± 44.235 150.00 P <0.0001 10.874 26

GROUP A
PEFR
POST 277.O37 ± 81.042 250.00

PRE 255.555 ± 91.161 240.00

GROUP A
P < 0.0001 16.142 26
6MWT
POST 307.037 ± 76.249 300.00

PRE 141.111± 39.936 140.00

GROUP B
P < 0.0001 11.784 26
PEFR
POST 293.703 ± 79.863 270.00
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 287

Cont... Table 1: Comparison of PRE and POST intervention showing Mean, Median, p Value of PEFR
and 6MWT of Group A and Group B respectively.

PRE 262.59 ± 93.99 240.00

GROUP B
P < 0.0001 15.834 26
6MWT
POST 312.22 ± 79.72 300.00

277.03 ± 81.04 250.00

GROUP A+ POST
P =0.4500 0.7611 52
GROUP B PEFR
293.70 ± 79.86 270.00

GROUP A+ POST 307.037 ± 76.249 300.00

P = 0.8080 0.2442 52
GROUP B 6MWT
312.22 ± 79.727 300.00

Statistics
In this, the effect of FET and Thera-PEP device in
The outcomes were assessed at the 1st day prior chronic bronchitis patients were investigated. They were
to treatment and at the end of 2nd week post treatment. investigated using PEFR and 6MWT. The intervention
Intra group analysis was done by paired t test and Inter was given for 6 days a week, twice daily for 2 weeks.
group analysis was done by using unpaired t test. The In group A FET with coughing was given and in group
inter and intra group analysis was done by using Instat B the Thera-PEP device with coughing was given. Both
3 application. the techniques were given in sitting erect position.

Discussion Post intervention it was found that there was

significant improvement in both PEFR and 6MWT in
Chronic Bronchitis patients experience a progressive
both the groups individually. But when both the groups
deterioration and disability leading to worsening of
were compared, it showed no significant differences in
their health related quality of life. Chronic Bronchitis
PEFR and 6MWT between group A and group B. This
is common but a variable phenomenon of COPD with
may be because of both the techniques having final
numerous clinical consequences and reduced lung
outcome by coughing out mechanism and another reason
function with increase in airflow obstruction [1]
may be due to patients getting nebulizers and other
Forced Expiratory technique (FET) is a technique medications which may have hampered the outcomes of
including huffs with controlled diaphragmatic breathing. PEFR and 6MWT.[3]
In this technique mucus is separated from the bronchial
Also during intervention, patient had initially
wall and moved to upper airways where expectoration
difficulty in coughing out due to dyspnea leading to
occurs with cough [2]. Thera-PEP device is an advance
changes in the baseline differences in the pre PEFR and
PEP device used in urban multi- Specialty Hospitals for
6MWT values. Patients were taught with instructions
airway clearance {2}.
about the device and its usage in patients own language
The main purpose of the study was to examine the i.e; Marathi.[4]
effect of FET and Thera-PEP device in chronic bronchitis
Also while teaching the patients in rural area ‘Karad’
patients. The objective of this study was to determine
the patients initially did not understand the technique to
the effect of FET and Thera-PEP device individually in
use and apply Thera-PEP device with the breath hold
mobilizing secretion and to compare both the techniques
mechanism. This lead to reduced differences in the
in chronic bronchitis patients.
PEFR and 6MWT values. So the patients were shown
In the present study, there were 15 males and 12 video clips of the Thera-PEP position and use to get a
females in group A whereas, 22 males and 5 females in biofeedback of the Thera-PEP device.[5]
group B. The mean age of group A and group B were
63.77 and 62.77 respectively.
 288 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Patients were taught with instructions about the differences that appeared to exist in the groups for PEFR
mechanism of the device in helping to mobilize the and 6 MWT.[10]
secretion and thus reducing the symptoms.[6]
In the present study, after comparing the results with
It was difficult to treat dyspnea in grade 3 patients the previous studies it suggests that both the techniques
as it includes breath hold mechanism of 3 secs, and are equally effective for chronic bronchitis patients and
some patients were non –co-operative and some didn’t on comparing there is no significant difference in both
do the intervention given independently, so once the the groups.
therapist has taught how to do the conventional as well
as the device usage prior intervention then the patient Conclusion
can effectively utilize the Thera-PEP device. Also some Based on the statistical presentation, analysis
patients did not follow the instructions and protocol of and interpretation it can be concluded that both the
the intervention i.e.; to do number of times in a day, techniques are effective on removal and mobilizing of
which hampered the results of the study and recovery in secretion individually in chronic bronchitis patients.
the patients.[7]
The present study provided the evidence to support
The adaptation and independency of Thera-PEP that both the techniques are effective on removal and
device in rural population was good and can be advised mobilizing of secretion individually in chronic bronchitis
for home care management for chronic bronchitis. Using patients.
Thera-PEP device gives a biofeedback to the patient and
thus helps the patient recovery and independency.[8] However, the techniques when compared with each
other were equally effective and there was no significant
Utilizing Thera-PEP device in rural area “Karad” can difference between each other.
be further studied considering the durability, feasibility
and cost of the device.[8] Conflict of Interest: Short Intervention duration as
patients did not stay in wards for more than two weeks.
6 MWT and PEFR depends on various nutritional,
psychological and comorbid factors which may be also Funding: This study was funded by Krishna
the reason for no improvement. Also the intervention Institute of Medical science Deemed to be University,
duration was for two weeks as patients in wards do not Karad.
stay for more than two weeks, which may be a short
duration for effectiveness of the Thera-PEP device.[9] Ethical Clearance: The study was approved by the
institutional ethics committee of KIMSDU.
Thera-PEP device is commonly used in urban
multispecialty hospitals and the awareness and usage References
of Thera-PEP device in rural population and the 1. Shabana Begum etal “ A Comparative study
effectiveness of the device with conventional techniques between Thera-PEP and Incentive Spirometer in
was the purpose of the study upper abdominal surgery patients”. Indian Journal
Elkins, Jones et al had also reported such a of Physiotherapy and Occupational Therapy,
preference in favour of treatments that allow greater October- December 2010, Vol 4 No 4, New Delhi.
independence of using Thera-PEP device. It is of great 2. Kerry West etal “Acapella vs PEP mask Therapy:
importance that the effectiveness of the Thera-PEP for A randomised trial in children with cystic fibrosis
home physiotherapy is evaluated. Adherence over longer during respiratory exacerbation”. Physiotherapy
periods of time is important, but it is unknown that the Theory and Practise, 20 february 2009, Australia.
Thera-PEP is more acceptable device for sustained use. 3. Jenifer Y So etal “Daily Peak Expiratory
Other factors to consider which could have impact on the Flow Rate and Disease instability in Chronic
uptake of Thera-PEP were its relative cost, durability, Obstructive pulmonary disease”. Journal of COPD
and ease of maintenance [10]. foundation,2016, Volume 3.
The small sample size and the short duration 4. Michael Mok etal “Prognostic Value of Exercise
intervention may be responsible for the baseline capacity as evaluated by the 6 minute walk test
in patients undergoing transcatheter aortic valve
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 289

implantation”. Journal of the American college of 2007, 52: 1198-1206.

Cardiology, 2013, volume 61. 8. Oldenburg FA Jr etal “Effects of Postural drainage,
5. T. Troosters etal “Physiological responses to the 6 exercise and cough on mucus clearance in chronic
min walk test in patients with chronic obstructive bronchitis. Am Respir Dis. 1979; 120:739-745.
pulmonary disease”. European Respiratory Journal, 9. Archana C Dogra “Six minute walk work in patients
2002, volume: 20: 564-569. with chronic obstructive pulmonary disease”.
6. Nisha Shinde etal “ Peak Expiratory Flow Rate: International Journal of Research in Medical
effect of body positions in patients with chronic Sciences, nov 2014, 2(4):1283-1288.
obstructive pulmonary disease”. Indian Journal of 10. Huchon GJ etal “Chronic Bronchitis among French
Basic and Applied Medical Research, September adults: high prevalence and underdiagnosis. Eur
2012, volume 1. Respir J 2002; 20:806-812.
7. Van Der Schans CP “Conventional Chest physical
therapy for obstructive lung disease”. Respir care,
 290 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Critically Apprising Tools to measure Oral Health Literacy

using the COSMIN Checklist

Suvi Kanchan1, Anitha. R. Sagarkar2, Ranadheer. R3

1Post graduate, 2Reader, 3Associate Professor, Public Health Dentistry, Faculty of Dental Sciences, M.S Ramaiah
University of Applied Sciences

Abstract
Purpose: Oral health literacy tools are important for assessing a population’s oral health knowledge and
awareness. The objective of this study was to critically appraise the methodology used for developing all the
existing oral health literacy assessment tools, by systematically reviewing the available evidence.

Materials & Method: Databases used for the search were Wiley, BMJ open, Pub Med/Medline and Science
Direct. We identified 10 studies, published in English during 2006 – 2016, that focused on the development
and validation of oral health literacy tools. We then assessed these studies using the COSMIN checklist,
which evaluates the methodological quality of studies on measurement properties.

Results: Most of the tools were adapted from the general health literacy tool. All the 10 tools had measured
validity and reliability, but lacked cross-cultural validity.

Conclusion: Findings from this review confirm that majority of the tools focus towards assessment of word
recognition, numeracy and reading skills, rather than indicative of aspects such as health behaviors and
service utilization. Developing tools that are adapted for specific populations will require further work, such
as incorporating tests to ensure their acceptability and cultural competence.

Key-words: Oral, health literacy, COSMIN checklist, tools, review

Introduction valuable in assessing overall oral health levels of a given

population.
Oral health literacy (OHL) is defined as the ‘degree
to which individuals have the capacity to obtain, process A number of tools have been developed to assess
and understand basic oral health information and OHL levels of populations, of which the most widely
services needed to make appropriate health decisions’ [1] used is the Rapid Estimate of Adult Literacy in
[2]
. This ability to access and leverage oral health-related Dentistry (REALD-99) [3], several variants of which
information and services serves as the most reliable were subsequently developed. Other popular tools, such
indicator of oral health levels, since a high degree of as the Test of Functional Health Literacy in Dentistry
OHL would correspond to a higher likelihood of good (ToFHLiD) [4], the Comprehensive Measure of Oral
oral health being maintained. Being able to measure Health Knowledge (CMOHK) [5] and the Health Literacy
such an important indicator would prove to be extremely in Dentistry scale (HeLD) [6], have also been greatly
successful.

Corresponding Author: A few reviews have been conducted for assessing

Suvi Kanchan OHL tools, including those by Dickson-Swift et al.
Department of Public Health Dentistry, (2014), and Navdeep Kaur and Daniel Kandelman
Faculty of Dental Sciences, M.S Ramaiah University (2015), which focus on what the different tools measure.
of Applied, M S R Nagar, New Bel Road, Bangalore, However, no review has so far been conducted to evaluate
Karnataka, India 560054 the methodology used for developing these tools, which
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 291

could help the researchers in understanding the critical Materials and Method
points that are to be considered while planning the
This systematic review was conducted based on the
development of new tools.
five steps mentioned by [7]. The studies which emphasize
This systematic review, hence, analyses, assesses on methodology of development and validation of
and benchmarks all the currently available tools. The different oral health literacy tools were included in the
aim of this study is to critically appraise the methodology review. All other studies were excluded from the review
used for developing all the existing oral health literacy during the step of screening. The final study selection
assessment tools, using the COSMIN checklist. was based on the inclusion and exclusion criteria
mentioned in Table 1.

Table 1: Inclusion and exclusion criteria for the studies

Inclusion Criteria Exclusion Criteria

1. Time period of studies from 2006- 2016.

2. The tools developed in different languages but 1. Tools adapted from an original tool.
published studies available in English language. 2. Commentary articles/conference reports/theses/
3. Studies based on development of Oral Health Literacy workshop summaries
tools.

The research for the review was started with Google this review, studies that met the inclusion criteria were
Scholar search and was completed with the help of scored.
Wiley, BMJ open and Pub Med/Medline databases. The
key words used for the following search were ‘health Results
literacy’, ‘oral’, ‘development’ and ‘tool’ with Boolean
In this review we identified all the original oral
search strategy. MeSH term used was ‘health literacy’.
health literacy tools and analyzed the methodologies
The time period selected for the review was 10 years.
adopted to develop and validate such tools. We observed
The search time frame was January 2006- April 2016.
that the first tool developed was the REALD- 30 in 2007
Study selection as shown in Table 2, which was adapted from Rapid
Estimate of Adult Literacy in Medicine (REALM).
Using the search items selected for this review, REALM was the commonly used tool for assessing
12585 turned up in the initial search. Then after applying general health literacy. REALD- 30 was based on word
various filters and removing duplicate studies, finally 10 recognition tests that helped in merely assessing the
studies were selected. reading ability of the population.
The quality of the studies selected were assessed Other recently developed tools such as the Adult
based on the methodology used for the development of Health Literacy Instrument for Dentistry (AHLID) [9],
the oral health literacy tool in the particular study. Oral Health Literacy Adults Questionnaire (OHL-AQ)
[10]including new measures of literacy skills (OHL
The Consensus-based Standards for the Selection of
Adults Questionnaire: OHL-AQ, etc. were also based on
Health Measurement Instruments (COSMIN) checklist
parameters such as reading comprehension, numeracy,
was used to evaluate the methodological quality of
literacy and decision-making (factual, procedural, and
studies on measurement properties [8]. It is a valid and
conceptual). Apart from these, population-specific tools
reliable tool for evaluating the methodological quality of
such as the Hong Kong Oral Health Literacy Assessment
health measurement instruments. The COSMIN uses a
Task for Pediatric Dentistry (HKOHLAT-P) [11] and
quality-rating system of nine domains including internal
Oral Health Literacy Inventory for Parents (OH-LIP) [12]
consistency, reliability, measurement error, content
were also developed, which helped in assessing the oral
validity, structural validity, hypotheses testing, cross-
health literacy of parents/ children with respect to word
cultural validity, criterion validity and responsiveness.
recognition, vocabulary knowledge and comprehension.
Each domain is assessed with a series of questions that
It did not measure the comprehensive skills.
are scored on a 4-point scale from excellent to poor. For
 292 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 2: Overview of oral health literacy tools

Name of tool Year Authors Type of tool

Multi-site assessment of oral health literacy 2016 Macek et al. Conceptual model with 3 domains

Health Literacy in Dentistry (HeLD) 2014 Jones et al. 29 item- Modelled on the HeLMS

Adult Health Literacy Instrument for Dentistry

2015 Stein et al. Based on an OECD instrument
(AHLID)

Oral Health Literacy Adults Questionnaire (OHL- 17 items in 4 sections, reading comprehension,
2014 Sistani et al.
AQ) numeracy, literacy and decision making

Literacy and numeracy tasks across three

Hong Kong Oral Health Literacy Assessment Task
2013 Wong et al. kinds of knowledge (factual, procedural, and
for Paediatric Dentistry (HKOHLAT-P)
conceptual)

3 parts- word recognition, vocabulary

Oral Health Literacy Inventory for Parents (OH-LIP) 2011 Richman knowledge, and comprehension of 35 terms used
in paediatric dentistry

Oral Health Literacy Assessment-Spanish 24 items- word recognition and a comprehension

2012 Lee et al.
(OHLA-S) section

38 item- reading comprehension and 19 item-

Oral Health Literacy Instrument (OHLI) 2009 Sabbahi et al.
numeracy sections

Test of Functional Health Literacy in Dentistry Reading comprehension and numeracy

(ToFHLiD) 2007 Gong et al. 68 item reading comprehension and
12 item numeracy

Rapid Estimate of Adult Literacy in Dentistry −30 30 item word recognition common
2007 Lee et al.
(REALD-30) dental words

Discussion retest reliability.

The present review focused on how over the Also, there were no proper measures followed for
years, various oral health literacy tools have been assessing the psychometric properties of the tool. As a
developed/adapted from original tools. For instance, the consequence, the results obtained from the REALD-30
REALMD-20 [17] has been adapted from the REALD-30. and the inferences drawn from them would include
But unlike such adapted tools, most of the original tools a significant level of inaccuracy, and would not be a
which were developed later included different domains reliable indicator of the true extent of oral health literacy
for assessing oral health literacy such as comprehension, in the given population.
knowledge, numeracy and vocabulary. In 2007, another
tool was developed, namely the Test of Functional A study done by Mark D. Macek and his colleagues
Health Literacy in Dentistry (ToFHLiD), which assessed in 2016 was based on a multi-site investigation which
the comprehensive and numeric ability of a population. included a conceptual model with three domains: Health
The tool showed satisfactory levels of reliability and Literacy (Domain #1), Behaviors/decisions (Domain
convergent validity. However, the ToFHLiD lacked test- #2), and Health Outcomes (Domain #3), influenced by
selected oral health-related and socioeconomic status
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 293

(SES) covariates. capable of incorporating communicative/ interactional

and critical nuances of oral health awareness. Efforts
Most of these tools were adapted from existing tools in the area of formal validation, however, are still
which were originally developed for measuring general required. In addition, further work would be required to
health literacy. For instance, the Health Literacy in develop tools that are adapted for specific populations,
Dentistry (HeLD) [6] was adapted from a general health by incorporating tests to ensure their acceptability and
literacy measure, the Health Literacy Management cultural competence.
(HeLM) scale. Similarly, REALD was based on the
Rapid Estimate of Adult Literacy in Medicine (REALM). Ethical Clearance- Taken from M.S Ramaiah
University of Applied Sciences Ethics committee
Despite successful adaptions of these original
tools, however, it was observed in the review that all Source of Funding- Self
of the tools that were reviewed lacked cross-cultural
adaptation. But there were a few tools which considered Conflict of Interest - Nil
the importance of language in assessing the literacy of a
population. The tools that were developed by [11] and [14],
References
for instance, were translated into Mandarin and Spanish 1. Wehmeyer MM, Corwin CL, Guthmiller JM, Lee
languages respectively. JY. The impact of oral health literacy on periodontal
health status. J Public Health Dent 2012;74(1):80–
In the past, there have not been many reviews 7.
for assessing oral health literacy tools. The results we
2. Raynor DKT. Health literacy. BMJ [Internet]
obtained by means of this study were similar to those
2012;344(march):1–2. Available from: http://
obtained from reviews done by [18] and [19], the latter
www.bmj.com/cgi/doi/10.1136/bmj.e2188
of which states that none of the current tools offer an
accurate assessment of oral health literacy level of a 3. Richman JA, Lee JY, Rozier RG, Gong DA, Pahel
given population. BT, Vann WF. Evaluation of a Word Recognition
Instrument to Test Health Literacy in Dentistry: The
With this review we observed that there is a need REALD-99. J Public Health Dent 2007;67(2):99–
of oral health literacy tools which are not only disease 104.
specific but consider all the domains of health literacy 4. Gong DA, Lee JY, Rozier RG, Pahel BT, Richman
such as word recognition, comprehension, decision JA, Jr WFV. Development and Testing of the
making etc. the tools should also be cross-culturally Test of Functional Health Literacy in Dentistry (
adapted for specific population. TOFHLiD ). J Public Health Dent 2007;67(2):105–
One of the limitations of this review was that only 12.
original studies were considered for the purpose of the 5. Macek MD, Haynes D, Wells W, Bauer-Leffler
review. The various tools adapted from original tools S, Cotten PA, Parker RM. Measuring conceptual
were not considered. health knowledge in the context of oral health
literacy: Preliminary results. J Public Health Dent
Conclusion 2010;70(3):197–204.
Findings from this review confirm that majority of 6. Jones K, Parker E, Mills H, Brennan D, Jamieson
the tools focus towards assessment of word recognition, LM. Development and psychometric validation
numeracy and reading skills, rather than indicative of of a Health Literacy in Dentistry scale (HeLD).
aspects such as health behaviors and service utilization. J Health Commun [Internet] 2014;31:37–43.
Of late, attempts have also been made to incorporate Available from: http://www.ncbi.nlm.nih.gov/
other parameters into the development phase of the tool, pubmed/25315594
which include parameters that are considered important, 7. Khan KS, Kunz R, Kleijnen J, Antes G. Five steps
including decision making and possibly service to conducting a systematic review. J R Soc Med
navigation. The incorporation of these parameters 2003;96(3):118–21.
should increase the validity of these tools as a measure 8. Mokkink LB, Terwee CB, Patrick DL,
of oral health literacy on a larger scale, as they are more Alonso J, Stratford PW, Knol DL, et al. The
 294 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

COSMIN checklist manual [Internet]. VU Univ. 14. Lee J, Stucky B, Rozier G, Lee S, Zeldin LP. Oral
Med.2012;56. Available from: http://www.cosmin. Health Literacy Assessment : development of an
nl/images/upload/File/COSMIN checklist manual oral health literacy instrument for Spanish speakers.
v9.pdf%5Cnwww.cosmin.nl 2012;30(7).
9. Stein L, Pettersen KS, Bergdahl M, Bergdahl JAN. 15. Sabbahi DA, Lawrence HP, Limeback H, Rootman
Development and validation of an instrument to I. Development and evaluation of an oral health
assess oral health literacy in Norwegian adult dental literacy instrument for adults. Community Dent
patients. Acta Odontol Scand 2015;(January):1–9. Oral Epidemiol 2009;37(5):451–62.
10. Naghibi Sistani MM, Montazeri A, Yazdani R, 16. Lee JY, Rozier RG, Lee SYD, Bender D, Ruiz RE.
Murtomaa H. New oral health literacy instrument Development of a word recognition instrument to
for public health: development and pilot testing. J test health literacy in dentistry: The REALD-30
Investig Clin Dent 2014;5(4):313–21. - A brief communication. J Public Health Dent
11. Wong HM, Bridges SM, Yiu CKY, Mcgrath CPJ, 2007;67(2):94–8.
Au TK, Parthasarathy DS. Validation of the Hong 17. Gironda M, Der-Martirosian C, Messadi D,
Kong oral health literacy assessment task for Holtzman J, Atchison K. A brief 20-item dental/
paediatric dentistry (HKOHLAT-P). Int J Paediatr medical health literacy screen (REALMD-20). J
Dent 2013;23(5):366–75. Public Health Dent 2013;73(1):50–5.
12. Richman JA. Beyond Word Recognition: 18. Dickson-Swift V, Kenny A, Farmer J, Gussy M,
Understanding Pédiatrie Oral Health Literacy. Larkins S. Measuring oral health literacy: a scoping
Pediatr Dent 2011;33(5):420–5. review of existing tools. BMC Oral Health [Internet]
13. Macek MD, Atchison KA, Watson MR, Holtzman 2014;14(148):1–13. Available from: http://www.
J, Wells W, Braun B, et al. Assessing health literacy pubmedcentral.nih.gov/ articlerender.fcgi?artid=
and oral health: preliminary results of a multi- 4417207&tool= pmcentrez& rendertype=abstract
site investigation. J Public Health Dent [Internet] 19. Kaur N, Kandelman D, Nimmon L, Potvin L. Oral
2016;(3):1–11. Available from: http://doi.wiley. Health Literacy: Findings of A Scoping Review.
com/10.1111/jphd.12156 EC Dent Sci 23 2015;2(3):296–306.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 295

Effect of Core Training with and without Yogic Practices on

Elasticity among College Female Athletes

R. Meera1, R.mohanakrishnan2, T. Arun Prasanna3

1Research Scholar, Dept. of Physical Education and Sports Sciences, SRMIST, Kattankulathur, 2HOD, Dept.of
Physical Education and Sports Sciences, SRMIST, Kattankulathur, 3Research Scholar, Dept. of Physical
Education and Sports Sciences, SRMIST, Kattankulathur

Abstract
The present study evaluates the impact of core strength training with and without yogic practices on elasticity
among the college female athletes. To attain the aim of the study forty five (N=45) female students were
selected randomly as subjects from Chennai, Tamilnadu, India aged between 17 to 25 years at random. The
athletes were separated into groups of three with 15 students each named as experimental group I with core
strength training , experimental group II with core strength training with yogic practices and group - III
with controlled training. Prior to and after the twelve weeks of experimentation, the subjects were tested.
The core strength training and the yogic practices were selected as training protocol. The core strength
training given based on stress given in each exercise and sets and the load administered between 5 and 10
repetitions in a set with the time lapse of 15 to 10 seconds for a set. The training protocol followed by proper
warming up and cooling down regime. The yogic practice was given on morning time with proper prayer
and warming up practice. The load of the yogic practice increased by the number of yogic practices by 2
to 8 repetitions with 2 to 5 sets. The obtained data from the experimental and control group initial and final
readings underwent statistical analysis along with analysis of covariance (ANCOVA) with the application of
Scheffe’s post hoc test to examine the groups’ difference and testing condition. The level of confidence had a
fixation of 0.05 confidence level. The group that acted as the experimental group had improved significantly
on flexibility in comparison with control group.

Keywords: Core strength training, Yogic practice, Female Athletes, Flexibility.

Introduction A wide practice of core strength training is

undergone by professionals. It aims to develop core
The spine, hips, pelvis, lower limb at the proximal
stability and improve core muscular strength leading
level and structures in the abdomen which forms the
to the improvement of the performance of the athletes.
musculoskeletal core of the body are responsible for
Core strength training is considered as an element of
stabilizing spine and pelvis. During the sports activities
strength and conditioning by the professionals of health
of a person, they help in the energy transformation
and fitness as it enhances the performance of the athletes
between the large and small parts of the body.1 Thoracic
and prevents injuries. 3 But few studies failed to show the
lumbar fascia, abdominals, hip girdle musculature, para
significance of changes in the lower extremity stability
spinals, hip joints, diaphragm, pelvic floor and spine
or performance. However, further studies are needed
have a central location as core muscles. They perform the
to transform core strength training to performance.
required stabilising functions of the body for the distal
Scientific studies that are limited were done to evaluate
segments to do their functions specifically. Also they
the effect of core strength training on the stability of
provide proximal stability of the limbs for their distal
lower extremity and the performance of the athletes. 4
mobilization and function. Along with these functions,
the core activity is involved with the oactivities that are The practice of Yogasana includes stretching,
limited, for example agility, kicking, throwing etc., 2 moving and holding the body of an individual into
various positions comfortably. This improves the muscle
flexibility, where the positions are believed by many
 296 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

practitioners. It helps in the maintenance of the balance earlier flexibility is largely depend upon anatomical
of varied internal glands and organs of the body. structure of the joint. The manner in which the bone
ends are joined each other basically decides the type of
Hence, the study examines the effect of yogasana movements possible in the joint. Greater mobility is in
exercise that may influence the significant changes in the ball and socket joint. The elasticity of ligaments can be
flexibility on experimental group. increased up to some extent by training, but length of the
Yoga is considered as the discipline of psycho- ligaments can’t be change by training.
somatic-spiritual being that helps in the unity and There are very few studies, which are measuring
peace of our mind, body and soul. It also helps in the effect of core stability training with and without yogic
unity of consciousness of an individual eventually with practices on flexibility in female athletes. Hence there
the universe.5 It allows a person to synchronize with is need to analyse the influence of core stability training
breathing through meditation and relaxation with a body with and without yogic practices on flexibility among
technique. female athletes.
Yoga is one of the most effective methods, by Statement of the problem
which the perfection of the latent potentialities, partially
expressed in man is attained. Perfection is not an addition The research aims to assess the impact of core
– addition of capacities or it is the manifestation of those strength training with and without yogic practices on
potentialities which are inherent in man and which elasticity among college female athletes.
lie idol until and efforts is made to bring them to the
surface. Jnana, Bhakti, Karma and Raja are the several Methodology
means to attain the perfection of personality.6 Flexibility To attain the aim of the study forty five (N=45)
can also be called the capacity for joint movements female athletes were selected randomly as subjects from
fluidly through its complete motion. It is the capability Chennai city, Tamilnadu, India aged between 17 and 25
of a person to move a part or body parts with a variety years at random. The athletes were divided into groups
of purposeful movements at the speed required. It helps of three with 15 each named as selected experimental
in joint movements with a normal variety of motion group I with core strength training, experimental group
devoid of undue stress to the muscular tendinous unit. II with core strength training with yogic practices and
7 Flexibility has important interrelationship with other
group - III controlled . The athletes were tested before
performance factors. The traction of anteflexion, skin and after the twelve weeks of experimentation. The core
among the two fixed points in the midline of the back strength training and the yogic practices were selected
was tested for the ante flexibility of the lumbar spine. as training protocol. The core strength training given
The mark in the beginning was positioned on the process based on stress given in each exercise and sets and the
of spine LV, set up by the` intersection of the midline in load administered between 5 and 10 repetitions in a set
the dorsal region with the connecting line of both lateral with the time lapse of 15 to 10 seconds for a set. The
lumbar fossae. training protocol followed by proper warming up and
Active flexibility is also of two types – static and cooling down regime. The yogic practice was given
dynamic. Static flexibility is required for movement done on morning time with proper prayer and warming up
while individual is in the static state i.e. standing, sitting practice. The load of the yogic practice increased by
or lying. Dynamic flexibility is required for executing the number of yogic practices by 2 to 8 repetitions with
movement with greater range when individual is 2 to 5 sets. The core training protocol are Crunches,
moving. Active flexibility is always less than the passive Decline Crunch, Cable Crunch, Oblique Crunches,
flexibility. 8 The dynamic flexibility is always less than Jack knife Sit-Up, Barbell Side Bend, Leg lift, Leg lift
static flexibility and is heavily dependent on the motor - Hang Position , Oblique Leg lift and yogic practices
coordination. The terms general & specific flexibility are protocol are Suryanamaskar. Tadasana, Trikonasana,
also commonly used to denote the levels of flexibility of Paschimottanasana, Chakrasana, Bhujangasana, Nadi
all the important joints of the body specifically shoulder, Sodhana, Bhastrika and Kapalapathi. The criterion
hip & trunk whereas special flexibility is the ability to variables measured by using sit and reach based test. The
do movements of a sport with greater range. As stated obtained data from the experimental and control group
initial and final readings underwent statistical analysis
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 297

with ANCOVA and Scheffe’s post hoc test to examine the groups difference and testing condition. The confidence
level is fixed at 0.05. The statistical analysis computed with IBM-SPSS – v21 software.

Results and Discussions

Table – I: The descriptive analysis of experimental and control group on flexibility

Core Strength Training Core Strength Training with Yogic

Test Control Group
group practice group

Mean 21.20 22.30 22.35

Pre Test
SD 0.86 0.58 1.45

Mean 25.45 28.56 22.56

Post Test
SD 0.86 1.25 1.02

Adjusted Post Test Mean 25.78 28.89 23.45

Magnitude of Improvement 17.76% 21.66% 4.69%

TABLE – II: Ancova on flexibility among groups

Test Sum of Squares Df Mean Square F ‘P’ Value

8.01 2 4.00
Pre Test 3.07 0.065
54.62 42 1.30

135.25 2 67.62
Post Test 44.48* 0.000
64.20 42 1.52

136.89 2 68.44
Adjusted Post Test 44.15* 0.000
63.58 41 1.55
*Significant at 0.05 level of confidence

TABLE-III: Scheffe’s post HOC test of paired mean difference on flexibility

Core Strength Core Strength Training with

Control Group Mean Difference ‘P’ Value
Training group Yogic practice group

25.78 28.89 - 3.11* 0.000

25.78 - 23.45 2.33* 0.000

- 28.89 23.45 3.44* 0.000

*Significant at 0.05 level of confidence

The results in table I-III on flexibility were similar that the adjusted post test paired mean differences on
before the training programme. The post test found flexibility between core strength training and training
significant among the groups on the chosen criterion of core strength with yoga, core strength training and
variables. Further, the Scheffe’s post test showed control groups and core strength training with yoga
 298 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

training groups and control group found significant flexibility in obese males. Study done by Stanton,R et
with the P value 0.000. Hence, the results show that the al 1 observed the impact of Swiss ball based training for
flexibility in the training with core strength along with 6-week on running economy and core stability. in an
yoga training groups and core strength training groups athletic population. After giving core stability training
improved significantly. The control group have shown program in improving function mobility as above study.
insignificant on flexibility. The data is represented Core stability extensively benefits the sport performance
graphically in Figure I and II. with a foundation for extensive force production in the
upper and lower level of extremity.

Conclusions
The conclusion based on the result and discussions
that the flexibility has improved both the experimental
groups such as core strength with yogic practice group
and core strength training group, in comparison with
the control group. Further, the core strength with yogic
practice group shows better improvement on flexibility
when compare with isolated core strength training group
on flexibility.
Figure I: The graphical presentation of data of descriptive
statistics on flexibility Ethical Clearance- Nil

Source of Funding- Self

Conflict of Interest- Nil

References
1. Khan K, Brunker K. Clinical Sports Medicine.
3rd edition. McGraw Hill Medical Publication
2009:158-73.
2. Stanton R, Reaburn PR, Humphries B. The effects
Figure II: The graphical presentation of magnitude of
of short-term swiss ball training on core stability
improvement from the initial to final means on flexibility
and running economy. J Strength Cond Res.
Discussion on Findings 2004;18(3):522–8.
Most of the previous research confirmed the finding 3. Scibek JS, Guskiewicz KM, Prentice WE, Mays
of the present study. It is apparent that core strength S, Davis JM. The effects of core stabilization
training and yogic practices is very specific to the training on functional performance in swimming.
flexibility. No well established was observed on the Unpublished master’s thesis, University of North
independent effects of aerobic training on flexibility. Two Carolina, Chapel Hill, North Carolina, USA. 2001.
previous studies showed no improvement on flexibility 4. Cosio-Lima LM, Reynolds KL, Winter C, Paolone
through the aerobic training. 9 Without the inclusion of V, Jones MT. Effects of physioball and conventional
the stretching based exercises in the training schedule floor exercises on early phase adaptations in back
there was no development in the flexibility with land- or and abdominal core stability and balance in women.
water-related aerobic training. The present study which J Strength Cond Res. 2003;17(4):721–5.
involves the yogasana exercises improved the flexion 5. Madanmohan (2008). Introducing Yog to Medical
and extension of the hip.10 The reason is the increase Students-The JIPMER Experience: Advanced
of the strength of muscle and collagen in the region of Centre for Yoga Therapy, Education and Research.
lower limbs. 11 However, this research also supports the
6. Putnam CA. Sequential motions of body segments
present study to derive the better training programme. In
in striking and throwing skills. J Biomech 1993; 26:
our study, we found that 12 weeks of yogasana training
125-35.
at medium intensity significantly improves lumbar
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 299

7. Zattara M, Bouisset S. Posturo-kinetic organization study. Med Sci Sports Exerc 1985; 17: 482–487.
during the early phase of voluntary limb movement. 10. Taunton J, Rhodes E, Wolski L. Effect of land-
J Neurol Neurosurg Psychiatry 1988; 51: 956-65. based and water-based fitness programs on the
8. Baechle TR, Earle RW, Wathen D. Resistance cardiovascular fitness, strength and flexibility of
training. In Baechle TR, Earle RW. Essentials women aged 65–75 years. J Gerontol 1996; 42:
of strength training and conditioning. 2nd ed. 204–210.
Champaign (IL): Human Kinetics, 2000: 395-425. 11. Michna H. Morphometric analysis of loading-
9. Marcinik E, Hodgdon J, Mittleman K, O’Brien induced changes in collagen- fibril populations in
J. Aerobic/calisthenic and aerobic/ circuit weight young tendons. Cell Tiss Res 1984; 236: 465–470.
training programs for Navy men: a comparative
 300 Indian Journal of Public Health Research &type:
Article Development, January 2020, Vol. 11, No. 1
Original research

Mental toughness in Indian Elite athletes: Psychometric

validation of the Psychological Performance Inventory

Tarun Jain1, Ritu Sharma2, Abha Singh3

1Research Scholar, 2Asst. Professor, 3Professor, Amity Institute of Psychology and Allied Sciences, Amity University
Noida, UP, India, 4Associate, Professor, Zakir Hussain College, Delhi University, India

Abstract
Background: Mental toughness is one of the psychological dimensions considered essential for performance
in sports. In this study, the Psychometric validation of the Psychological Performance Inventory (PPI) was
validated for the measurement of mental toughness in elite athletes. Materials and method: A sample of 76
elite athletes was selected via purposive sampling. To assess mental toughness, we used the Psychological
Performance Inventory, by Loehr (1986). A confirmatory factor analysis was conducted to confirm the factor
structure of the Psychological Performance Inventory in an Indian context. Results: The mean scores for
negative energy control, positive energy control, attention control, and attitude control were 3.41 (SD = .18),
3.88 (SD = .23), 3.68 (SD = .15), and 3.86 (SD = .23), respectively. Only 29 items were adequately internally
consistent in assessing mental toughness for Indian elite athletes. In composite reliability (CR), all factors
had values above .85, indicating good reliability.

Conclusion: The lack of success among elite Indian athletes is their excessive focus on affective skills,
neglect of cognitive skills. Balancing affective and cognitive skills is the way to improve mental toughness,

Keywords: Affective, cognitive, Indian elite athletes, mental toughness, skill

Introduction and mastery of knowledge, skills, and abilities and

In today’s increasingly competitive games, the the capability to consistently and reliably deliver (i.e.
already thin margin between winning and losing (i.e., perform) at the time of performance’. 3
performance) is becoming progressively thinner. Contesting every athletic should have ability to
These decreasing margins are causing immense stress manage the delicate mind–body connection, which
for athletes, as achieving the highest level of success becomes dramatically clear within the competitive
requires a blend of complex technical skills, self- arena.4
efficacy, and understanding the dynamic mental and
physical environmental constraints. Sugarman reported that athletes often spend so much
time on physical practice in order to gain an edge in
Performance in competitive sports comprises competition that they end up ignoring another essential
three domains: technical movement or mechanics aspect of sports performance, namely, mental skills. A
(skill), cognitive skills (ability to deal with the trained mind is essential to achieve this skill. 5
environment), and affective skills (an emotional
component).1,2. An Aoyagi and Portenga have noted, Mental toughness is considered as an important
‘successful performance requires both the development psychological dimension for performance excellence.
Mental toughness is used as a measure of the specific
cognitive and affective skills that athletes must possess
Corresponding address for good sports performance. 6-10. Broadly, mental
Tarun Jain toughness has been denoted as the quality necessary to
Research Scholar, Amity Institute of Psychology and perform better than others in a competition or to perform
Allied Sciences, Amity University Noida, UP, India well in a competition. 11,12,13
E-mail id : [email protected]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 301

The cognitive aspect of mental toughness refers to with Cronbach’s alphas for the seven subscales indicating
the ability to deal with problems on and off the field 12 high reliability (self-confidence = 0.69; negative energy
and deal with the pressure, negativity, and adversity 13- control = 0.42; attention control = 0.75; visualization
14 by staying calm and focused and maintaining belief and imagery control = 0.82; motivation = 0.70; positive
in one’s own plans and actions 6. The affective aspect, energy control = 0.71; attitude control = 0.71). The PPI
on the other hand, refers to athletes’ ability to remain demonstrated acceptable psychometric properties when
motivated and confident11 despite numerous failures on used on athletes performing at a National or international
a daily basis, both during and after competitions. level 22,23. PPI was selected because its subscales allow
easy breakdown of items into affective and cognitive
Presently, most studies on mental toughness in skills.
Indian athletes focused on comparing mental toughness
among various competitive levels of a single sport, such Procedure
as the school, university, and national levels.15-18 Few
studies have examined how mental toughness correlation Structural equation modelling (SEM) was employed
with other factors like win to win, winners to losers, to test the validity of the PPI using confirmatory factor
anxiety state across various sports, such as badminton, analysis, which involves confirming how well the scale
gymnastics, athletics, and cricket19,20. There is no items fit the subscales (self-confidence, visualization and
reported study on mental toughness and its correlations imagery control, motivation, positive energy control,
with various components of mental toughness. negative energy control, attention control, and attitude
control) forming the construct of mental toughness. First,
This study was conducted to validate the PPI in the the internal consistency was examined and maximized
Indian context for elite athletes and to measure mental using Wille’s stepwise procedure, which was repeated
toughness and assess the psychological reasons for the until removal of any of the remaining items in the
poor performance of Indian athletes at the international scale did not lead to an increase in the corresponding
level. subscale’s alpha. Second, a partial least squares SEM
(PLS-SEM) approach was used to determine whether
Materials and Method the factor loadings of all remaining items in the final
The purposive sample of 76 elite Indian athletes model of mental toughness were more than5 which
competing at the national and international levels, in would indicate the presence of convergent and factorial
golf (n = 20), shooting (n = 15), track and field (n = validity. High internal consistency and reliability further
17), tennis (n = 5), squash (n = 2), wrestling (n = 4), serve as proof of construct validity.
swimming (n = 2), and boxing (n = 3) were included in the
Results
study. The sample was collected at various international
competition events in India, such as the Indian Open golf The obtained data was statistically evaluated with
tournament, the Women’s Indian Open, the International IBM SPSS Statistics for Windows, Version 21.0.
Shooting Sport Federation (ISSF) World Cup, the Asian Armonk, NY: IBM Corp using t-test, Cronbach’s alpha
Athletics Championship, and various camps held for coefficient Regression (β) path coefficients, at p value
national players in competition at the international level. 0.05. The mean scores of self-confidence, visualization
and imagery control, and motivation were 4.33 (SD =
The Psychological Performance Inventory (PPI; .16), 4.13 (SD = .20), and 4.56 (SD = .04), respectively.
Loehr 1986) 21 was used to measure mental toughness. The mean scores for negative energy control, positive
This 42-item scale yields a total mental toughness score, as energy control, attention control, and attitude control
well as seven 6-item subscale scores: (a) self-confidence; were 3.41 (SD = .18), 3.88 (SD = .23), 3.68 (SD = .15),
(b) negative energy control; (c) attention control; (d) and 3.86 (SD = .23), respectively. Subscales of the PPI
visualization and imagery control; (e) motivation; (f) were significantly correlated (p < 0.05, Table 1).
positive energy control; and (g) attitude control. Each
item is rated on a five-point Likert scale anchored by Table 2 indicates the significance of reliability and
‘almost always’ and ‘almost never’. The subscale scores validity of Psychological Performance. The internal
range from 6 to 30 (with higher scores indicating more consistency reliability of each of the seven subscales
desirable levels), with total scores ranging from 42 to was good. Using Wille’s method, we found that only 29
210. The PPI has been found to be internally consistent, items were adequately internally consistent in assessing
 302 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

mental toughness for Indian elite athletes. Regarding the composite reliability (CR), all factors had values above
.85, indicating good reliability All subscales also had average variance extracted (AVE) values of greater than 59,
indicating good convergent validity. To assess the common method bias, we used Harman’s one factor test (based
on a principal component analysis) to see if all the items loaded onto one factor. We found no common variance or
a common latent factor (Table-3, 4).

Table 1: Descriptive statistics and correlations of Psychological Performance Inventory

Std. Cronbach’s
Subscale Mean SC VI ML NE PC AC AT
Deviation alpha

Self-confidence .79
4.33 .16 .85
(SC) ***
Visualization and .82
imagery control 4.13 .20 .86
(VI) ***

.74
Motivation (ML) 4.56 .04 .88
***

Negative .53
3.41 .18 .78
energy control (NE) ***

Positive .53
3.88 .23 .74
energy control (PC) ***

Attention control .54

3.68 .15 .70
(AC) ***

.59
Attitude control (AT) 3.86 .23 .81
***

Table 2: Reliability and validity of Psychological Performance Inventory

Visualization
Self- Negative Positive energy Attention Attitude
and imagery Motivation
confidence energy control control control control
control

Cronbach’s alpha 0.85 0.86 0.88 0.78 0.74 0.70 0.81

Composite
0.89 0.89 0.91 0.86 0.85 0.85 0.87
reliability

Convergent
0.62 0.59 0.67 0.61 0.65 0.75 0.63
validity
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 303

Table 3: Factor loadings of Psychological Performance Inventory items after deletion of items with poor
reliability and validity

Visualization Negative Positive

Self- Attention Attitude
Observed and imagery Motivation energy energy
confidence control control
control control control

1 0.68 0.77 0.70 0.85 0.88

2 0.74 0.77 0.81 0.83 0.84

3 0.80 0.76 0.89 0.79 0.93 0.73

4 0.82 0.84 0.80 0.76 0.79 0.71

5 0.81 0.72 0.74

6 0.74 0.81 0.82 0.84

Table 4: Regression (β) path coefficients, t-statistics, and p-values for model paths obtained by estimating
standard errors

Standard
Original Sample
Mental Toughness (PPI) deviation t (|O/STDEV|) p
sample (O)* mean (M)
(STDEV)

Attention Control → Mental Toughness 0.09 0.08 0.04 2.038 0.043

Attitude Control → Mental Toughness 0.16 0.14 0.09 1.778 0.077

Motivation Level → Mental Toughness 0.28 0.27 0.06 4.572 0.000

Negative Energy Control → Mental Toughness 0.14 0.12 0.08 1.729 0.085

Positive Energy Control → Mental Toughness 0.12 0.10 0.07 1.715 0.088

Self Confidence → Mental Toughness 0.28 0.26 0.07 3.828 0.000

Visual Imagery → Mental Toughness 0.33 0.31 0.07 4.281 0.000

*Original Sample (O): Path Coefficients

Discussion assessing mental toughness. 21,22 We found that only

29 of the original 42 items of the PPI were relevant to
Mental toughness is a key quality for athletes, measuring mental toughness in Indian elite athletes.
especially the elite level, where the margin for victory Following removal of the other 13 items, we were able
can be millimetres or milliseconds. to confirm the convergent and discriminant validity
of the seven factors through an examination of the
The PPI has been used in a number of empirical
individual parameter estimates. Furthermore, the internal
studies and is recommended as a useful instrument for
 304 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

consistency coefficients of the seven factors were display, direct their attention appropriately, and extract
satisfactory, indicating that all subscales were internally meaning from these areas efficiently and effectively.
consistent. Taken together, the scale items appeared to
be suited to assessing mental toughness. The psychometric support found for the PPI
after item reduction in an Indian context can increase
Affective skills help athletes maintain a strong faith researchers’ confidence in the instrument’s usability to
in their ability to achieve a set goal, despite the low odds evaluate elite athletes in India in both future research
and lack of success 6. This faith does not appear to fade and professional practice. It could be used in developing
even in the face of self-doubt about their performance or mental training programmes that place emphasis on
questions posed by others about their poor performance. assessing and training cognitive skill, in addition to
These athletes remain in a state of optimal motivation, affective skills.
confidence, and control. 23 which helps them overcome
and rebound from adversities and failure. In the present The results of our study suggest that a probable
study, the subscales corresponding to the affective cause of the lack of success among elite Indian athletes
skills—motivational, visualization and imagery control, is their excessive focus on affective skills, neglect
and self-confidence—made strong contributions to of cognitive skills, when they are developing mental
the construct of mental toughness among elite Indian toughness. Balancing affective and cognitive skills is the
athletes. Of these, self-confidence and visualization and way to improve mental toughness, and may help to bring
imagery control were dominant, although motivation consistent success for Indian athletes at the international
still had a high and significant contribution. By level.
contrast, the cognitive skills of attitude control, positive
energy control, and negative energy control did not
Conclusion
have significant contributions; attention control did The lack of success among elite Indian athletes is
have a significant contribution, but it was somewhat their excessive focus on affective skills, to the neglect of
weak. These findings show that the Indian athletes are cognitive skills. Balancing affective and cognitive skills
continuously trying and motivated to achieve success via is the way to improve mental toughness,
affective skills, rather than by relying on their cognitive
skills. Conflict of Interest- NIL

However, during competition, the difference Ethical Clearance: It was obtained from Amity
between winners and losers at the elite level is not Institute of Psychology and Allied Sciences, Amity
a matter of motivation rather, it is down to their level University Noida, UP, India
of cognitive skills. Such skills allow athletes to assess
and understand the situation, and then act accordingly.
References
Numerous researchers have shown that successful 1. Bloom, SB, Max D. Engelhart, MD. Furst EJ,
athletes utilize cognitive skills to effectively deal with Hill WH, David RK. Taxonomy of educational
challenges, stressors, and pressure, irrespective of the objectives: The classification of educational goals:
prevailing circumstances 13. Studies have also shown handbook I: cognitive domain. New York, US: D.
that reliance on affective skills particularly a higher Mckay, 1956.
motivational intensity can weaken cognitive skills and 2. CôTé J. Lidor R, Hackfort D. ISSP position stand:
lead to poor decision making 24. Higher-than-optimal To sample or to specialize? Seven postulates
motivational levels can make a person act hastily and about youth sport activities that lead to continued
hurry without analysing the situation; this makes them participation and elite performance.” International
more result-oriented in their approach, as opposed to Journal of Sport and Exercise Psychology.
process-oriented. 25 2009;7(1): 7-17.
The results of this study might be useful for 3. Aoyagi MW, Portenga ST. The role of positive
facilitating athletes’ reflection on their lack of specific ethics and virtues in the context of sport and
cognitive skills, which may be a reason for their limited performance psychology service delivery.
success in international competitions. Athletes must be Professional Psychology: Research and Practice.
able to identify the most information-rich areas of their 2010; 41(3):253-59.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 305

4. Loehr J E. Athletic excellence: Mental toughness university teams. Ovidius University Annals, Series
training for sport, Forum publishing company, Physical Education and Sport/Science, Movement
1982. and Health.2012; 12(2):193-198
5. Sugarman, K. Winning the mental way: A practical 16. Patil, A, Pasodi MS. Performance of Male and
guide to team building and mental training. Step Up Female Athletes at All India Inter-University
Pub, 1999. Athletic Meet. International Journal of Sports
6. Clough PJ, Earle K, Sewell D. Mental toughness: Science.2012; 2(4):42-44.
The concept and its measurement. In I. Cockerill 17. Yadav, Angad, Deepak Mehtaa, Bharat Verma, and
(Ed.), Solutions in Sport Psychology, London: E. Sameer Bhagirathi. A study of mental toughness
Thomson.2002: 32-43. of high and low level cricket players of madhya
7. Bull SJ., Shambrook CJ, Wil James, Brooks JE. pradesh. International Journal of Sports Sciences
Towards an understanding of mental toughness in and Fitness.2013; 3(1):139-151
elite English cricketers. Journal of applied sport 18. Khan Z, Ali A, Ahmed N. Aggression and mental
psychology.2005;17(3):209-227. toughness among Indian Universities basketball
8. Crust L, Clough PJ. Relationship between mental players: A comparative study. Journal of Physical
toughness and physical endurance. Percept Mot Education Research. 2015;2(3):53-61
Skills. 2005 Feb;100(1):192-4. 19. Gupta S. A critical analysis of mental toughness
9. Jones G, Hanton S, Connaughton D. A framework and will to win between throwers and jumpers:
of mental toughness in the world’s best a psychological probe. International Journal
performers. The Sport Psychologist.2007; 21(2): of Behavioral Social and Movement Sciences.
243-264. 2013;2(2): 162-168.
10. Connaughton, Declan, Ross Wadey, Sheldon 20. Jagat Reddy RC, Berhanu T. Mental toughness
Hanton, and Graham Jones. The development and in sport: In case of Mekelle university sport
maintenance of mental toughness: Perceptions of teams. International Journal of Applied Research
elite performers. Journal of sports sciences 26, no. 2016; 2(3): 01-03
1 (2008): 83-95. 21. Loehr JE. Mental Toughness Training for Sports:
11. Jones G. What is this thing called mental toughness? Achieving Athletic Excellence. Lexington, MA:
An investigation of elite sport performers. Journal Stephen Green Press. 1986
of applied sport psychology.2002;14(3): 205-218. 22. Golby J, Sheard M. Mental toughness and hardiness
12. Thelwell R, Weston N, Greenlees I. Defining at different levels of rugby league. Personality and
and understanding mental toughness individual differences.2004; 37(5): 933-942.
within soccer. Journal of Applied Sport 23. Goldberg AS. Sports slump busting. Human
Psychology.2005;17(4): 326-332. Kinetics in Champaign, IL , 1998.
13. Gucciardi, DF. Hanton S, Gordon S, Mallett CJ, 24. Harmon-Jones E, Gable PA, Price TF. Does negative
Temby P. The concept of mental toughness: tests affect always narrow and positive affect always
of dimensionality, nomological network, and broaden the mind? Considering the influence of
traitness. Journal of Personality.2015;83(1): 26-44. motivational intensity on cognitive scope. Current
14. Middleton CS, Martin AJ, Marsh HW. Development Directions in Psychological Science.2013; 22(4):
and validation of the mental toughness inventory 301-307.
(MTI). Mental toughness in sport: Developments in 25. Harmon-Jones E, Gable PA, Price TF. Toward an
research and theory. Publisher: Taylor and Francis, understanding of the influence of affective states
Editors: Gucciardi, and Gordon, pp.91 on attentional tuning: Comment on Friedman and
15. Tomar R, Tiwari S, Tiwari S, Hamdan M. Mental Förster(2010). Psychol Bull. 2011 May;137(3):508-
toughness: a comparative study on KFUPM 12
 306 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

An Assessment of Trust in Medical Profession Amongst People

Residing in A Semi-Urban Area,Tamil Nadu

Taseen Sida.A.S1, Alice Matilda Mendez2, Nisha B2, Timsi Jain3

13rdyear MBBS, Saveetha Medical College and Hospital, Thandalam, TamilNadu, 2Assistant Professor, 3Professor
and Head , Department of Community Medicine , Saveetha Medical College and Hospital, Thandalam, Tamil Nadu

Abstract
Introduction: The fundamental basis in health care system and relationship is Trust. Trust is a
set of expectations that the health care provider will do the best for the patient.The word “Trust”
has been in a state of crisis over the last decade in India particularly in medical profession.
Unlimited and implicit access to health care system and medical information from a varied
range of source helps patients in one way and in contrary to that it may also misinform and
adversely affect “Trust” in medical profession.
Objectives

• To assess trust in medical profession among people (>18years ) residing in a semi urban
area of TamilNadu.

• To assess the factors affecting Trust in medical profession.

Methodology: A community based cross-sectional study was conducted during February 2019 in
Thirumazhisai , a semi-urban township in Chennai. 150 Men and Women above 18 years were included in
the study. Data Collection was done using semi structured questionnaire. TMP(Trust in Medical Profession)
scale was used to measure trust in medical profession.

Result: 56.4% have good trust on Doctors and 44.33% have trust lower than the expected score based on
TMP scale. Trust was higher among unemployed, women , people below poverty line , those not suffering
from chronic illness though statistical association could be established only with socio economic status(p
0.04) and system of medicine followed (p 0.01).

Conclusion: The trust in doctors have largely been reduced and hence understanding this would lead to
better ways of responding to patients requests that preserve or enhance patients trust, leading to better
outcomes.

Key words: trust in medical profession, TMP scale, semi urban area.

Introduction that the health care provider will do the best for the
patient. Research shows that the number of hospital jobs
The fundamental basis in health care system and
increased by 306% in 2015 and hence it’s the high time
relationship is Trust. Trust is a set of expectations
that we focus on the basis “TRUST “(1). The word “Trust”
has been in a state of crisis over the last decade in India
Corresponding Author : particularly in medical profession. Generally public in
Dr. Alice Matilda Mendez today’s world have unlimited and implicit access to
Assistant Professor, Department of Community health care system and medical information from a varied
Medicine, Saveetha Medical College and Hospital, range of source, this access helps patients in a way and
Thandalam, Tamil Nadu in contrary to that it may also misinform and adversely
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 307

affect “Trust” in medical profession. Views also varied point likert scale
by sex, age, health, education, income, number of visits/
years with physician, past dispute with a physician, and ( Table 1) with responses grading from Strongly
satisfaction with care (2). Trust also depends on patients agree,Agree,Disagree,Strongly disagree.Here
willingness to seek care , reveal sensitive information , maximum score is 1 for strongly agree and 2,3 and 4
submit to treatment and follow physician. Measurement for agree, disagree and strongly disagree respectively.
of trust also suggest an important tool for monitoring In the questionnaire the negative format question is also
performance of individual providers and health plans changed and recoded according to the format above.
(3)
. Trust in doctors is found to have five main domains: Total TMP score was calculated for each individual by
Fidelity, competence, honesty , confidentiality and adding the scores of the 11 questions. The maximum
global trust (4). Importance of studying Trust is twofold possible score would be 44 (least trust) and minimum
– at macro-level , Trust is an indicator of support for score will be 11 (maximum trust) Mean score was taken
the health system and changes in the health system and as the cut off for categorising into good trust( a score less
at micro-level, there is relationship between trust and than mean ) and reduced trust (score more than mean).
peoples’ behaviour in real choice situations. The study was initiated after obtaining approval
from institutional ethical committee of Saveetha Medical
Methodology College. Informed consent was obtained from the study
A community based cross-sectional study was participants and confidentiality of data was assured and
conducted in Thirumazhisai, a semi-urban area of maintained throughout the study. Data was entered in
Chennai during February 2019. Thirumazhisai is the Microsoft Excel and analysed using SPSS software.
urban field practice area under department of Community Qualitative data is expressed as frequencies and
Medicine , Saveetha Medical College and hospital. The proportions, quantitative data were summarised as mean
study population included men and women who have (standard deviation). Chi-square test was applied for
completed 18 years of age residing in Thirumazhisai bivariate analysis to find association between Trust and
for more than 6 months. Sample size was calculated to qualitative factors like age category, gender, occupation,
be 150 using formula for cross sectional study with an education, socio economic status (APL/BPL), presence
anticipated population proportion of 40 % (5) , confidence of chronic disease and system of medication followed.
level of 95% at 5% significance level and allowable Logistic Regression was done for multivariate analysis.
relative error of 20%. A two stage sampling technique
was used to enrol individuals to the study. There are Results
15 municipal wards in Thirumazhisai and each ward A total sample of 150 people of both men and
has 10 to 15 streets. At the first stage simple random women above 18 years of age were interviewed.
sampling was done to select one street from each ward. Analysis of the demographic data revealed that there
A ward wise list of all the streets was prepared. One were more number of women about 60.66% and males
street was selected by lot method from each of the 15 about 39.33%. Mean (SD) age of the study population
wards . Systematic random sampling was done to select was 43.3 (15.6). Majority of people interviewed were
10 households from each ward . The first family was in the age group of 18-40 years of age(51.33%) . 38 %
selected randomly from street wise list of family folders of the study population were unemployed followed by
maintained in Urban Health Centre of Saveetha Medical 23.3 % unskilled workers. 82% were educated till High
College at Thirumazhisai using random number tables. school or above. 18 % were Below Poverty Line (BPL)
Every third house was visited starting from the randomly with respect to the ration card that was possessed.
selected house till 10 houses were covered . Only one
member (above 18 years) per household was chosen to The mean(SD) TMP score of the study population
avoid cluster bias. was 21.3 (6.214). The maximum score obtained was 37
and minimum was 14. A score below mean (21.3)was
Data was collected orally by interview method considered as “Good Trust” for comparison purpose
using structured questionnaire which included in our study . Among the study population 85(56.7%)
sociodemographic profile and TMP(TRUST IN individuals were found to have “good” trust in medical
MEDICAL PROFESSION) scale(2) to measure trust in profession while 65 (43.3%) had reduced trust. When
Medical Profession. TMP scale is a validated 11-item 4 61% of the males in our study population was found to
 308 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

have good trust , only lesser number of females (53.84% which is similar to study conducted in China by Da-
) had good trust in Medical profession . While all the four Hai Zhao et al showed that the 67% has strongly trusted
participants above 80 years had good trust in Medical and about 33% had reduced trust.(7) Since this is a cross
profession, 62.5% of those in the middle age group sectional study, deducing a continuous trend in long
(40-60) had good trust. Trust did not vary significantly term was not possible. Mean score in this study is 21.3
among the various occupational groups. Trust is higher out of 44 and in the previous study by Da-Hai Zhao et al
amongst those belonging to below poverty line (74.1%) the mean score is 35.4 out of 50 (5 point likert 10 item
while only 52.8% of APL card holders were found to scale)(8) . Here it’s important to note that level of trust
have good trust. Other factors influencing trust also is good in middle age group (40-60) in this study and
were analysed and showed that trust has been slightly is compared to study conducted in north-east Poland by
lower(51.1% ) amongst people having at least one of Marcinowicz et al(9) . Based on the Table- 1 ,question
the chronic diseases(hypertension, Diabetes Mellitus, number 3 “ Doctors are thorough and careful “ scored the
cardiovascular disease, bronchial asthma) and it is 59.2% highest about 68% and shows that the public is confident
amongst people without any chronic disease .Trust also with Doctors knowledge and which is one of the factor
varied according to the system of medicine followed by influences trust in medical profession. Question number
the individuals as shown in Table 2. 8 in Table 1 “Doctors use their best skills and efforts”
scored the least about 42% and shows that public has
Bivariate analysis was done using chi-square to test less confidence in transparency and skills in medical
the statistical association between the various factors profession. During interrogations some people have
and trust in medical profession (table 2). Socioeconomic lower Trust but were reluctant to express to medical
status (p value - 0.04) and system of medicine followed students. Here the reduced trust may be due to recent
by the participants (p value- 0.010) had a significant media coverage of unethical practices by the doctors.
association with Trust. Multivariate analysis by logistic
regression with “good trust” as the dependant variable Factors affecting trust was studied and there
did not reveal significant association with any of the is statistical significance obtained between two
independent variables. independent variables ,socio economic status and the
system of medications followed and Trust. Economic
The most important quality of a doctor that can factors were found to be determinant of trust in doctors
influence the trust in medical profession as perceived by studies done by Birkha et al and Gopichandran (10,11)
by the study participants were as follows: 44% of the . Another study done in older population by Guerrero et
participants perceived verbal communication as most al also showed similar result (12). Consistent results with
important followed by behavioural competence(25%), association of trust in medical profession and system of
comfort level(16%) and simple elegant appearance(15%). medicine were not available. In this study participants
Question number 11 in TMP (table 1) which individually perceived verbal communication and behavioural
measures the over all trust showed that 74% of the competence as more important and physical appearance
study participants agreed that they “trusted their doctor as less important factor in influencing trust. Similar
completely”. results were seen in another study done in rural and
urban setting of Tamil Nadu(13) .
Discussion
A cross sectional study was done to assess “trust in One of the limitations of this study is that it
medical profession” among adults population in a semi- was conducted in a single geographic area . The
urban township of Chennai, TamilNadu. Proportion of representativeness of study population was not adequate
females and unemployed persons were more in our study as the data collection was done during day time and
population when compared to census figures of Tamil hence the responses of males and working group could
Nadu.(6) This may be due to the reason that the data not be captured fully.
collection was done during day time when males who
Conclusion
were engaged at their occupation were not available at
household . In this study based on the score calculated The final outcome from this study is that 56.7%
trust in medical profession is found to be 56.7% have has good trust and 43.3% have reduced trust in medical
good trust and about 43.3% have reduced trust and profession. Trust have been higher among unemployed,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 309

women , people below poverty line, those following alternate systems of medicine and those not suffering from
chronic illness though statistical association could be established only with socio economic status(p 0.04) and system
of medicine followed (p 0.01). Doctor’s verbal communication skills was perceived by majority(44%) of the study
participants as the most important quality that would determine trust in medical profession which should be focused
on . The study would recommend the medical professionals to build up a close relationship with their patients
and be still more transparent to avoid unethical issues. The trust in doctors have largely been reduced and hence
understanding this would lead to better ways of responding to patients requests that preserve or enhance patients
trust, leading to better outcomes.

Table-1 : 11-item Trust in Medical Profession( TMP scale)

1. Doctors care their patients health more than or as similar to their parents

2. Doctors care more about their convenience than their patients medical need

3. Doctors are thorough and careful

4. Completely trust Doctors about which medical treatments are best

5. Doctors are honest in telling their patients about different treatment option available

6. Doctors think about what is best for their patients

7. Doctors do not pay full attention to what patient tells

8. Doctors use their best skills and efforts

9. You have no worries on putting your life in Doctors hand

10. Doctors would never mislead you about anything

11. You trust your doctor completely

Table-2: Factors associated with trust in medical profession

Factors Good trust n(%) Reduced trust n(%) P value (chi-square)

Age
18-40 42(54.5%) 35(45.5%)
40-60 30(62.5%) 18(37.5)
0.139
60-80 9(42.9%) 12(57.1)
>80 4(100%) 0(0%)
Gender
Male 36(61%) 23(39%)
0.387
Female 49(53.8%) 42(46.2%)
Occupation
Professional 4(66.7%) 2(33.3%)
Semi-professional 9(47.4%) 10(52.6%)
Skilled 21(63.6%) 12(36.4%) 0.717
Semi-skilled 21(60%) 14(40%)
Unemployed 30(52.6%) 27(47.4%)
Socioeconomic status
APL 65(52.8%) 58(47.2%)
0.044*
BPL 20(74.1%) 7(25.9%)
 310 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Cont... Table-2: Factors associated with trust in medical profession

System of medication
Allopathy 65(55.6%) 2(44.4%)
Homeopathy 1(12.5%) 7(87.5%)
0.010*
Ayurveda 15(71.9%) 6(28.1%)
Unani 4(100%) 0(0%)
Chronic disease
Present 24(51.1%) 23(48.9%)
0.224
Absent 61(59.2%) 42(40.8%)
*significant at p<0.05
2. Hall MA, Camacho F , Dugan E, Balakrishnan R.
Trust in the medical profession: conceptual and
measurement issues. Health ser Res 2002;37:1419-
39.
3. Thom DH, Hall MA, Pawlson LG. Measuring
patients’ trust in physicians when assessing quality
of care. Health Aff(Millwood) 2004;23:124-32.
4. Steven D Pearson. Patients’ Trust in Physicians:
Many theories, Few Measures and Little Data.
Boston : Journal of General Internal Medicine;2000
Figure-1 : Distribution of trust in medical profession
jul;15(7):509-513
5. Collier R. Professionalism: the importance of trust.
CMAJ.2012;184(13):1455-1456.doi:10.1503/
cmaj.109-4264.
6. Census2011coin.
Census2011coin. [Online]. Availablefrom:
https://www.census2011.co.in/census/state/.html
[Accessed 10 September 2019]
Figure-2 : Perceived quality of a doctor that influence trust 7. Yi Yong Lee , Choon Ta Ng, M Ghazalie siti
Conflict of Interest – NIL Aishah. Public Trust in primary care doctors,the
medical profession and the Health care system
Source of Funding- NIL
among Redhill residents . Singapore: Annals of the
Ethical Clearance – Approval was obtained from Academy of Medicine; 2007;36(8):655-61.
Institutional Research Board of Saveetha Medical 8. Researchgatenet. Research Gate. [online]. Available
College and Hospital , Thandalam , Chennai. from: https://www.researchgate.net/ publication/
298918284_Patient_Trust_in_Physicians_
References Empirical_ Evidence_ from_Shanghai_ China
1. John. Right Patient. An Essay on Right patient [accessed on10 September 2019]Researchgatenet.
http://www.rightpatient.com/blog/6-things- ResearchGate. [Online]. Available from: http://
medical-institutions-gain-patient-trust/ [ Accessed lup.lub.lu.se/search/ws/files/ 24176727/24176687.
: 10 August 2019. pdf [Accessed 10 august 2016]
10. Birkha ̈uer J, Gaab J, Kossowsky J, Hasler S,
Krummenacher P, Werner C, et al. (2017) Trust in
the health care professional and health outcome:
A meta-analysis. PLoS ONE 12(2): e0170988.
doi:10.1371/journal.pone.0170988.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 311

11. Gopichandran V, Chetlapalli SK. Dimensions and doi:10.1111/jgs.13316

determinants of trust in health care in resource 13. Gopichandran V, Chetlapalli SK. Factors influencing
poor settings--a qualitative exploration. PLoS trust in doctors: a community segmentation strategy
One. 2013;8(7):e69170. Published 2013 Jul 16. for quality improvement in healthcare. BMJ Open.
doi:10.1371/journal.pone.0069170 2013;3(12):e004115. Published 2013 Dec 2.
12. Guerrero N, Mendes de Leon CF, Evans DA, Jacobs doi:10.1136/bmjopen-2013-004115
EA. Determinants of trust in health care in an older
population. J Am Geriatr Soc. 2015;63(3):553–557.
 312 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Effectiveness of Eccentric Exercises on Selfie Elbow

Tharani.G1, Rajalaxmi.V², Yuvarani.G1, Kamatchi.K1, Lakshmiprabha.P3,

1Assistant Professor, 2Professor, 3B.P.T Student, Faculty of Physiotherapy, Dr.M.G.R Educational and Research
institute, Vellapanchavadi, Chennai, Tamilnadu, India

Abstract
Background: Selfitis is an genuine mental condition where people have an obsessive-compulsive desire
to take photos of one self and post them on social media as a way to make up for the lack of self- esteem.
While clicking a selfie, there is always a possibility that by incorrect stretching of the tendons, an injury can
occur to joints like the elbow. Selfie elbow is more of an abnormal and repetitive loading of muscles around
elbow, leading to micro ruptures, which cause inflammation and pain. Hence, this study intended to analyze
the effects of eccentric exercises on selfie elbow.

Aim: To analyze the effectiveness of eccentric exercises on selfie elbow.

Method: This is an experimental study done in Faculty of physiotherapy, Dr.M.G.R Educational and
Research Institute. After approval of the study by Institutional Review Board, both male and female with
severe selfitis (using selfie behaviour questionnaire) between 18-21 years having pain on lateral epicondyle
& lateral forearm with positive cozens were included in the study. The subjects with any musculoskeletal
injuries, neurological disorders and having pain due to other reasons were excluded. Eccentric exercises
protocol was given for four weeks along with patient education program. All the exercises was performed
5times/weeks, 3 sets, 1 set = 15 rep, 1 min rest between each Set

Results: A Positive Association was found between the selfie behaviour scale & oxford elbow pain
questionnaire in subjects with selfitis and on comparing the oxford elbow pain questionnaire score significant
improvement in the post test mean value was seen which suggest that eccentric exercise program is effective
in selfie elbow.

Conclusion: The result of this study suggests that proper patient education and eccentric exercise program
among selfie takers with sefie elbow will reduce the pain over the lateral epicondyle.

Keywords: Selfie, Selfitis, elbow pain, Selfie elbow, Selfie behaviour questionnaire, Eccentric exercises,
Oxford elbow pain question

Introduction up for the lack of self-esteem.1 Selfie takers trust that

selfies could boost their self-confidence, the number
Selfitis is an genuine mental condition where people
of positive comments and likes in social media will
have an obsessive-compulsive desire to take photos of
increase self-confidence level. It may lead to orthopedics
one self and post them on social media as a way to make
complications like carpal tunnel syndrome, tennis elbow,
frozen shoulder etc.2 Like tennis elbow or golfer’s
Corresponding author: elbow, an addition to selfie-taking can cause a pain in the
Tharani.G, elbow due to primary pic- snapping3. The selfie statistics
M.P.T (Neuro), Assistant Professor, Faculty of indicated that about half (47%) of adults were taking
Physiotherapy, Dr.M.G.R Educational and Research selfies about 40% of people between 18 and 34 years
Institute, Vellapanchavadi, Chennai- 6000077, admitted of taking selfies at least once per week. At the
Tamilnadu, INDIA, Phone- +919003653330 same time, women are believed to take selfies 1.3 times
E-Mail: [email protected] more than men4.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 313

Taking selfies involves an unusual arm position and categorizing the disorder of selfitis into borderline,
with excessive forearm pronation and repeating the act acute and chronic selfitis. Pre and post selfie elbow
eventually put strain over the elbow muscles and pressure pain was assessed using oxford elbow questionnaire.
on the bone, leading to inflammation and excruciating The Oxford elbow questionnaire comprises three
pain5. Due to this abnormal and repetitive loading of unidimensional domains: elbow function, pain and
muscle there are micro ruptures around the elbow even social-psychological, with each domain comprising four
by minimal stress3. The smart phone is not that heavy items with good measurement properties. As there is
but during selfie the wrist is in awkward position that dearth of research on selfie elbow, this study intended to
will lead to injury, so using selfie stick while taking find whether eccentric exercise is effective in reducing
selfie will reduce injury. The proper positioning of the symptoms of selfie elbow.
elbow and patient education can reduce the risk of selfie
elbow. Clinical signs make diagnosis and symptoms Methodology
that are discrete and characteristic with the elbow fully This is an experimental study done in Faculty of
extended, the patient feels point of tenderness over physiotherapy, Dr.M.G.R Educational and Research
the affected point on the elbow, which is the origin of Institute. After approval of the study by Institutional
the extensor carpi radialis brevis muscle in the lateral Review Board, both male and female with severe
epicondyle. There is also pain with passive wrist flexion selfitis (using selfie behaviour questionnaire) between
and resistive wrist extension. 18-21 years having pain on lateral epicondyle & lateral
Eccentric exercise can help to heal tendon injury forearm with positive cozens were included in the study.
including chronic tendinitis6. It effectively lengthens After the initial assessment the pretest score of elbow
muscle tendon, increase tensile strength of the pain questionnaire was taken for all the subjects. Then
tendon, and reduce pain7. Eccentric exercises provide all the subjects underwent 4 weeks of eccentric exercise
neuromuscular benefits through central adaptation of training program. All the exercises were performed 5
both agonist and antagonist muscles8. It also provides times a week, 3 sets with 1 min rest between each set
structural and functional benefits during tendinopathy (1set = 15 rep). The patient education program regarding
rehabilitation9. It will increase the muscle strength10. proper positioning of mobile phone for taking selfie was
given. At the end of 4 week, the posttest score of elbow
Selfie behaviour scale appears to a reliable and valid pain questionnaire was taken.
instrument that was used in this study for assessing selfitis

Eccentric Exercises:

PHASE:1 PHASE:2
With forearm supported on a table, the subjects were asked to lift The subjects were asked to take the unaffected hand away and
the wrist up with the unaffected hand. slowly lower and repeat this process for each repetition.

Addition of Weights:

PHASE:1
PHASE:2
The subjects were asked to keep the elbow at 90 degrees and
The subject were asked to turn the forearm so that your palm
locked in at the side and hold the weight with the forearm in a
faces the ceiling. Return to the starting position. Repeat this
neutral position.(palm neither facing floor or ceiling and lift the
process for every repetition.
wrist up and down.

Patient Education Use bilateral arms: Prefer using both arms instead of
over using dominant arm.
Pre selfie stretches: Stretch wrist extensor and
flexors muscles priors to clicking selfies. Selfie sticks: Prefer using selfie stick instead of
extending your elbow.
Alternate the arms: Keep switching your arm to
prevent over stress
 314 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Avoid prolonged posture maintenance: Keep The above table reveals the Pearson Correlation
changing your posture. of coefficient ‘ r ‘ value and p-value within subjects
between Selfie Behaviour Scale & Oxford Elbow Pain
Data Analysis Questionnaire.
The collected data were tabulated and analyzed There was a positive correlation between Selfie
using both descriptive and inferential statistics. All Behaviour Scale & Oxford Elbow Pain Questionnaire
the parameters were assessed using statistical package in subjects with selfitis. The Selfie Behaviour Scale
for social science (SPSS) version 24. Paired t-test was had the strongest correlation with Oxford Elbow Pain
adopted to find the statistical difference within the Questionnaire within subjects. (P ≤ 0.05)
groups & Pearson Correlation of coefficient was adopted
to find the Correlation between Selfie Behaviour Scale & (Graph-II).
Oxford Elbow Pain Questionnaire.

Table - 1: Pearson Correlation of Coefficient

between Selfie Behaviour Scale & Oxford Elbow
Pain Questionnaire in Subjects with Elbow Pain.

Subjects
Parameters
‘r’ value P value

SBS 0.417 ≤ 0.05

OEPQ 0.555 ≤ 0.05

(#SBS - Selfie Behaviour Scale, OEPQ - Oxford Graph - I: Pearson Correlation of Coefficient between
Elbow Pain Questionnaire) Selfie Behaviour Scale & Oxford Elbow Pain
Questionnaire in Subjects with selfitis.
Table - 2

PRE TEST POST TEST

#OEPQ t – TEST SIGNIFICANCE
MEAN S.D MEAN S.D

SUBJECTS 35.10 2.68 57.10 2.48 -35.83 .000***

OEPQ - OXFORD ELBOW PAIN QUESTIONNAIRE SCORE

(***- P ≤ 0.001)
The above table reveals the Mean, Standard Results
Deviation (S.D), t-value and p-value within subjects A Positive Association was found between the Selfie
between pre-test and post-test values. Behaviour Scale & Oxford Elbow Pain Questionnaire
in subjects with selfitis. The Selfie Behaviour Scale
Oxford Elbow Pain Questionnaire Score shows
had the strongest correlation with Oxford Elbow Pain
that there is a statistically highly significant difference
Questionnaire within subjects at (P ≤ 0.05).
between the pretest and posttest values within subjects

(***- P ≤ 0.001).(Graph-I)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 315

On comparing the Oxford Elbow Pain Questionnaire between selfitis and selfie elbow and proper positioning
Score within Subjects between Pre & Post Test Values, of the mobile phones during selfie taking and exercise
it shows significant improvement in the Post Test Mean training can prevent its occurrence.
values (57.10) when compared with pre test mean values
(35.10) at P ≤ 0.001. Hence Null Hypothesis is rejected. Acknowledgement: We thank Dr.M.G.R
Educational and Research institute for granting
Discussion permission for doing this research work at ACS
medical college and hospital. Our sincere thanks to
While clicking a selfie, the awkward position of arm Dr.Senthilnathan, Principal, Faculty of physiotherapy
and repetitive loading of muscles around the elbow leads for his support and guidance in completion of this work.
to micro ruptures, which cause pain and inflammation
around the elbow. Hence, this study intended to analyze Ethical Clearance- Taken from institutional review
the effects of eccentric exercise on selfie elbow. board committee, Dr.M.G.R Educational and Research
institute.
The common symptom reported by the subjects
where pain and tenderness over the extensor origin. The Source of Funding- Self
reason behind this seems to be abnormal stretching of
tendon and repeated high movements of force beyond Conflict of Interest - Nil
the adaptive capacity of the tissue because progressive
References
degeneration as previously stated by Lee DG11. In most
of the subjects, tenderness was present over the lateral 1. Balakrishnan, J. & Griffiths, M. D. An
epicondyle. It is because the muscle undergoes micro Exploratory Study of “ Selfitis “ and the Development
rupture easily at its attachment to the bone rather than of the Selfitis Behavior Scale An Exploratory Study of
at muscle belly. B Selfitis ^ and the Development of the Selfitis Behavior
Scale. Int. J. Ment. Health Addict. (2017). doi:10.1007/
P.Malliaras et al in his study stated that eccentric s11469-017-9844-x
exercises help to reduce and manage tenderness and pain
by increasing the strength at the angle of contraction 2. Vats, M. Selfie syndrome : an infectious gift of
without producing any discomfort or worsening the IT to health. J. Lung, Pulm. Respir. Res. 2, 70–71 (2015).
inflammatory12. The findings of this study was similar
to that showing reduction in intensity of pain after the 3. IANS. ‘ Selfie Elbow ’ condition waiting
eccentric exercise training. The loads of exercises were to afflict Indians. INDIAN EXPRESS 3–9 (2016). at
increased as the patient symptoms declined. Patients <2/18/2019 ‘Selfie Elbow’ condition waiting to afflict
performed the exercise at low speed, because slow Indians %7C Lifestyle News, The Indian Express
and static stretching enhances tissue healing and gives Advertising ‘Sel?e Elbow’ condition waiting to af?ict
comfort to the patient. Indians%0AEven minimal stress can initiate severe pain
in your elbow. This leads to painful inhibiti>
In this study patient who followed the patient
education after the eccentric exercise training reported 4. Sai krishna G, K. krishna. . Selfie Syndrome : A
less recurrence of pain. Charles kim suggested that Disease of New Era Research in Pharmacy and Health
the selfie takers, using a selfie stick can work like an Sciences Review Article Selfie Syndrome : A Disease of
arm extensor and take the pressure off the elbow and New Era. Res. Pharm. Heal. Sci. (2017).
stretching the wrist extensor and flexors before taking 5. Mitral, P. Now, ‘selfie elbow’ becoming new
selfie and alternating and using bilateral arms while medical condition. The Times of India 2–4 (2016).
taking selfie prevent over stress on elbow13. at <http://timesofindia.indiatimes.com/city/kolkata/
This study revealed that through proper patient Now-selfie-elbow-becoming-new-medical-condition/
education and eccentric exercise training the occurrence articleshow/53136829.cms>
of selfie elbow can be reduced. 6. Page, P. a New Exercise for Tennis Elbow
2010. North Am. J. Sport. Phys. Ther. 5, 189–193
Conclusion
7. Stanish, W. D., Rubinovich, R. M. & Curwin, S.
This study reveals that there is a strong correlation
 316 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Eccentric Exercise in Chronic Tendinitis. Clin. Orthop. 10. Nuhmani, S. & Bashir, F. Therapeutic management
Relat. Res. NA;, 65???68 (1986). of tennis elbow. Saudi J. Sport. Med. 15, 13 (2015).
11. Lee, D. G. “Tennis Elbow”: A Manual Therapist’s
8. M, P., A, M. & NA, M. Central versus peripheral
Perspective. J. Orthop. Sport. Phys. Ther. 8, 134–
adaptations following eccentric resistance training.
142 (2013).
Int. J. Sports Med. 23, 567–574 (2002).
12. Malliaras, P., Maffulli, N. & Garau, G. Eccentric
9. Fernández-Carnero, J., Fernández-De-Las-Peñas,
training programmes in the management of lateral
C., De La Llave-Rincón, A. I., Ge, H. Y. & Arendt-
elbow tendinopathy. Disabil. Rehabil. 30, 1590–
Nielsen, L. Prevalence of and referred pain from
1596 (2008).
myofascial trigger points in the forearm muscles in
patients with lateral epicondylalgia. Clin. J. Pain 13. Bilone W. Young. Move Over Tennis Elbow – Here
23, 353–360 (2007). Comes ‘ Selfie ’ Elbow. Orthopedics this week 1–2
(2016). at <https://ryortho.com/breaking/move-
over-tennis-elbow-here-comes-selfie-elbow/>
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 317

Evaluation of Cyclic Fatigue Resistance of Three Different Niti

Rotary Systems-An Invitro Study

Thirunavukkarasu Manojkumar1, Paramasivam Vivekanandhan2, Malarvizhi Dhakshinamoorthy 3,

Ramachandran Tamilselvi4, Arunajatesan Subbiya5
1Post graduate Student, 2Professor, 3Assistant Professor, 4Reader, 4HOD & Professor, Department of Conservative
dentistry and Endodontics, Sree Balaji Dental College and Hospital, Bharath University, Chennai

Abstract
Aim: The aim of this study is to compare and evaluate the cyclic fatigue resistance of 3 different Nickel
Titanium rotary file systems: Hyflex CM, Neoendo Flex files and ProTaper Gold by static method in three
different curvatures, namely, 45º,60º and 90º.

Materials and Method: Thirty Hyflex CM (25/.06), Thirty Neoendo Flex (25/.06) and Thirty Protaper
Gold (25/.08) instruments were included in this study. The static cyclic fatigue test was performed using a
custom-made jig. The artificial canal is made of stainless steel jig with an inner diameter of 1.5mm, a 450,
600, 900 angles of curvature and radii of curvature of 5 mm. All the instruments were rotated according to
manufacturer’s recommendations until failure occurred. The time taken to failure was recorded in seconds
for each group using a digital chronometer. The data were analyzed statistically using one way ANOVA,
Post hoc test of Bonferroni was performed to identify pair-wise significance via SPSS 21.0 software (SPSS
Inc, Chicago, IL). The statistical significance was set at 5%.

Result:In 45º and 60º Hyflex CM and Neoendo Flex are better than Pro Taper Gold. At 90º, Neoendo Flex
is better than Hyflex CM (P< .05)

Conclusion: Within the limitation of this study, it can be concluded that, Neoendo Flex files exhibited
highest cyclic fatigue resistance at 90º angle of curvature. In 45º and 60º angle of curvature Neoendo Flex
files and Hyflex CM rotary instrument were more resistant to cyclic fatigue. Protaper Gold showed the least
cyclic fatigue resistance than the other files tested.

Key Words: Cyclic fatigue, Nickel Titanium alloy, Neoendo flex, Protaper Gold, Hyflex CM, Instrument
design.

Introduction NiTi instruments are relatively superior to

previously used manual stainless steel instruments and
The introduction of nickel-titanium rotary (NTR)
its use increases the success rate of root canal treatment
instruments have vastly influenced endodontic practice
compared to stainless steel hand instruments.2
by the virtue of its speed, quality, accuracy, and reduction
in risk during the vital phase of chemo mechanical root In spite of their advantages, NTR instruments
canal preparation.1 possess a high risk of fracture, especially in curved
canals. Instrument fracture in clinical practice used
multiple times has an incidence of 0.39% to 21% (Shen
Dr. D.Malarvizhi MDS, et al.2013) The problem is compounded by sudden,
Corresponding author: unexpected fracture without any previous permanent
Assistant Professor deformation or another visible warning signs. Radius
Department of Conservative dentistry and Endodontics, and angle of curvature, instrument size and cross-
Sree Balaji Dental College and Hospital, Bharath sectional area, rotational speed, design, technique and
University, Chennai 600100 operator experience, torque, metal surface treatments,
 318 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

and metallurgical characterization of the NiTi alloys are Cyclic fatigue testing device:
the variables that contribute to file separation.3
The static cyclic fatigue test was performed using a
Though both flexural fracture and torsional fracture custom-made jig fabricated for this study. The artificial
occur simultaneously, studies have found cyclic fatigue canal was made of stainless steel, with an inner diameter
to be the cardinal cause of file separation accounting for of 1.5 mm, total length of 20 mm and an arc at the end
50% - 90 % of mechanical failures.4 with a curvature radius of 5 mm which simulates the
instrument size and taper. This steel jig was constructed
The cyclic fatigue resistance is improved by altering in order to retain the rotary instruments within the canal
the metallurgy, design, kinematics of the files and heat groove by means of a metal frame. It is enveloped by a
treatment of file.5 glass fiber screwed on either side in order to prevent the
Hyflex CM (Controlled Memory) NiTi files (Coltene instrument from distortion. The jig is constructed with
/ Whaldent, Switzerland) was introduced in 2010. This 5mm radius of curvature and 45º, 60º and 90º angles of
CM thermomechanical surface treatment makes the files curvature to provide a suitable trajectory with curved
extremely flexible without rebound providing superior segment of canal being 6mm in length (Figure 1).
canal tracking and more resistance to cyclic fatigue than
non –CM NiTi files.6

Neoendo flex files(Orikam Healthcare India Private

limited) are recently introduced files designed with a
triangular cross section and a proprietary heat treatment
rendering them highy flexible. The manufacturers also
claim that the flutes do not open when the stress level
is reached, which helps in increasing the cyclic fatigue
resistance.

Protaper Gold (PTG, Dentsply Tulsa Dental

Specialties) has a convex triangular cross-section and
a variable progressive taper. PTG is manufactured by
Figure-1: Customized Jig
proprietary metallurgy that reportedly increases its
flexibility and its resistance to cyclic fatigue.7 The dental hand piece (16: 1 reduction hand piece)
was attached to the descending cross head of the
There are no studies in the literature that evaluates Instron(8874) testing machine (Boston, US) (Figure
the cyclic fatigue resistance of these new rotary file 2&3a).
systems. Hence, the aim of the present study is to
compare the cyclic fatigue resistance of three different
NiTi rotary file systems: Hyflex CM, Protaper Gold and
Neoendo Flex files.

Materials and Method

A total of 90 NiTi instruments of 3 different
rotary systems of length 21mm were included in the
present study. Before testing, all files were autoclaved
and examined using a stereomicroscope to detect any
deformation. The files were divided into 3 experimental
groups (n = 30) as follows: Group A: Hyflex CM
instruments of size 25, 0.06 taper Group B: Neoendo
Flex files instruments of size 25, 0.06 taper Group C:
Protaper Gold instruments of size 25, 0.08 taper
Figure-2: INSTRON (8874) testing machine
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 319

Cyclic fatigue test

All the instruments groups (n=90) was tested

according to manufacturer ’s recommendations as
follows: Hyflex CM at 500rpm/2.5Ncm; Neoendo Flex
at 350rpm/1.5Ncm; Protaper Gold at 300rpm/1.5Ncm
until failure occurred(figure-3b). The time taken to
failure was recorded and stopped as soon as the failure
was detected visually and/or audibly with the help of
computer aided software (figure-3c). The failure was
easily detectable because the tip of the instrument was
visible at the end of the curve (Figure 4a, 4b, 4c).Mean
values were then calculated. The formula to calculate
number of cycles to failure (NCF) is NCF = revolutions
per minute × time to failure (seconds)/60

Figure-3a: Before failure

Figure-3b During procedure Figure-3c: After failure

Figure-4 Instruments before and after testing

4a-HyflexCM;4b-Neoendoflex;4c-Protaper Gold
 320 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Statistical Analyses significance. The criteria for statistical significance P

value < 0.05.
The mean, standard deviation and standard error of
the three groups were calculated. The mean time taken
Result
to failure (seconds) and the number of cycles to failure
were statistically analyzed using SPSS software 21.0 A statistically significant difference was observed in
version (SPSS Inc., Chicago, IL). One - way ANOVA the mean number of cycles to failure (NCF) between the
was done to determine significant differences among the three groups tested (P< 0.05). The result showed Hyflex
systems, between groups and within groups. When the CM and Neoendo Flex to be better than Pro Taper Gold
overall F test indicated significant difference, Post Hoc at 45º and 60º, (Table-1&2) whereas at 90º Neoendo
test of Bonferroni was performed to identify pair wise Flex performed better than Hyflex CM (Table-3).

Table 1: Pair wise comparison of Hyflex CM, Neo Endo Flex and Pro Taper Gold files placed at 45º

95% Confidence
Interval
Mean
(I) File
(J) File name 0Difference (I-J) Std. Error Sig. Lower Upper
name
Bound Bound

Neo Endo 112.900 56.225 .164 -30.61 256.41

Hyflex Pro taper

280.200* 56.225 .000 136.69 423.71
Gold

Hyflex -112.900 56.225 .164 -256.41 30.61

450
Neo Endo
Pro taper
167.300* 56.225 .018 23.79 310.81
Gold

Hyflex -280.200* 56.225 .000 -423.71 -136.69

Pro taper
Gold
Neo Endo -167.300* 56.225 .018 -310.81 -23.79

*The mean difference is significant at the 0.05 level.

Table 2: Pairwise comparison of Hyflex, Neo Endo and Pro Taper Gold files placed at 60
degrees

95% Confidence
Mean Interval
Angle (I) File name (J) File name Difference (I-J) Std. Error Sig. Lower Upper
Bound Bound
Neo Endo 97.300 54.851 .262 -42.71 237.31

Hyflex Pro taper

164.900* 54.851 .017 24.89 304.91
Gold

Hyflex -97.300 54.851 .262 -237.31 42.71

60º
Neo Endo
Pro taper
67.600 54.851 .685 -72.41 207.61
Gold

Pro taper Hyflex -164.900* 54.851 .017 -304.91 -24.89

Gold
Neo Endo -67.600 54.851 .685 -207.61 72.41

*The mean difference is significant at the 0.05 level.

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 321

Table 3: Pairwise comparison of Hyflex, Neo Endo and Pro Taper Gold files placed at 90
degrees

95% Confidence
Mean Interval
Angle (I) File name (J) File name
Difference (I- Std.
Sig.
J) Error Lower Upper
Bound Bound

64.09
Neo Endo -180.300*
6
.027 -343.90 -16.70

Hyflex
Pro taper 64.09
Gold
-38.900
6
1.000 -202.50 124.70

64.09
Hyflex 180.300*
6
.027 16.70 343.90
90º
Neo Endo
Pro taper 64.09
Gold
141.400
6
.108 -22.20 305.00

64.09
Hyflex 38.900
6
1.000 -124.70 202.50
Pro taper
Gold 64.09
Neo Endo -141.400 .108 -305.00 22.20
6

*The mean difference is significant at the 0.05 level.

Discussion compressive and tensile stresses in a particular area

of the instrument leading to premature failure.9 Thus
The clinical performance of endodontic files and
in this study, a static model was preferred because
their resistance to fracture by torsion and/or cyclic
the instruments being tested could be constrained in a
fatigue are mainly affected by variables, such as
precise trajectory and to rule out the confounding factors
instrument size, taper, cross-sectional design, and
caused by other mechanisms of instrument separation
manufacturing techniques.8 for this reason, many studies
apart from cyclic fatigue.
are performed on the cyclic fatigue resistance of NiTi
rotary files. Manufactures aim to improve the cyclic Cyclic fatigue resistance refers to the number of
fatigue resistance of NiTi rotary files by altering the cycles to failure that an instrument is able to resist under
design, metallurgy and kinematic of the files and through a specific loading condition. In this study, the fatigue
the various thermal and surface treatments applied to the life of the instruments was evaluated by multiplying the
files. This study is the first to compare cyclic fatigue rotational speed by the time elapsed until failure.10
resistance of Neoendo flex, Protaper Gold, Hyflex CM
using a well-established cyclic fatigue model The rotational speed at which NiTi rotary instruments
should be driven is a variable that remains to be clarified.
Several non-tooth devices were used to investigate Ideally, rotary instruments should be used at a rate that
the in-vitro cyclic fatigue resistance in both static and minimizes the incidence of fracture while maintaining
dynamic models. In a static model, the instrument efficiency. De -Deus et al., (2010) stated that higher
does not move axially. Therefore, this creates alternate rotational speeds are more susceptible to fracture than
 322 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

lower rotational speeds. Hence in this study, continuous Hyflex CM and neoendo Flex files with triangular
rotations according to manufacturer ’s recommendations cross section had higher fatigue resistance than Protaper
was delivered using endodontic motor (X - Smart™ Gold which has convex triangular cross section. NiTi
Endomotor with 16:1 reduction handpiece, Dentsply, instruments with larger cross-sectional areas present
UK). Synthetic oil was applied as recommended by lower cyclic fatigue resistance.13 Therefore, this could
Grande et al., (2006) to reduce the friction of the file. contribute to the difference in cyclic fatigue resistance
of these instruments.
The result of this study showed that Neoendo Flex
(#21.06) had higher cyclic fatigue resistance values than The mechanical properties of NiTi instruments are
the other groups. Thus, the null hypothesis was rejected. affected by the type of alloy used in the manufacturing
The Hyflex CM, Neoendo Flex, and Protaper Gold process (Zhou H., Shen Y., 2012) and also proprietary
instruments have the same tip sizes (#25). However, the surface treatments. Hyflex CM was manufactured by
tapers differ among them; Hyflex CM and Neoendo Flex controlled memory wire technique, whereas Neoendo
have a taper of 0.06 mm/mm, and ProtaperGold has a and Protaper Gold are subjected to gold surface
taper of 0.08 mm/ mm. The lower taper value of Hyflex treatment. Since the manufacturers do not reveal the
CM and Neoendo Flex when compared with Protaper manufacturing process of newer rotary files systems,
Gold should ensure a higher cyclic fatigue time; we could not relate the effect of these manufacturing
nevertheless, our results showed that only Neoendo Flex processes in improving the cyclic fatigue resistance.
presented better results than Hyflex CM and Protaper
Gold in 90º angle of curvature. In addition, the Hyflex The clinical implication of this study is that Neoendo
CM group showed a significantly higher cyclic fatigue files can be preferred in all types of canal curvatures
resistance value than the Protaper Gold group (P < .05) including severely curved canal as it had the highest
in all three subgroups. Other variables, such as cross cyclic fatigueresistance in all angles of curvature such
-sectional design, and manufacturing process should as 45º, 60º, and 90º. Another advantage of Neoendo Flex
also be taken into account. The results of this study were files are that they are cost effective and hence can be
probably caused by the different cross –sectional designs preferred in all clinical situations. In this study, Hyflex
and types of NiTi alloy of the instruments, which affect CM is found to have good cyclic fatigue resistance in
the mechanical properties of NiTi instruments.11 curved canals in accordance with the previous studies.
Though Hyflex CM can be used in mild to moderately
A study using a finite elemental analysis curved canals, it should be used with causation in
demonstrated that a triangular cross-sectional design severe acute curvature as the cyclic fatigue resistance
possessed a higher cyclic fatigue resistance than a square of Hyflex CM is less compared to Neoendo flex files
and rectangular cross-sectional design.12 This difference in 90º curvature. In this study, Protaper Gold had least
is related to the reduced metal mass of the instruments resistance when compared to Hyflex CM and Neoendo
with a triangular cross-section compared with that of Flex in all types of canal curvatures. So Protaper Gold
instruments with other cross-section design. Hence, we has limited use in curved canals.
have chosen files Hyflex CM and Neoendo Flex files
with triangular cross sections and Protaper Gold with Conclusion
convex triangular cross section. Within the limitations of this study, it can be
This study showed that its results are in accordance concluded that, Neoendo Flex files exhibited highest
with the study done by Kim et al., (2008) in which they cyclic fatigue resistance than the Hyflex CM and
have shown that the Convex Triangular design at the tip Protaper Gold file systems at 90º angle of curvature. In
of the file showed significantly higher von Mises stress 45º and 60º angle of curvature Neoendo Flex files and
values when compared with the Triangular group and Hyflex CM rotary instrument were more resistant to
they stated that the outcome of the study may be due to cyclic fatigue followed by Protaper Gold file systems .
the presence of internal residual stresses indicating that Protaper Gold showed the least cyclic fatigue resistance
the file has undergone cold work during loading, which than the other files tested.
eventually led to reduced flexibility at the cutting edge. Conflict of Interest: Authors have no conflict of
interest
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 323

Some of Funding: Self-funding Nov;45(11):1027 –34.

7. Hieawy A, Haapasalo M, Zhou H, Wang Z, Shen
Ethical Clearance : Not applicable
Y. Phase Transformation Behavior and Resistance
References to Bending and Cyclic Fatigue of ProTaper Gold
and ProTaper Universal Instruments. Journal of
1. Gavini G, Pessoa OF, Barletta FB, Vasconcellos Endodontics. 2015 Jul;41(7):1134 –8.
MA, Caldeira CL. Cyclic fatigue resistance of
8. Gao Y, Shotton V, Wilkinson K, Phillips G, Ben
rotary nickel-titanium instruments submitted to
Johnson W. Effects of Raw Material and Rotational
nitrogen ion implantation. J Endod 2010;36:1183-
Speed on the Cyclic Fatigue of ProFile Vortex
1186.
Rotary Instruments. Journal of Endodontics. 2010
2. Cheung GSP, Liu CSY. A Retrospective Study Jul;36(7):1205–9.
of Endodontic Treatment Outcome between
9. Yared GM, Dagher FEB, Machtou P. Cyclic
Nickel- Titanium Rotary and Stainless Steel Hand
fatigue of ProFile rotary instruments after clinical
Filing Techniques. Journal of Endodontics. 2009
use. International Endodontic Journal.
Jul;35(7):938–43.
2000 May;33(3):204–7.
3. Aggarwal V, Arora DV, Gupta S. Comparative
10. Pedullà E, Grande NM, Plotino G, Gambarini
evaluation of dynamic torsional resistance of the
G, Rapisarda E. Influence of Continuous or
nickel titanium instruments manufactured with
Reciprocating Motion on Cyclic Fatigue Resistance
different technologies. International Journal of
of 4 Different Nickel-Titanium Rotary Instruments.
Applied Dental Sciences.:4.
Journal of Endodontics. 2013 Feb;39(2):258 –61.
4. Parashos P, Gordon I, Messer HH. Factors
11. Capar ID, Kaval ME, Ertas H, Sen BH.
Influencing Defects of Rotary Nickel- Titanium
Comparison of the Cyclic Fatigue Resistance of 5
Endodontic Instruments After Clinical Use. 2004;
Different Rotary Pathfinding Instruments Made of
30(10):4.
Conventional Nickel-Titanium Wire, M-wire, and
5. Ferreira F, Adeodato C, Barbosa I, Aboud L, Controlled Memory Wire. Journal of Endodontics.
Scelza P, Zaccaro Scelza M. Movement kinematics 2015 Apr;41(4):535–8.
and cyclic fatigue of NiTi rotary instruments:
12. Turpin Y, Chagneau F, Vulcain J. Impact of Two
a systematic review. International Endodontic
Theoretical Cross-Sections on Torsional and
Journal. 2017 Feb;50(2):143–52.
Bending Stresses of Nickel-Titanium Root Canal
6. Peters OA, Gluskin AK, Weiss RA, Han JT. An Instrument Models. Journal of Endodontics. 2000
in vitro assessment of the physical properties of Jul;26(7): 414–7.
novel Hyflex nickel-titanium rotary instruments:
In vitro assessment of Hyflex rotary instruments.
International Endodontic Journal. 2012
 324 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Prediction of Normal & Grades of Cancer on Colon Biopsy

Images at Different Magnifications using Minimal Robust
Texture & Morphological Features

Tina Babu1, Deepa Gupta2, Tripty Singh3, Shahin Hameed4

1
Research Scholar, 2Associate Professor, 3Assistant Professor, Department of Computer Science and Engineering,
Amrita School of Engineering, Bengaluru, Amrita Vishwa Vidyapeetham, India, 4Specialist, Department of
Pathology, Aster Medcity, Kochi, India

Abstract
Classification of colon biopsy images to normal and various cancer grades is a pivotal task for histopathologists
as it involves visual analysis under the microscope at different magnifications and hence may give rise to
observational inconsistency. This paper emphasis on categorization of colon biopsy images into normal, well,
moderate and poor classes thereby analyzing the best magnification and classifier suited for classification.
A hybrid feature set consisting of morphological and texture features are obtained from images followed
by class balancing to overcome imbalancing problem and then optimized feature selection. Classifiers such
as SVM, Random Forest, Multilayer Perceptron and Naive Bayes are experimented for classification. The
proposed model is evaluated with colon biopsy images acquired from Aster Medcity, Kochi, India at different
magnifications 10X, 20X and 40X where all the magnifications performed well, but 20X gave an improved
accuracy of 94.27% with the Random Forest classifier. Advance measures based on entropy triangle are used
to rank classifiers apart from the standard performance measures, where Random Forest classifier is best for
the proposed model for all magnifications.

Keywords: Colon biopsy image, cancer, Texture, Morphology, Features, Classification, Normal, Malignant,
Magnification

Introduction Existing Method

One of the leading cancers that occur today is In colon cancer identification techniques, various
colon cancer and its second cause for death and third investigations are done and detailed survey of them are
incident cancer worldwide1. Identification of colon summarized in 5 where simple texture and object-oriented
cancer is performed by microscopic study of biopsies texture-based techniques performed well. Colon Cancer
of colon which are obtained either through surgery or detection techniques6, 7, based on texture, morphological,
colonoscopy. Further pathologist manually examines the geometric features are extracted on single magnified
structure of colon tissues through microscope and then images. However, in 8, different magnified images were
detects the presence of cancer by analyzing the shape used for segmentation and classification. In the initial
of tissue and degree of distortion to assign different experiments of9, 10 combined texture and morphological
grades to the cancerous ones. This analysis is subjective feature set gave better classification of 91.3\% with
as pathologist observes the morphology of tissues and Multilayer Perceptron classifier for 10X magnification.
grades them accordingly and also lead to inter and intra
observer variability2,3. Thus an automated diagnostic Apart from colon cancer detection techniques,
support system is needed to detect and grade colon some grading techniques of the malignant colon
cancer, thus overcoming the limitations of manual images are proposed. In 11,12 grading was done with
process and hence assist pathologist4. single magnified images based on Haralick, statistical
moments of intensity, morphological and topological
features. Later classification and grading of colon
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 325

images were done with single magnification13 where Pink and Purple are given Cw, Cp and Cr respectively.
95.4% of detection and 93.47% of grading efficiency In each cluster nine morphological features such as area,
was obtained. Multiclass classification based on texture perimeter, euler number, extent, orientation, eccentricity,
analysis was done14 where 87.4% was obtained. convex area, major and minor axis length are found and
their average is taken as the feature vector.
In this paper, multiclass classification of colon
images into normal and different grades is proposed where ui is the morphological features. The final
depending on the texture and morphological features. morphological feature vector m is of length 27 containing
Class balancing of the image dataset is addressed to feature extracted from white, pink and purple clusters.
avoid imbalance data problem where results are skewed
towards majority class. With attribute selection, only the Class imbalance is a predominant problem as there
contributing features are considered for classification is a difference in the number of images in each class and
from rich hybrid feature set of texture and morphological affects the classification ability of the model. Synthetic
features. Different classifiers are analyzed to know their Minority Over-sampling Technique (SMOTE)15 is
performance. The work will be evaluated on colon images adopted so that the minority class samples are over-
taken at different magnifications from Aster Medcity, sampled to the sample numbers in the majority class
Kochi, India to analyze the best magnification for the leading to same number of images in each of the class.
proposed model. Apart from standard performance Once the class balancing is done, Attribute Selection is
evaluation measures, information theoretic measures done as feature selection so as to select the most relevant
will be experimented for the multiclass classification. features for the classification.
The results indicate the proposed model performs more The combined feature vector after the class balancing
accurate where the best magnification of images and and attribute selection, is taken for classification where
classifier are identified. it’s classified into four classes namely normal, well,
Proposed Method moderate and poor using 5 popular standard classifiers
are used such as Naive Bayes, Random Forest, Support
The framework of the proposed system consists Vector Machine (SVM) with poly kernel and Multilayer
of four stages namely (1) Pre-processing (2) Feature Perceptron.
Extraction (3) Class Balancing and Feature Selection
(4). The pre-processing module consists of two phases. Data Statistics, Performance Evaluation Measures
In the first phase of preprocessing, color normalization & Experimental Set up
and contrast enhancement are done on the images so as The dataset consists of images at different
to increase the quality of images. Later, in the second magnifications 10X, 20X and 40X taken from 5-6µm
phase of preprocessing, for the extraction of texture thick tissue section colon biopsy samples which are
features, gray scale conversion is performed whereas stained with H&E taken from Aster Medcity, Kochi,
for the extraction of morphological features, K-Means India. For each of the magnifications, 70 Normal, 25
clustering with K=3 is done where three clusters pink, Well, 30 Moderate and 20 Poor images are available.
purple and white are obtained. Dr. Sarah Kuruvila and Dr. Shahin Hameed, the
In the next phase, features are extracted and combined respective Senior consultant and Specialist, Department
to form a feature set. Two major features extracted are of Pathology, Aster Medcity, Kochi, India analyzed
the texture and morphological features. Texture features the H&E slides of colon biopsy and the dataset were
such as Histogram, LBP, GLCM, Gabor, GLRLM, HOG prepared and ground truth label were given by them.
is obtained from the colon images after the gray scale The classification capability of the proposed work
conversion after which they are unified to form a texture is evaluated using the performance measures such
feature set. Three clusters obtained from the K-Means as Accuracy, F-Score, Area under Curve (AUC) and
clustering are converted to its binary for extraction of Entropy Triangle. To evaluate the multi-class problems
Morphological. From each of the clusters, the connected apart from the standard performance measures, Entropy
components are chosen where each of the connected triangle16,17 is plotted. The classifier at the apex of the
components has a minimum area T. The number of entropy triangle indicates good ones.
connected components in each of the clusters White,
 326 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Results and Discussion accuracy for all the classifiers as 94.27% with Random
Forest classifier followed by Perceptron and SVM
Proposed model was evaluated on Aster Medcity
classifier with 93.22% and finally Naive Bayes classifier
images of different magnifications with various
with 83.85%. 40X magnification gives next highest
classifiers in terms of the standard performance measures
accuracy followed by 10X for the Random Forest
and thus contributing features are analyzed for each
classifier. Fig.2.1 (b) gives the F-Score for different
magnification. Further, the proposed system is compared
classifiers for the proposed model, where it’s almost
with the existing models and other standard colon image
same as accuracy for all classifiers. Fig.2.1 (c) shows the
datasets available.
AUC, where Random Forest classifier gives better result
Performance Measure Evaluation & Reduced across all magnifications with 0.968, 0.99, 0.975 for
Feature Space Analysis 10X, 20X and 40X respectively. AUC also, 20X gave
better result for all the classifiers in order of Random
When analyzing accuracy of the proposed model, Forest, Perceptron, Naive and SVM. Then comes 40X
Fig.2.1 (a) shows that Random Forest classifier and 10X magnifications for values of AUC. Thus, for the
performs well all magnifications with 84.84%, 94.27% proposed model, 20X magnification is best suited with
and 86.19% respectively for 10X, 20X and 40X the Random Forest classifier.
magnification respectively. However 20X gives highest

Figure 1.1: Performance Evaluation Measures on Proposed System with Magnifications (a) Accuracy (b) F-Score and (c) AUC.
Figure1.2: Entropy Triangle for three magnifications

When analyzing the entropy triangle and the system followed by Multilayer Perceptron, SVM and
information theoretic measures, Random Forest is the Naive Bayes.
best classifier across all magnifications. Multilayer
Perceptron is second best for 10X and 40X as shown For each magnification, the relevant features
in Fig.2.2. Thus considering all evaluation measures, selected for the classification after the Feature Selection
Random Forest is the best classifier for the proposed may be different. The features selected from the Texture
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 327

and morphological features are given in Table.1. Out pink and white. It’s observed that most features in all
of 184 features from 20X magnification 42 is selected, magnifications are selected from the white cluster
whereas from 10X and 40X, 41 is selected. 37 features followed by pink and purple cluster. Out of the
are selected out of 157 features for classification with morphological features extracted eccentricity, extent,
20X magnification, in which HOG, Histogram, GLRLM major axis length and minor axis length contribute more
and LBP features contribute the more in the order as for classification.
shown in Table.2. In all the three magnifications, after
the attribute selection, Histogram, GLRLM and HOG The variation in the number of features selected
texture features are more relevant for classification for different magnifications may be due to image
followed by LBP, Gabor and GLCM. Only for 20X acquisition illumination condition as well as the staining
magnification, GLCM feature is taken. difference. However white cluster contribute more for
the morphological feature.
Table.3 shows the morphological features selected
after attribute selection from each cluster, purple,

Table 1: Total Number of Features Selected After Attribute Selection

Magnification Texture Feature Morphological Feature Total No. of Features Selected

10X 34 7 41

20X 37 5 42

40X 33 8 41

Table 2: Texture Features Selected After Attribute Selection

Magnification GLCM (5) LBP (59) HOG (20) Gabor (60) Histogram (6) GLRLM (7)

10X 0 10 7 13 2 2

20X 1 16 7 9 2 2

40X 0 6 14 11 1 1

Table 3: Clusters Selected from Morphological Features after Attribute Selection

Cluster
Morphological Features
10X 20X 40X

Area Pink ---- ----

Perimeter ---- ---- White

Euler Number ---- ---- ----

Eccentricity White White Purple, white

Convex Area Pink ---- ----

Extent Purple, white Pink, white Pink, white

 328 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Cont... Table 3: Clusters Selected from Morphological Features after Attribute Selection

Orientation Pink, white ---- ----

Major Axis Length ---- White White

Minor Axis Length ---- white Purple, white

Total No. of Features Selected 7 5 8

Proposed Model Comparison with Existing

shown in Table.4. These techniques are implemented in
models & Evaluation with other colon datasets
Matlab 2017b and performance measures are evaluated
Multiclass categorization of colon images into with Aster Medcity images of 10X magnification as
four classes on different magnifications has not been these works were evaluated with this magnification.
experimented and hence comparison to direct similar The proposed model is evaluated with Random Forest
work is not possible. However, the proposed system classifier. While comparing, the proposed system shows
could be compared to almost similar works such as significant results when comparing all the measures such
Stoean et. al12, Rathore et. al11 and Kather et. al14 as as accuracy, F-Score and AUC.

Table 4: Comparison of proposed method with existing models on 10X magnification

Technique Accuracy F-Score AUC

Stoean et. al12 65.13 0.645 0.752

Rathore et. al11 51.74 0.498 0.722

Kather et. al14 75.64 0.744 0.850

Proposed Method 84.84 0.848 0.968

Table 5: Comparison of proposed method with other Colon Image Datasets

Dataset Magnification Accuracy F-Score AUC

Warwick QU 18 20X 87.71 0.871 0.974

Stoean et. al12 10X 98.00 0.98 0.999

The proposed model with the Random Forest is Conclusions

evaluated with other colon image datasets which are In this work, classification of colon images into four
available in public such as Warwick QU dataset18 classes such as normal, well, moderate and poor is done
and Stoean et. al.12. Table.5 shows the analysis of the based on the minimal features comprising of texture
proposed model with Random Forest classifier with and shape features. In order to address class balancing
other colon image datasets. For both datasets, the problem and feature reduction, SMOTE and Attribute
proposed model performed well in both magnifications. Selection were applied respectively before classification.
Thus, when analyzing the performance measures of The model is evaluated on the Indian scenario colon
proposed model with both datasets, the proposed model images, acquired from Aster Medcity, Kochi, India at
gives promising results for the multiclass classification. various magnifications. The proposed model performed
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 329

well for all magnifications of Aster data, however 20X 7. S. Rathore, M. Hussain, A. Khan, Automated colon
is found to be better across others were an accuracy cancer detection using hybrid of novel geometric
of 94.27% with the Random Forest classifier. Entropy features and some traditional features, Computers
triangle performance measure is used to address the in Biology and Medicine 65 (2015) 279 -296.
multiclass classification problem apart from accuracy, 8. S. Rathore, M. Aksam Iftikhar, Cbisc: A novel
F-Score, AUC in order to rank the classifier where approach for colon biopsy image segmentation and
Random Forest was best for the model. There are several -classification, Arabian Journal for Science and
possible future enhancements for the system. First, the Engineering 41 (2016) 5061-5076.
model could be tested on large set of images. Second,
9. T. Babu, T. Singh, D. Gupta, S. Hameed, Colon
some other structural features could be extracted from
cancer detection in biopsy images for Indian
the region of interest and classified. Color features could
population at different magnification factors using
also be extracted and tested on the system.
texture features, in: 2017 Ninth International
Conflict of Interest: Nil Conference on Advanced Computing (ICoAC),
2017, pp. 192-197.
Source of Funding: Self 10. T. Babu, D. Gupta, T. Singh, S. Hameed, R. Nayar,
Ethical Clearance: My research article what R. Veena, Cancer screening on indian colon biopsy
we have written is completely self-depended which images using texture and morphological features, in:
enrolls complete research depended on the prototype of 2018 International Conference on Communication
each individual so it doesn’t match any other research and Signal Processing (ICCSP), 2018, pp. 0175-
proposals/research persons. 0181.
11. M. A. Iftikhar, M. Hassan, H. Alquhayz, A colon
References cancer grade prediction model using texture and
statistical features, smote and mrmr, in: 2016 19th
1. MedicineNet, Colon cancer description. URL
International Multi-Topic Conference (INMIC),
https://www.medicinenet.com/colon_cancer/
2016, pp. 1-7.
article.htm#what_is_the_colon_and_what_does_
it_do 12. C. Stoean, R. Stoean, A. Sandita, D. Ciobanu, C.
Mesina, C. L. Gruia, Svm-based cancer grading
2. G. D. Thomas, M. F. Dixon, N. C. Smeeton, N.
from histopathological images using morphological
S. Williams, Observer variation in the histological
and topological features of glands and nuclei, in: G.
grading of rectal carcinoma. 36 (4) (1983) 385-391.
D. Pietro, L. Gallo, R. J. Howlett, L. C. Jain (Eds.),
3. A. Andrion, C. Magnani, P. G. Betta, A. Donna, Intelligent Interactive Multimedia Systems and
F. Mollo, M. Scelsi, P. Bernardi, M. Botta, B. Services 2016, Springer International Publishing,
Terracini, Malignant mesothelioma of the pleura: Cham, 2016, pp. 145-155.
interobserver variability. 48 (9) (1995) 856-860.
13. S. Rathore, M. Hussain, M. Aksam Iftikhar, A. Jalil,
4. A. Andrion, C. Magnani, P. G. Betta, A. Donna, Novel structural descriptors for automated colon
F. Mollo, M. Scelsi, P. Bernardi, M. Botta, B. cancer detection and grading, Comput. Methods
Terracini, An automated machine vision system for Prog. Biomed. 121 (2) (2015) 92-108.
the histological grading of cervical intra epithelial
14. J. Kather, C.-A. Weis, F. Bianconi, S. Melchers, L.
neoplasia. 192 (3) (2000) 351-362.
Schad, T. Gaiser, 595 A. Marx, F. Zllner, Multi-
5. S. Rathore, M. Hussain, A. Ali, A. Khan, A recent class texture analysis in colorectal cancer histology
survey on colon cancer detection techniques, IEEE/ 6 (2016) 27988.
ACM Transactions on Computational Biology and
15. N. V. Chawla, K. W. Bowyer, L. O. Hall, W. P.
Bioinformatics 10 (3) (2013) 545-563.
Kegelmeyer, Smote: Synthetic minority over-
6. S. Rathore, M. Hussain, M. Aksam Iftikhar, A. sampling technique, J. Artif. Int. Res. 16 (1) (2002)
Jalil, Ensemble classification of colon biopsy 321-357.
images based on information rich hybrid features,
16. F. J. Valverde-Albacete, C. Pelez-Moreno,
Comput. Biol. Med. 47 (2014) 76-92. doi:10.1016/j.
100accuracy considered harmful: The normalized
compbiomed.2013. 12.010.
information transfer factor explains the accuracy
 330 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

paradox, PLOS ONE 9 (1) (2014) 1-10. 18. K. Sirinukunwattana, D. R. J. Snead, N. M.

17. V. K, D. Gupta, Text plagiarism classification using Rajpoot, A stochastic polygons 655 model for
syntax based linguistic features, Expert Systems glandular structures in colon histology images,
with Applications 88 (2017) 448-464. IEEE Transactions on Medical Imaging 34 (11)
(2015) 2366-2378.
 Indian Journal of Public Health Article
Original Research & Development, January 2020, Vol. 11, No. 1 331

Effect Of Scapular Position- Motion Maintenance Exercise

Programme During Post Traumatic Shoulder Immobilization

Trusha Shambhubhai Goti1, Sandeep Babasaheb Shinde2

1Intern, BPTh. Faculty of Physiotherapy, Krishna Institute Of Medical Sciences Deemed To Be University, Karad,
Maharashtra, India, 2MPTh, Department of Musculoskeletal Sciences. Karad, Maharashtra, India

Abstract
Background: The scapula plays a key role in nearly every aspect of normal shoulder function. Alteration in
scapular position and motion is found in association with most shoulder injuries. This alteration is term as
scapular dyskinesis. Prevalence of scapular dyskinesis is about 67 to 100 %. But many literature focus on
treatment after occurrence but very few aim at prevention during immobilization phase.This made indeed
to study the effect of scapular position – motion maintenance programme during shoulder immobilization
phase.

Objectives: To determine the effect of scapular position -motion maintenance exercise programme during
post traumatic shoulder immobilization phase, To compare the effect of scapular position -motion maintenance
exercise programme and conventional physiotherapy during post traumatic shoulder immobilization phase.

Method: A Total of 40 subjects were selected aged between 20 to 50 years. They were divided into two
groups. Group A (experimental) and group B (conventional). Both groups received treatment for 6 weeks for
a duration of 30 minutes. The outcome measure used wereVAS, Posture assessment, pectoralis minor muscle
length ,Linnies test and scapular assistance test.

Result:The study concludes that experimental group (scapular position- motion programme)proved more
efficacious in reducing risk of scapular dyskinesisin patients with humerus fracture during immobilization
phase as compared with conventional treatment.

Keyword: scapular dyskinesis, Immobilization phase, proximal humerus fracture, exercise therapy

Introduction shoulder function. In some cases like labral tear, rotator

Effective shoulder position, motion, stability, cuff disease , dyskinesis may be causative ,creating
muscle performance and motor control are largely pathomechanics that predispose the arm to such
dependent on the scapular performance. Mechanically, injuries.2Humeral fractures accounts for approximately
the coordinated coupled motions between the scapula 7 to 8% of all adult fractures, further incidence has
and humerus, is called scapula humeral rhythm.1 been reported to increase with age. Proximal humerus
Scapular Dyskinesis is found in association with various fractures being most common(50%) of all humerus
shoulder pathologies , although exact relationship fractures.3According to a study “Prevalance of scapular
between dyskinesis and clinical pathology is doubted.In dyskinesis in patients with Distal radius fracture with
case of nerve injury , fracture , Ac separation , muscle or without shoulder pain” by Hector it was found that
detachment , the injury results in dyskinesis, affecting almost 80% of all patients with distal radius fracture
showed scapular dyskinesis, with an increase in value
90.9% in group of patients with shoulder pain.4 Scapular
Correspondence Author: Motionsprovide optimal muscle length – tension ratios
Dr. Sandeep Shinde, for accurate movement pattern, and promotes muscular
MPTh, Department of Musculoskeletal Sciences. energy conservation during arm motion. The most
Karad, Maharashtra, India common causative mechanisms of scapular dyskinesis
 332 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

is soft tissue alterations i.e inflexibility or tightness of The Inclusion criteria in this study was Age group of
pectoarlis minor creating anterior tilt and protraction, 20 – 50 age,Both the genders and Patients with Proximal
glenohumeral internal rotational deficits, which creates Humerus post reduction or post operative immobilization
a wind up of scapula on thorax leading to horizontal phase andExclusion criteriawas Neurological condition,
abduction.5 Non cooperative patients, Patients with Fracture of
scapula, Patients with External fixators, Patients with
One of the most important abnormalities in distal neurovascular deficit and Patients with rib and
abnormal scapular biomechanics is the loss of linking spinal fractures.
function in kinetic chain.6 The scapula and shoulder are
dependent links in kinetic chain. It helps transferring The Outcome measures was Pain assessment – VAS
the forces from the large segments, the legs and trunk, scale,Posture assessment, pectoralis minor muscle length
to the smaller, rapidly moving small segments of the and special test for Linnies test and scapular assistance
arm. If scapula becomes deficient in motion or position, test.
transmission of the large generated forces from the lower
extremity to upper extremity is impaired. This creates a The materials used in the study was Plinth, Towel,
situation of catch up in which more distal segments work Inch-tape, Swiss ball, Pressure biofeedback, Data
at a higher level of activity for compensation of the loss collection sheet, Consent form.
of proximally generated forces. Calculations depicts that Procedure
20% decrease in kinetic energy delivered from hip and
trunk to the arm necessitates an 80% increase in mass An approval for the Study was obtained from the
and 34% increase in rotational velocity at shoulder to Protocol committee and institutional Ethical committee
deliver the same amount of resultant forces to hand .The of KIMSDU scapular dyskinesis.Subjects who fulfilled
kinetic chain is the most efficient system for developing the inclusion and Exclusion Criteria was divided into
energy and force.7-8 two groups. Informed consent was taken from each of
the subject prior to Participation. Instructions weregiven
Scapular diskinesis causes weakness, tightness and to the subjects about techniques performed. A total of
muscle imbalance. most of the scapular motion and 40 subjects were divided equally into two groups by
position can be treated by means of physical therapy Simple random Sampling (Group A and Group B). The
relieving the symptom associated with in flexibility subjects were divided into two groups according random
or trigger points, re-establishing muscle strength and allocation.
activation patterns.9 But many literature focus on
treatment after occurrence but very few aim at prevention Pre-test:
during immobilization phase. This made indeed to study
the effect of scapular position – motion maintenance Visual Analogue Scale (VAS) and Posture
programme during shoulder immobilization phase which assessment, pectoralis minor muscle length and special
primarily focuses on linking function of kinetic chain. test for Linnies test and scapular assistance test was used
to assess the Subjects.
Materials and Methodology Group A
This experimental study was carried out with 40
The treatment program was include:
subjects in Krishna Hospital Karad. A total of 40 subjects
was divided equally into two groups by Simple random First 3 week scapular stabilization exercise and next
Sampling (Group A and Group B). Subjects were in 3 week spinal stabilization exercise will be added with
immobilization phase with proximal humerus fracture. scapular stabilization exercise.
Both males and females between the age group of 20-50
years were included.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 333

Group A(Experimental)10-12 Week 5

Swiss ball exercise
Week 1
• Sitting knee raise on swissball
1. Posture training
• Abdominal slide
• Scapular retraction exercise
• Lying trunk curl with leg lift
2. Isometric exercise for scapular muscle
• Wall slides
• .Shoulder Depression

• Shoulder Protraction

• Shoulder retraction
Week 6
Week 2 1. pelvic floor exercise
• Pelvic bridging
Scapular stabilization exercise
2. diaphragmatic strengthening exercise
1. Scapular clock exercise on a wall 3. single leg standing on foam

2. T to Y to W exercise on swiss ball

Week 3
Scapular motion exercise (closed chain stabilization) Group B(control group)

• Static close chain exercise (weight bearing)

Week 4 • Rest
• Isometric exercise for scapular muscle(Shoulder
Spinal stabilization exercise was added with scapular stabili- Depression ,Shoulder Protraction ,Shoulder retraction), active
zation
exercise (daily for 6 weeks)
• Pressure biofeedback in supine

 Lumbar flexion

1. Multifidus facilitation
Post-test:
2. Alternate single leg heel touch
Visual Analogue Scale (VAS) and Posture
 Lumbar extension assessment, pectoralis minor muscle length and special
1. Oblique abdominal facilitation test for Linnies test and scapular assistance test was used
to assess the Subjects.
2. Alternate single leg heel touch

• Lumbarmultifidus activation

• Transv. erseabdominis activation

 Abdominal hollowing: activa-

tion of transverses abdominis in
crook-lying position.

 Abdominal hollowing: activa-

tion of transverses abdominis in
sitting.

 Abdominal hollowing: activa-

tion of transverses abdominis in
four point kneeling.

 Activation of multifidus from sit-

ting to lumbar neutral position
 334 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Data Analysis
Between the group comparison

Table no 1: Baseline parameters comparison between both the groups (visual analog scale, Linnies test,
pectoralis minor muscle length)

Group A & B

Parameters post A post B t value p value

Visual analog scale 4.8±1.32 3.90±1.16 2.28 0.028

RIGHT 8.32±0.94 8.42±1.61 0.23 0.81

T2
LEFT 9.1±1.93 10.22±2.67 1.25 0.21

RIGHT 9.22±0.52 9.27±0.75 0.79 0.8

Linnies test T4
LEFT 9.21±0.80 9.82±1.51 0.24 0.12

RIGHT 10.8±1.24 9.57±2.57 1.95 0.05

T7
LEFT 10.52±1.77 9.42±2.64 1.54 0.13

Pectoralis minor muscle length RIGHT 2.54±0.16 2.64±0.10 1.11 0.27

LEFT 2.58±0.15 2.64±0.10 1.38 0.17

Table no 2: Baseline parameters comparison between both the groups (scapular abnormalities, scapular
motion)

Group A & B POST A POST B

Present 6 13
TILT
Absent 14 7
Scapular abnormalities
Present 2 6
WING
Absent 18 14

Type 1 4 7

Type 2 0 0

Type 3 0 0
Scapular motion
Type 4 14 7

Type 1,2 0 0

Type 1,2,3 2 6

Positive 14 7
Scapular assistance test
Negative 6 13
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 335

Discussion effective in management of supraspinatus tendinitis.19

The present study “Effect of scapular position - The majority of studies included utilized visual
motion maintenance exercise programme during post observation of abnormal scapular rhythm to identify
traumatic shoulder immobilization phase” was conducted scapular dyskinesis. Two major abnormalities noted were
to see the effect of scapular stabilization and spinal scapular winging and scapular tilting. Scapular tilting
stabilization exercise during immobilization phase in was found in almost all subjects in Group A and Group
post traumatic shoulder. The scapula is anatomically and B.Scapular winging was present in 8 subjects in Group
mechanically linked with shoulder function. Alteration A and 6 subjects in Group B.This interprets the fact not
in scapular position and motion is found in association all patient with scapular tilting present with scapular
with most shoulder injuries, termed as scapular winging. The mean pain values recorded using VAS
dyskinesis. In a previous study “Prevalence of Scapular showed a significant level of pain in both groups with
dyskinesis in patients withdistal radius fractures with or pre values of 7 in Group A and 6.65 in Group B. There
without shoulder pain” by Hector states that prevalence was a significant reduction in pain levels post treatment
of Scapular Dyskinesis is shown in 80% of all patients with 4.8 and 3.9 mean values respectively. The two
with Distal Radius Fracture , with an increasing value main components scapular motion and scapular position
of 90.9 % in patients with shoulder pain.The ratio was were assessed using Kiblers classification and Linnes
found to be 10 times greater in patients with Distal test respectively. According to Kiblersclassification it
Radius Fracture accompanying with shoulder pain.13 was found that majority of subjects belonged to Type
I dyskinesis with 12 subjects(60%) in group A and 14
A group of adult population with proximal humerus
subjects(70%) in group B. This interprets that inferior
fracture treated conservatively with plaster cast or closed
angle positioning was severely affected .Group A was
reduction were evaluated.In a similar study by AyhanEt.
found to be more effective in correction of this fault
Al .stated following findings: Distal Radius Fracture had
by reduction of number from 12(60%) to 4(20%) as
influence on scapular motion, exhibit altered scapular
compared to Group B in which only 7 subjects(35%)
kinematics, increased posterior tilt , internal and upward
showed corrections. Also subtype 3 and 4 that is
rotation.14-16Further the study added to find the quality
medial border prominence and excessive superior
of motions at scapula if more proximal structures were
border elevation was found to be noted though there
affected. Another study by Edward Sheilds, “Scapular
rates were relatively less as compared to Type 1. Post
dyskinesis following displaced fractures of the middle
treatment it was found that Group A had 14 Subjects
clavicle”similar results were noted ,Scapular Dyskinesis
(70%) showing T4 subtype that is symmetric and normal
is common after displaced middle third clavicle
scapulae and group B had 7 subjects(35%) which
fractures.17 In the present study we found a significant
showed thatcorrection of scapular motion rate was
relation of scapular dyskinesis with proximal humerus
almost double in Group A proving efficacy of scapular
fracture .Though there is no enough literature to support
positioning program.The second component that is
this evidence, but may studies approve findings of
linnies test added to the results of Kiblers classification
Scapular Dyskinesis occurrence after or with shoulder
by providing objective findings. The results of Linnies
injuries. In a previous study by Mathew B.“Prevalence
test showed significant results in group A. However
of scapular dyskinesis in overhead and non overhead
group B showed not significant results. This measure
athletes” reported that Scapular Dyskinesisin overhead
although a subjective approach doesn’t much count on
athletes (61%) was more compared to those with non
the therapist findings rather the results are patient based
overhead athletes(33%).6In a previous study by Poonam
.From the above gained results we can state that scapular
SS, “effect of desensitization methods during the early
position and motion programme is more effective in
mobilization phase in post fracture conditions of upper
prevention of scapular dyskinesis.
extremity” reported that combination of desensitization
along with the conventional physiotherapy was effective Dyskinesis may be caused by multi factors such
in decreasing pain, improving ROM and muscle strength as bony causes, joint causes, neurological causes and
than the conventional therapy alone.18Another study soft tissues causes of alteration. Bony causes include
by Diksha U, “Effect of movement with mobilization thoracic kyphosis or clavicle fracture non-union or
in supraspinatus tendinitis” had noted that movement shortened mal-union. Joint causes include high grade
with mobilization, ultrasound, TENS and exercises are acromioclavicularinstability, glenohumeral joint internal
 336 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

derangement. Neurological causes include cervical Br J Sports Med. 2013 Sep 1;47(14):877-85.
radiculopathy, long thoracic or spinal accessory nerve 2. Kibler BW, Sciascia A, Wilkes T. Scapular
palsy. Soft tissue mechanisms for scapular dyskinesis dyskinesis and its relation to shoulder injury.
involve inflexibility or intrinsic muscle problems. The JAAOS-journal of the American academy of
upper and lower trapezius force couple may be altered, orthopaedic surgeons.2012 Jun 1;20(6):364-72.
with delayed onset of activation in the lower trapezius,
3. Kim SH, Szabo RM, Marder RA. Epidemiology of
which alters scapular upward rotation and posterior
humerus fractures in the united states: nationwide
tilt. Altered scapular motion or position both decrease
emergency department sample, 2008. Arthritis care
linear measures of the subacromial space, increase
& research. 2012 Mar;64(3):407-14.
impingement symptoms, decrease rotator cuff strength,
increase strain on the anterior glenohumeral ligaments 4. Gutierrez-Espinoza H,Olguin-Huerta C, Zavala-
and increase the risk of internal impingement. 1 The Gonzalez J, Rubio-OzarzunD,Araya-Quintanilla F.
Mechanism contributing to scapular dyskinesis primarily prevalence of scapular dyskinesis in patients with
include the following factors like Inadequate serratus distal radius fracture with or without shoulder pain.
anterior activation, excess upper trapezius activation, PhysiotherRehabil. 2017;2(140):2.
pectoralis minor tightness, posterior glenohumeral joint 5. Ben Kibler W. The role of the scapula in athletic
soft tissue tightness, thoracic kyphosis or flexed posture. shoulder function. The American Journal of sports
This associated effects leads to lesser scapular upward medicine. 1998 Mar;26(2):325-37.
rotation and posterior tilt, greater clavicular elevation, 6. Burn MB, McCulloch PC, Lintner DM, Liberman
greater scapular medial rotation and anterior tlit, greater SR, Harris JD. Prevalence of scapular dyskinesis in
scapular anterior tilt, greater scapular medial rotation overhead and non overhead athletes: a systematic
and anterior tilt, lesser scapular upward rotation.13 review. Orthopaedic journal of sports medicine.
2016 Feb 17; 4(2):2325967115627608.
This study had some limitations but were majorly
due to the small sample size. Further studies can be done 7. Kibler BW, McMullen J. Scapular dyskinesis and
on a larger sample size including more age groups. Also its relation to shoulder pain. JAAOS – Journal of
similar studies can be done taking into account some the American academy of Orthopaedic Surgeons.
other fractures like distal humerus fractures, radius 2003 Mar 1 ;11(2):142-51.
fractures, wrist fractures, elbow dislocation. 8. Moezy A, SepehrifarS,Dodaran MS. The effects
of scapular stabilization based exercise therapy
Conclusion on pain, posture, flexibility and shoulder mobility
in patients with shoulder impingement syndrome:
The study concludes that experimental group
a controlled randomized clinical trial, medical
(scapular position- motion programme) proved more
journal of the Islamic Republic of Iran, 2014;28:87.
Efficacious in reducing risk of scapular dyskinesis
patients with humerus fracture during immobilization 9. Akhtar MW, Karimi H, Gilani SA, Effectiveness
phase as compared with conventional treatment. of core stabilization exercises and routine exercise
therapy in management of pain in chronic
Acknowledgement: we acknowledge the guidance nonspecific low back pain: A randomized controlled
and support from faculty of physiotherapy. clinical trial, Pakistan journal of medical sciences,
2017 jul,33(4):1002.
Conflict of interest: There is no conflict of interest.
10. C Kisner, L.A Colby, therapeutic exercise:
Source of funding: Krishna institute of medical foundation and techniques, 6th edition, Jaypee
sciences ‘deemed to be’ university,karad. brothers medical publishers (P) Ltd, 2013.
11. Luque-Suarez A, Diaz-Mohedo E, Medina-
Referances Porqueres I, etal, stabilization exercise for the
1. KiblerBW,Ludewing PM, McClure PW, Michener management of low back pain, In low back
LA, Bak K, Sciascia AD. Clinical implications of pain,2012, In Tech.A randomized controlled
scapular dyskinesis in shoulder injuries: the 2013 clinical trial, Pakistan journal of medical sciences,
consensus statement from the ‘Scapular Summit’. 2017 jul,33(4):1002.
12. S. B. Brotzman and K. E. Wilk, clinical orthopedic
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 337

rehabilitation, second edition Mosby, 1996. 17. Shields E, Behrend C, Beiswenger T, Strong
13. David J Magee. Orthopaedic physical assessment B, English C, Maloney M, VoloshinI.
.sixth edition. Reed Elsevier India Private scapulardyskinesis following displaced fractures of
Limited.2014 the middle clavicle. Journal of shoulder and elbow
surgery. 2015 Dec 1;24(12):e331-6
14. McQuade KJ, Dawson J, Smidt GL. Scapulothoracic
muscle fatigue associated with alterations in 18. Poonam SS, Sandeep BS. Effect of desensitization
scapulohumeral rhythm kinematics during methods during the early mobilization phase in
maximum resistive shoulder elevation. Journal post fracture conditions of upper extremity. Asian
Orthopaedicand Sports Physical Therapy. 1998 journal of pharmaceutical and clinical research.
Aug;28(2):74-80. 2018 Feb 15;11(7):93-96
15. Gould D . Visual analogue scale (VAS) 19. Diksha U, Sandeep BS. Effect of movement
.JClinNurs2001 ; 10 :697 – 706 . with mobilization in supraspinatus tendinitis.
International journal of science and research. 2017
16. Struyf F, NijsJ,Mottram S, etal, clinical assessment
Feb;6(2):673-676
of the scapula: a review of the literature, Br J Sports
Med.2014 Jun 1;48(11):883-90.
 338 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Hand Hygiene Practices and Training Gap in a Neonatal

Intensive Care Unit at Coastal Karnataka India

Usha Rani1, Kiran Chawla2, Leslie E Lewis3, Indira Bairy4, Vasudeva Guddattu5, Jayashree Purkayastha6,
Christy Thomas Varghese7
1Assistant Professor, Dept. of Health Innovation, Prasanna School of Public Health (PSPH), Manipal Academy of
Higher Education (MAHE), Manipal, Udupi, Karnataka, India, 2Professor & Head, Department of Microbiology,
3Professor, Department of Pediatrics, Kasturba Medical College (KMC), Manipal Academy of Higher Education

(MAHE), Manipal, Udupi, Karnataka, India, 4Professor, Department of Microbiology, MMMC, Manipal Academy
of Higher Education (MAHE), Manipal, Udupi, Karnataka, India, 5Associate Professor, Department of Data
Sciences, Prasanna School of Public Health (PSPH), Manipal Academy of Higher Education (MAHE), Manipal,
Udupi, Karnataka, India, 6Department of Pediatrics, Kasturba Medical College (KMC), Manipal Academy of
Higher Education (MAHE), Manipal, Udupi, Karnataka, India, 7Postgraduate Student, Dept. of Health Innovation,
Prasanna School of Public Health (PSPH), Manipal Academy of Higher Education (MAHE), Manipal,
Udupi, Karnataka, India.

Abstract
Background: Non-adherence to hand hygiene practices is a well-known factor contributing to healthcare-
associated infections in any healthcare setting. Mere knowledge of such practices doesn’t guaran

tee the compliance to the practices by healthcare personnel. In this study we explored the quantum of
adherence to hand hygiene practices, the opportunity missed, the steps and the duration to be followed for
hand hygiene practices and the training gap among the healthcare providers.

Methodology: A six-month cross-sectional study using a mixed-method approach of observations, interview

and feedback mechanism is used to find the effectiveness of hand hygiene practices and any training gap to
prevent healthcare-associated infections. Observations for two thousand opportunities for hand washing and
written interview of 40 healthcare workers is carried out on hand hygiene practices at a neonatal intensive
care unit of coastal Karnataka, India.

Results: The hand hygiene practices are as low as 0% observed while performing an invasive activity
like clearing an alarm at the bedside. There is a gap found in the duration of hand-washing practices, hand
hygiene before and after any care activity is performed on the neonate. This gap resulted in the spread of
healthcare-associated infections.

Conclusion: During the infections control training emphasis should also be given on the opportunities and
hands on practices of hand hygiene.

Keywords: Hand hygiene; Infection control; Healthcare-associated infections; Neonate; India

Introduction
Corresponding author:
Leslie E Lewi Handwashing is the foundation for infection
MD, Professor, Department of Pediatrics, Kasturba control practices1. Healthcare providers are trained
Medical College (KMC), Manipal Academy of Higher and empowered to practice hand hygiene during their
Education (MAHE), Manipal, Udupi, Karnataka – formal training. There can be a high rate of healthcare-
576104, India. Email: [email protected]; associated infections if the perception and practice of
hand hygiene are mismatched2. Performing hand hygiene
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 339

and compliant to complete hand hygiene practices are Findings

two different avenues. When all the five steps of hand
hygiene are not performed in timely manner is considered Two thousand observations and forty interviews
ineffective and when all steps are completed with on twenty-five variables were carried out for healthcare
appropriate time duration hand hygiene is considered workers at NICU. There was a mismatch in the practices
to be effective1. There can be instances when one may observed and knowledge of hand hygiene reported
presumes completing optimum hand hygiene but it is among healthcare workers. We categorized observations
not. We are exploring the gaps in training adherence to and responses under three subheadings; time duration,
the steps needed to be followed, the opportunity missed hand hygiene before an activity and hand-hygiene after
for hand hygiene practice and maintaining stipulated an activity performed.
time for each step by healthcare provider. Time duration: Nearly 65% of healthcare workers
reported that the ideal duration for handwashing with
Materials & Method soap and water is <20 sec. However, only 12.5%
In a neonatal intensive care unit (NICU) of a tertiary healthcare workers practice handwashing with soap and
care teaching hospital situated at coastal Karnataka, water for >40 sec. 75% opportunities to carry out hand-
India, a cross-sectional study was carried out for six washing practices were of less than 20-sec duration with
months duration July 2017-Jan 2018. Hand washing soap and water. None of the healthcare workers reported
and hand hygiene practices of all the healthcare the durations of hand hygiene using hand rub solution as
workers were recorded for all the five moments and 21 to 40 sec and we also observed the similar findings.
steps of handwashing as suggested by the world health Only one opportunity was recorded complying to 21-40
organization. The questionnaire on five moments of sec duration of hand hygiene using hand rub solution
hand hygiene was prepared; content and face validation (Table 1).
were done. A sample size of 40 healthcare workers
considering a 95% confidence level for a definite Table 1: Showing time duration for hand hygiene
population N=44 with 5% confidence limit were practices by healthcare workers
selected for written interview based on their availability The
and consent for participation. The healthcare workers Observations
gap in
working in NICU responded on these questionnaires Reported n =40 reported
Variables n=80
vs
that include five physicians, 23 nurses, six paramedic observed*
trainee and six pediatric postgraduate trainees. Eighty n (%) n (%)
observations at each opportunity for a total two (%)
Duration of hand washing with soap and water
thousand chances of performing hand hygiene were
observed for these healthcare providers randomly on
different time interval, preferably at non-peak hours 05-20 sec 60 (75.0) 26 (65) -10
using a checklist. The observations and questionnaire
were related to WHO five moments of hand hygiene1. 21->40 Sec 20 (25) 14 (35) -10
In each observation, if any step or opportunity was
missed or partially completed, it was considered as non- Duration of hand disinfection with hand rub
compliance. Completion of activity as per the standard solution (Min)
was considered as compliance with the practices. The
data obtained was entered in Microsoft excel was 05 - 10 Sec 62 (77.5%) 4 (10%) -67.5
analyzed further using R software version 3.1.1. The
qualitative variables were summarized as number and
11- 20 Sec 17 (21.2%) 36(90%) +68.8
percentage. The difference between the reported and
observed practices is considered as a gap that needs to be
focused on further training on hand-hygiene practices. 21 - 40 Sec 1 (1.2%) 0 (0) +1.2
Institutional ethic committee approval was taken with
IEC approval number “MUEC/014/2016-17”. Informed * The gap is the percentage difference between reported
written consent for participation was obtained from all and observation practices. A positive or negative gap of
the participants before interviewing them. more than 20% is considered a significant gap in practice.
 340 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Hand hygiene before an activity: Reported compliance for hand hygiene before contacting neonate, handling
or moving baby or applying a mask or giving massage was 57.5%, but observations showed more compliance than
reported 83.8 % and 57.5% respectively. While performing non- invasive procedures or examination reported hand
hygiene was always more than the observed. Considering any opportunity to perform hand hygiene during non-
invasive procedure reported and observed was as low as 37.5% and 0% respectively. In case of performing hand
hygiene before invasive procedure, reported and observed was always >80% (Table 2)

Table 2: Hand hygiene practice before any activity

Observations The gap in

Reported n
reported vs
n=80 =40
observed*
Variables

n (%) n (%) (%)

Compliance for practice hand hygiene before having contact with

53 (66.2) 23 (57.5) -8.7
neonate

Clean hands before providing personal care activities: handling,

33 (41.2) 23 (57.5) +16.3
moving, bath/sponge, feeding, changing linen, etc.

Clean hands before delivering care and other non-invasive treatment:

67 (83.8) 23 (57.5) -26.3
applying oxygen mask, giving a massage.

Clean hands before Performing a physical non-invasive examination:

30 (37.5) 22 (55) +17.5
Taking pulse, blood pressure, chest auscultation, recording ECG.

Clean hands before Instilling eye drops, examining mouth, nose, ear
with or without an instrument, inserting a suppository, suctioning 34 (42.5) 27 (67.5) +25
mucous.

Clean hands before Dressing a wound with or without an instrument,

applying ointment On vesicle, making a percutaneous injection/ 76 (95) 32 (82.5) -12.5
puncture.

Clean hands before Inserting an invasive medical device 68 (85) 35 (87.5) +2.5

Clean hands before Preparing food, medications, pharmaceutical

80 (100) 25 (62.5) -37.5
products, sterile material.

* The gap is the percentage difference between reported and observation practices. A positive or negative gap of
more than 20% is considered a significant gap in practice.

Hand hygiene practices after an activity: 0%. Compliance for hand hygiene was recorded better,
Reported compliance towards hand hygiene practices >60% in post invasive procedure/ touching any mucosal
post non-invasive procedure was nearly 50% whereas part of neonate & the noted observations showed >95%
observed was as low as 2.5%. Hand hygiene compliance compliance (Table 3).
was reported less than 35% post touching any part of
the neonatal environment and observed was nearly
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 341

Table 3: Hand hygiene practices after an activity

Observations Reported n The gap in reported

n=80 =40 vs observed*
Variables
n (%) n (%) (%)

Clean hands after the contact with a mucous membrane and with non-
78 (97.5) 28 (70) -27.5
intact skin end.

Clean hands after A percutaneous injection or puncture; after inserting

80 (100) 34 (85) -15
an invasive medical device

Clean hands after Removing an invasive medical device. 18 (22.5) 33(82.5) +60

Clean hands after Removing any form of material offering protection

22 (27.5) 29 (72.5) +45
(napkin, dressing, gauze, sanitary towel, etc.).

Clean hands after handling a sample containing organic matter,

after clearing excreta and any other body fluid, after cleaning any 63 (78.8) 34 (85) +6.2
contaminated surface and soiled material (soiled bed linen, diaper etc.).

Clean hands after providing personal care activities: handling, moving,

44 (55) 20 (50) -5
bath/sponge, feeding, changing linen, etc.

Clean hands after Delivering care and other non-invasive treatment:

26 (32.5) 20 (50) +17.5
applying oxygen mask, giving a massage.

Clean hands after Performing a physical non-invasive examination:

67 (83.8) 18 (45) -38.8
Taking pulse, blood pressure, chest auscultation, recording ECG.

Clean hands after an activity involving physical contact with the

patients’ immediate environment: changing linen, holding a side of the 2 (2.5) 20 (50) +47.5
cradle, clearing sides of cradle.

Clean hands after A care activity: adjusting perfusion speed, clearing a

0 (0) 11 (27.8) +27.8
monitoring alarm.

Clean hands after Other contacts with surfaces or inanimate objects:

0 (0) 14 (35) +35
leaning against the cradle, leaning against a side table /ventilator.

Practice hand hygiene after having contact with neonate? 53 (66) 24 (60) -6

Practice hand hygiene after removing gloves? 26 (32.5) 29 (72.5) +40

Wear gloves when hands may be contaminated with bodily fluid (e.g.
65 (81.2) 33 (82.5) +1.3
Suctioning)
* The gap is the percentage difference between reported and observation practices. A positive or negative gap of
more than 20% is considered a significant gap in practice.

Discussion worker may be aware of the hand hygiene practices

required to follow hence they reported at various
No healthcare worker want any patient especially
instances the hand hygiene practices is required.
neonate to suffer from healthcare-associated infection
However due to various reasons the practice is not
because of any preventable cause. Maintaining good
followed and that can be captured through observations3.
hand hygiene is vital for infection control practices,
There are reports supporting our findings that there is
but mere awareness on how to perform handwashing is
a gap in the awareness and practices among healthcare
an incomplete effort to achieve a goal. The healthcare
workers for handwashing practices4–6. The very fact
 342 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

that even the healthcare providers were not aware of workers were not clear whether to use hand rub solution
performing hand hygiene post touching the neonatal or do handwashing or do both the practices. The
environment or clearing the alarm provides scope to significant importance of making the hand dry after any
work further and improve on training programs. Any hand hygiene practice was missing that was captured
invasive procedure requires thorough handwashing during observations. The difference in reporting and
using soap and water, whereas for non-invasive observation practices gives insight to the training team
activities like clearing an alarm or changing linen etc., about the focus area. If the gap is considerably high, as
a hand rub disinfectant solution should be used 7such we considered a gap >20% as high, such instances need
as after fecal contact and before eating, but it is time- immediate special attention and training.
consuming. We aimed to assess the impact of reducing
the duration of structured observation on the number and Conclusion
type of critical events observed. The study recruited 100 Training on handwashing must include sessions on
randomly selected households, 50 for short 90-minute when to perform hand hygiene how to perform, and the
observations and 50 for long 5-hour observations, in six minimum duration required for optimum hand hygiene.
rural Bangladeshi villages. Based on the first 90 minutes Various identified opportunities should be enlisted in
in the long observation households, we estimated the healthcare settings to minimize any mis-opportunity.
number of critical events for handwashing expected, and
compared the expected number to the number of events Conflict of Interest: All the authors declare of no
actually observed in the short observation households. conflict of interest.
In long observation households, we compared soap use
at critical events observed during the first 90 minutes to Source of Funding: Self
soap use at events observed during the latter 210 minutes Ethical Clearance: Institutional ethical clearance
of the 5-hour duration. In short 90-minute observation was obtained before the conduct of the study with
households, the mean number of events observed was number “MUEC/014/2016-17”
lower than the number of events expected: before
eating (observed 0.25, expected 0.45, p < 0.05. Invasive References
activities do include any contact with bodily fluid during
the procedure. Many training programs are carried for 1. WHO. WHO Guidelines on Hand Hygiene in
healthcare workers to optimize hand hygiene practice. Health Care First Global Patient Safety Challenge
There are limited training opportunities to learn when to Clean Care Is Safer Care.; 2009.
perform hand hygiene practices8. Routinely in healthcare 2. Whitby M, Pessoa-Silva CL, McLaws M-L, et
organizations professionals are also not made aware of al. Behavioural considerations for hand hygiene
the quantity of liquid soap solution or hand-rub solution practices: the basic building blocks. J Hosp Infect.
required for appropriate hand hygiene. The study not 2007;65(1):1-8. doi:10.1016/j.jhin.2006.09.026
only highlights the importance for the healthcare workers 3. Legeay C, Bourigault C, Lepelletier D, Zahar JR.
to learn and plan for training program on how to perform Prevention of healthcare-associated infections
hand-washing but also when to perform which type of in neonates: room for improvement. J Hosp
hand hygiene is equally important to prevent healthcare- Infect. 2015;89(4):319-323. doi:10.1016/j.
associated infection. Studies have reported that a single jhin.2015.02.003
classroom training approach may not work alone, rather 4. Hwang JH, Choi CW, Chang YS, et al. The efficacy
a multimodal approach including role-play, video of clinical strategies to reduce nosocomial sepsis
and game activities may show better results9,10hand in extremely low birth weight infants. J Korean
hygiene compliance among health care workers (HCWs. Med Sci. 2005;20(2):177-181. doi:10.3346/
Whenever we are planning for handwashing campaign jkms.2005.20.2.177
or training program, we need to prepare holistically to
5. Asare A, Enweronu-Laryea CC, Newman MJ.
get optimum desired outcome. The healthcare workers
Hand hygiene practices in a neonatal intensive care
also need to be clarified on the quantity of hand hygiene
unit in Ghana. J Infect Dev Ctries. 2009;3(5):352-
substance either soap or disinfectant solution along
356.
with clear demarcation on which practice to follow in
which circumstances. As it was observed the healthcare 6. Won S-P, Chou H-C, Hsieh W-S, et al. Handwashing
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 343

program for the prevention of nosocomial Surg Br. 2012;94(4):441-446. doi:10.1302/0301-

infections in a neonatal intensive care unit. Infect 620X.94B4
Control Hosp Epidemiol. 2004;25(9):742-746. 9. Lam BCC, Lee J, Lau YL. Hand hygiene practices
doi:10.1086/502470 in a neonatal intensive care unit: a multimodal
7. Halder AK, Molyneaux JW, Luby SP, et al. intervention and impact on nosocomial infection.
Impact of duration of structured observations on Pediatrics. 2004;114(5):e565-71. doi:10.1542/
measurement of handwashing behavior at critical peds.2004-1107
times. BMC Public Health. 2013;13(1):705. 10. Moghnieh R, Soboh R, Abdallah D, et al. Health
doi:10.1186/1471-2458-13-705 care workers’ compliance to the My 5 Moments
8. Chou DTS, Achan P, Ramachandran M. The for Hand Hygiene: Comparison of 2 interventional
World Health Organization “5 Moments of Hand methods. Am J Infect Control. 2017;45(1):89-91.
Hygiene” The Scientific Foundation. J Bone Jt doi:10.1016/j.ajic.2016.08.012
 344 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A Study to Assess the Effectiveness of Protocol on Care of

Newborn in Phototherapy on Knowledge and Practice among
Nurses at Selected Hospitals in South India

V.Santhi 1, S.Nalini1, Lisy Joseph2

1Lecturer, 2Lecturer Faculty of Nursing, Sri Ramachandra Institute of Higher Education &
Research(DU), Porur, Chennai
Abstract
• Background: The present study assess the Effectiveness of Protocol on

• Care of Newborn in Phototherapy on Knowledge and Practice among Nurses at

• Selected Hospitals in South India

Method and Material: A pre - experimental one group pre and post test study design was used to collect all
the necessary and relevant data from nurses. The study was conducted in the maternity ward and phototherapy
unit of two hospitals. Based on inclusion criteria 50 nurses were selected and non probability convenient
sampling techniques were used.

Results: In pre test level of knowledge of nurses regarding care of newborn in phototherapy, 17 (34%)
had inadequate knowledge, 19 (38%) had moderately adequate knowledge and 14 (28%) had adequate
knowledge. In post test majority of 44(88%) had adequate knowledge, 6 (12%) had moderately adequate
knowledge and no one had inadequate knowledge. The improved mean value for knowledge was 10.43 with
“t” value of 13.47 and improved mean value for practice was 6.78 with “t” value of 17.26. This results shows
the high statistical significance at p<0.001.

Conclusion: The study concludes that there was a significantly improvement of knowledge and practicable
in post test after administration of protocol. Thus protocol was observed to an effective tool to improve
the knowledge and practice on care of newborn in phototherapy and it may be useful to implement future
reference.

Keywords: Protocol, Nurses, Newborn, Knowledge, Practice, Hospital and south India.

Introduction dependent fetal existence to an independent being

capable of carrying on the physiological processes.
Newborns are considered to be tiny and powerless
This transition, in many babies takes place in a smooth,
beings, completely dependent on others for their
uneventful way.
adaptation in the external environment. Within one
minute of birth the normal newborn adapts from the In controversy to the above, a few newborns
face some minor disorders. During the process of
physiological adaptation for its survival, the neonate has
Corresponding Author: to face many life threatening problems, such as asphyxia,
Mrs.V.Santhi, M.Sc. Nursing hypothermia, hyperbilirubinemia, infections etc.
Lecturer, Sri Ramachandra Institute of Higher
One of the most important minor disorder that
Education and Research (DU), Porur, Chennai-600116,
occur in the newborn during the transition phase is
India, Phone no: 9952026153
hyperbilirubinemia. It is the yellow discoloration seen
Email:[email protected]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 345

in the skin and sclera due to an increase in the serum term newborn with a view to develop a nursing care
bilirubin level. Excess amount of bilirubin in the blood protocol. The study concluded that, most often newborns
that causes hyperbilirubinemia. (Halliday, H. L. 1989) with hyperbilirubinemia are treated with phototherapy
which was effective. It was noted that development of
Globally, 65% of the newborns develop a valid protocol for care of newborns in phototherapy
hyperbilirubinemia making it one of the most common would help practicing nurses to act promptly and
problems in the majority of the newborn.(William,W. independently.
Hay,. 2009).In India approximately 4 million babies are
born every year. Of them, 60 to 70% of the newborns Many studies in this area have been conducted in the
develop hyperbilirubinemia. These statistics indicate western countries and protocols have been developed.
that hyperbilirubinemia is a very common condition. But in India the investigator has observed that there is no
specific protocol used by nurses while caring for babies
Stokowski, L. A.3 (2006) said that proper nursing in phototherapy. Hence the care provided was observed
care enhances the effectiveness of phototherapy and to be inadequate and many complications arose for the
minimizes complications. Nursing responsibilities newborns. Having this in mind the investigator took up
include ensuring effective irradiance delivery, the responsibility of preparing a protocol to be followed
minimizing skin exposure, providing eye protection while providing care for babies in phototherapy and also
and eye care, carefully monitoring thermoregulation, decided to test the effectiveness of the protocol through
maintaining adequate hydration, promoting elimination a pre- experimental study. The investigator tries to focus
and supporting parent-new born interaction. the effectiveness of the protocol which is cheap and
Nurses play a vital role in providing comprehensive resourceful intervention to care for the newborn during
care for neonates on phototherapy based on their phototherapy and to assess the knowledge and practice
needs. Meticulous and appropriate nursing care during among nurses for the same.
phototherapy is the best way to prevent the complications.
Method and Material
Newman & Esterling4 (2000) stated that according The study was designed to assess the the
to the British Columbia Reproductive Care Program of effectiveness of protocol on care of newborn in
Neonates, hyperbilirubinemia is a common neonatal phototherapy on knowledge and practice among nurses
problem especially during the 1st week of life when at selected hospitals, Madurai. Investigator obtained
approximately 50 percent of all newborns have visible formal permission from the administrative officer of
jaundice, of them 8-20 percent of term neonates exceed Kasthuriba hospital and from the medical director of
the total serum bilirubin values of 13 mg/dl, and need Leonard hospital, Madurai prior to the initiation of the
phototherapy. study
All the above studies tell about the various Study Design: A quantitative research approach
complications that occur due to phototherapy, and stress includes the research design in this study was pre
that prevention can be possible with good care of the experimental one group Pretest – Post test study design
newborn. Neonates need close monitoring and careful was considered to be the most appropriate to achieve the
nursing measures to improve their health status and to set of objectives in this study. The objectives were to
prevent complication. assess the pre & post test level of knowledge and practice
During this time nurses play a very vital role in of nurses regarding care of newborn in photo therapy.
preventing complications and maintaining the well being To compare the pre and post test level of knowledge and
of the newborn. With growing technology in the health practice of nurses regarding care of newborn in photo
sciences and increasing specialization of the Nursing therapy. To correlate the mean improvement level of
profession, more rigorous control is required to ensure knowledge and practice among nurses regarding care
that nurses should possess sound scientific knowledge of newborn in phototherapy. To associate the mean
and skills to deliver safe and quality care. improvement knowledge and practice scores on care
of newborn in phototherapy with selected demographic
Asha P. Shetty 5 (2003) conducted an experimental variables. The study was conducted in maternity
study, to assess the effect of photo therapy among full ward and photo therapy units of two hospitals viz...
 346 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Kasthuriba hospital and Leonard hospital, Madurai. Content Validity and Reliability of the Tool
Kasthuriba hospital is a 200 bedded hospital which
has well established maternity ward and photo therapy Content validity of the tool and protocol was got
unit. Totally 35 - 40 newborns were admitted per from three nursing experts in the field of obstetrics and
month for the treatment of hyperbilirubinemia. Leonard gynecological nursing and two medical (DGO) experts.
hospital is a 250 bedded hospital.The phototherapy The reliability of the tool was established by using test-
unit has 15 phototherapy machines in which 25-30 retest method to assess the reliability for knowledge with
newborns were admitted per month for the treatment the same samples at different timings. The reliability
of hyperbilirubinemia. Totally 25 nurses are employed, score r = 0.9. To assess the reliability for the observational
all of them are posted in the maternity ward and check-list, inter -rater method was used. The r value was
phototherapy unit in a rotation. 0.87. It indicated highly positive correlation.

Study Population: Fifty nurses who are qualified Data Collection Procedure: The formal permission
and working in maternity ward and phototherapy unit was obtained from the administrative officer and from
were included in this study the medical director of hospital, Madurai. The data for
the study was collected with in the period of 4 weeks.
Inclusion Criteria: The nurses were working in During data collection period the investigator worked
photo therapy units and maternity wards and nurses were from 8 am to 4 pm for 5 days a week. The investigator
qualified as Diploma, B.Sc (N) Postbasic and B.Sc Basic covered 3-4 nurses per day. After getting their oral
(N). consent the investigator collected the pre test data using
structured questionnaire to assess the knowledge and
Description of the Tool: A non probability observational check list for assessing the practice. Each
convenience sampling technique was used in this study. nurse took 30 – 40 minutes to answer all the questions.
The tool of the study has three section. Section A: The The investigator spent 25-30 minutes for assessing the
demographic variables which includes age, gender, nurses’ practice on care of newborn in phototherapy.
professional education, year of experience in service, After the completion of the pre test data collection,
total year of experience in phototherapy unit and source the protocol on care of newborn in phototherapy was
of information. administered to the nurses. After 7 days post test was
Section B:A structured knowledge questionnaire, conducted by using the same structured questionnaire
it’s consists of 30 multiple choice questions with 4 and observational check list for the same samples. The
options and a single correct answer. Correct answer data obtained were analyzed using both descriptive and
carries 1 mark and wrong answer carries-0 mark.The inferential statistics.
Questions covered the following aspects -Knowledge
about hyperbilirubinemia–13, Knowledge about
Findings
phototherapy – 7 and Care of newborn in phototherapy The findings from the study are tabulated, analyzed
- 10. and interpreted below. In relation to demographic
variables, the majority of 14 (28%) were in the age
The knowledge and practices score range as group of more than 31 years, 40 (80%) were females, 28
follows (56%) had completed GNM.

Range Score

> 75 % Adequate knowledge

50 – 75 % Moderately adequate knowledge

< 50 % Inadequate knowledge

Section C : The observation check list has 25 items.

The items were in the ‘Yes’ or ‘No’ form. The score for
yes is ‘one’ and No ‘Zero’.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 347

Table 1 : Frequency and percentage distribution of the Pre test & Post test level of knowledge of nurses
regarding care of newborn in phototherapy.

N=50

Pre Test Post Test

Moderately Moderately
Inadequate Adequate Inadequate Adequate
Adequate Adequate
VARIABLES (< 50%) (> 75 %) (< 50%) (> 75 %)
(50 – 75%) (50 – 75%)

NO % NO % No % NO % NO % NO %

Knowledge about 16 32 25 50 9 18
- - - - 50 100
hyperbilirubinemia

Knowledge about 19 38 26 52 5 10
- - 6 12 44 88
phototherapy.

Care of Newborn in
13 26 19 38 18 36 - - - - 50 100
phototherapy

Table 2: Frequency and percentage distribution of the Pre & Post test level of practice of nurses regarding
care of newborn in phototherapy. N-50

Inadequate Moderately Adequate Adequate

(< 50%) (50 – 75%) (> 75 %)
PRACTICE
VARIABLES
NO % NO % NO %

Pre test 2 4 38 76 10 20
88
Post test - - 6 12 44

Table 3 : Comparison of pre test and post test level of Knowledge and practice among nurses regarding
care of newborn in phototherapy. N= 50

Variables Knowledge Practice

Mean SD ‘t’ value Mean SD ‘t’ value

Pre test 2.55

17.78 6.67 16.24
13.47 *** 17.26 ***
Post test 2.48
28.12 2.88 23.02
*** P < 0.001
 348 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 4 : Correlation between the overall mean source of information at p<0.05. The other demographic
improvement level of knowledge and practice of variables have no significant association with the
nurses regarding care of newborn in phototherapy. knowledge of nurses. Regarding practice the results
revealed that there was no statistically significant
N = 50 association of the mean improvement level of practice
with the selected demographic variables.
POST TEST
Conclusion
VARIABLES
Mean S.D ‘ r’ Value The present study was conducted to assess the
effectiveness of protocol on knowledge and practice
Knowledge 28.12 2.88 regarding care of newborn in photo therapy among
0.813 ***
nurses in maternity ward and photo therapy unit of
Practice 23.02 2.48 Kasthuriba and Leonard hospitals at Madurai, 2009.
*** P < 0.001 From the results of the study it was concluded that
protocol on care of newborn is an effective method to
With regard to level of knowledge the post test improve the knowledge and practice level of nurses.
mean score was 28.12 and S.D was 2.88. With regard The findings revealed that the nurses, who had good
to level of practice, the mean was 23.02 and S.D. was knowledge about care of newborn in photo therapy, will
2.48 .The calculated ‘r’ value was 0.813 which show have good practice too.
that there was a positive correlation between the overall
mean improvement level of knowledge and practice at a Implications:
statistically significant level of p < 0.001.
Nursing Practice:
The present study supported by Milly Mathew
Nurses working in maternity ward and photo therapy
(2003) on the topic can the self instructional module
unit should have adequate knowledge and practice about
improves the nurse’s knowledge on neonatal
care of newborn in photo therapy . The nurses should
hyperbilirubinemia. The findings revealed that the self
update their knowledge by in service education and
instructional module was effective in increasing the
continue nursing education programs. Nurses who have
knowledge level of nursing personal with a t value of
good knowledge and practice regarding care of newborn
t=15.68 at p<0.5 level. The correlation r value between
in photo therapy will be able to promote the newborns
the knowledge and practice was r=0.93 which showed a
health and thereby reduce the neonatal morbidity and
good positive correlation.
mortality.
Discussion Nursing Administration:
The present study was done to assess the The administrator has important role in creating
effectiveness of protocol on care of newborn in awareness to increase the knowledge about care
phototherapy on knowledge and practice among nurses of newborn in photo therapy. In order to develop
at selected hospitals, Madurai. The implementation of professional knowledge she has to make arrangements
protocol was effective intervention during phototherapy to conduct regular in-service education and continue
on the nurses and the overall health profession. Data nursing education programs on care of newborn in photo
were analyzed from 50 nurses. The overall pre test mean therapy.
score was 16.24 with S.D was 2.55 and the post test mean
was 23.02 with S.D was 2.48 and the calculated ‘t’ value Nursing Education:
was 17.26 which had statistically high significance at P
< 0.001 level. The protocol was found to be effective in The nursing curriculum should be strengthened
improving the practice of nurses regarding phototherapy to enable nurses to excel in knowledge and practice
of care of newborn in photo therapy. Students should
Regarding association of mean improvement level be encouraged to have hands on experience in photo
of knowledge of nurses regarding care of newborn in therapy units. Monitoring and assessing the newborn
phototherapy with selected demographic variables of condition during photo therapy should be included as a
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 349

clinical procedure. 3. Stokowski .L.A,. Fundamentals of phototherapy for

neonatal hyperbilirubinemia. Advanced Neonatal
Nursing Research: Care. 2006; 6(6):303-312.
The findings of study can be disseminated to clinical 4. Newman et al. Jaundiced noted in first 24hours after
nurses and student nurses through web site, literature, birth in managed care. Journal of Pediatrics. 2001;
journals etc. The findings of the study will help the 12(6):1388-1393.
professional nurses and nursing students to improve 5. Asha .P. Shetty. Effect of phototherapy among newborn
their knowledge and practice with a view to develop a nursing care protocol.
Nursing Journal of India. 2003; 114(7):149-150.
Recommendations:
6. Milly Mathew. The topic can the self instructional
− The protocol can be placed in the maternity and module improve the nurses knowledge on neonatal
phototherapy units for the nurses to read and follow. hyperbilirubinemia. Manipal Academy of Higher
Education, Manipal University. 2003; 15 (6): 205-
− A similar study can be conducted by increasing 210
the samples size in different setting for better
7. Abrol .P. Effect of phototherapy on behavior of
generalization.
jaundiced Neonates. The Journal of Indian
− A comparative study can be done at various Pediatrics. 2008June; 38(3):278-280.
setting. 8. Agarwal. Deorari R T. Hyperbilirubinemia in newborn.
Indian Journal of Pediatrics. 2001; 68(10):977-980.
− A comparative study can be done on knowledge
and practice between diploma nurses and B.Sc nurses. 9. Agarwal Ramesh. Phototheapy units. Journal of
Neonatology. 2001; 12 (1):61-68.
Limitation: 10. Amirshaghaghi et. al. Knowledge and practice of
nurses on neonatal hyperbilirubinemia. Journal of
- The investigator faced difficulty in seeking
Biological Science.2008; 15(6):942-945.
permission in selected hospitals.
11. Atkinson et.al. Phototherapy use in jaundiced
- The investigator faced ample difficulty in newborns. Journal of Perinatology. 2003;14(8):126-
collecting related literature as there was an only limited 128.
study on knowledge and practice among nurses. 12. Augustiion T. Common Clinical problems
Ethical Clearance- Taken from institutional ethical in newborn. Journal of Neonatology. 2000;
committee faculty members 46(10):464-466.
13. Berg and Lindelf. Phototherapy of newborns skin
Source of Funding- Self funding       risk factor for malignant melanoma. Journal of
Conflict of Interest – Nil Indian Pediatrics. 2001; 39(10):915-917.
14. Bertini .G. et. al. Bronze baby syndrome and the
References risk of kernicterus. Journal of Pediatrics. 2005;
94(7):968-971.
1. Halliday H L, McClure B G, Reid M. Neonatal
intensive care. In: Glenys Connolly, editor. Hand 15. Boo G, Lee.M. Effectiveness of Oral versus IV
book of Neonatal intensive care. 4 ed. London: fluid supplementation during phototherapy. Journal
Bailliere Tindall; 1989:111 of Indian Pediatrics. 2002; 35(1):52-56.
2. William,W.Hay, Neonatal Emergencies. In 16. Boyd .S. Treatment of physiological Neonatal
Georg Hansmann, editor. Textbook of Neonatal jaundice. Nursing Times. 2004; 100(33):40-43.
Emergencies. 1 ed. St Louis : Missouri Saunders
publication ;2009:84
 350 Indian Journal of Public Health Research
Type&ofDevelopment, January 2020, Vol. 11, No. 1
manuscript: Research

Analysis of Dermatoglyphic Pattern in Potentially Malignant

Disorder and Oral Carcinoma Patients

Vaishali.S1, Sreedevi Dharman2

1Graduate Student, 2Reader, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences,
Chennai, India.

Abstract
Aim: To assess the association between dermatoglyphic pattern and potentially malignant disorders and
oral squamous cell carcinoma patients which might help in predicting the occurrence of these two disorders.

Background: Dermatoglyphics are the dermal ridge configuration on the digits, palms and soles. They
are genetically determined and influenced by environmental forces that are operating before birth. Several
studies have shown association between dermatoglyphics and different types of cancer. Hence this study
was undertaken to determine whether specific dermatoglyphic patterns exists which help in predicting the
occurrence of oral squamous cell carcinoma (OSCC) and oral potentially malignant disorders.

Materials and Method: After explaining about the study to the subjects, an informed consent will be
obtained. A detailed history with thorough clinical examination will be done and findings will be recorded
. The clinically diagnosed cases of potentially malignant disorders and oral squamous cell carcinoma will
be confirmed histopathologically and will be included in the study. Finger and palm prints will be collected
using ink method from 10 subjects with oral squamous cell carcinoma, 15 subjects with potentially malignant
disorders and 25 healthy controls and will be evaluated qualitatively and quantitatively.

Results: Arches and loops were more frequent in cases than in controls whereas whorls were more frequent
in control group. 80% of the patients with potentially malignant disorders have loop pattern, 40% of the
patients has arches and 30% have whorls. 50% of the patients with oral squamous cell carcinoma have loop
pattern, 30% have arch pattern and 20% have whorl pattern. 68% of the control group have whorl pattern,
20% have arch pattern and 12% have loop pattern.

Conclusion: This study concluded that dermatoglyphic patterns may have a role in identifying individuals
either with or at risk for developing potentially malignant disorders like leukoplakia, oral submucous fibrosis
, lichen planus etc and oral squamous cell carcinoma . Hence it can be used to identify high risk group, so
that early primary and secondary preventive measures can be instituted in order to prevent the occurrence
of these lesions.

Keywords: Potentially malignant disorders, oral squamous cell carcinoma, dermatoglyphics, arches, loops,
whorls.

Introduction
Corresponding Author
Dr. Sreedevi Dharman Since the early days of civilization, the features
Department of Oral medicine and Radiology, of the hands have fascinated scholars, doctors, and
Saveetha Dental College, Saveetha Institute of Medical laymen alike. Through decades of scientific research,
and Technical Sciences, 162, Poonamalle High Road the hand has come to be recognized as a powerful tool
Chennai 600077, Tamil Nadu, India. in the diagnosis of psychological, medical, and genetic
Email id: [email protected] conditions. Cummins in 1926 first introduced the term
Telephone number: 9841009003 “dermatoglyphics” which refers to the study of the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 351

naturally occurring patterns of the surface of the hands obtained. A detailed history with thorough clinical
and feet1.Dermatoglyphics is a relatively new science, examination will be done and findings will be recorded
which involves the study of fine patterned dermal ridges . The clinically diagnosed cases of potentially malignant
on digits, palms and soles. Cummins and Midlo (1926) disorders and oral squamous cell carcinoma will be
coined the term dermatoglyphics (derma = skin; glyphics confirmed histopathologically and will be included
= carvings), for the scientific study of ridges as well as the in the study. Finger and palm prints will be collected
ridges themselves 2. Since then, this approach has been using ink method from 10 subjects with oral squamous
used in various scientific studies to establish relationship cell carcinoma, 15 subjects with potentially malignant
of fingerprints as genetic and/or chronic health markers. disorders and 25 healthy controls and will be evaluated
Dermatoglyphic patterns are genetically determined and qualitatively and quantitatively.
remain unchanged from birth to death. Dermatoglyphics
is considered as a window of congenital and intrauterine
abnormalities. At present, several researches claim this
study of dermatoglyphics as an important diagnostic tool
for some diseases especially the diseases with obscure
etiology and mysterious pathogenesis 3. Widespread
interest in epidermal ridges developed only in the last
several decades when it became apparent that many
patients with chromosomal aberrations had unusual ridge
formations. Unusual ridge configurations have been
shown to exist not only in patients with chromosomal
defects but also in patients with single gene disorders
and in some in whom the genetic basis of the disorder
is unclear 4. In dentistry, dermatoglyphics have been
studied to help predict disorders like cleft lip and cleft
palate, dental caries, malocclusion, congenital anomalies Fig 1: Patient with oral submucous fibrosis.
like ectodermal dysplasia, gingival fibromatosis,
periodontitis, bruxism etc 5. Since epidermal ridge
patterns form early in fetal development and remain
unchanged throughout life 6,7 unusual dermatoglyphics
may indicate gene or chromosomal abnormalities
consistent with diseases such as oral leukoplakia, oral
submucous fibrosis and oral squamous cell carcinoma.
Potentially malignant disorders, conveys that not
all lesions and conditions may transform to cancer,
some may have an increased potential for malignant
transformation. These disorders of the oral mucosa are
also indicators of risk of likely future malignancies Fig 2: Patient with leukoplakia
elsewhere in the oral mucosa and not only site specific
predictors 8.This study was undertaken to study
dermatoglyphic patterns in individuals with potentially
malignant disorders and oral squamous cell carcinoma,
so that individuals with habits and similar patterns can
be identified at the earliest and preventive measures can
be instituted in these susceptible individuals to prevent
the occurrence of potentially malignant disorders and
oral squamous cell carcinoma.

Materials and method: After explaining about

the study to the subjects, an informed consent will be
Fig 3: Patient with lichen planus
 352 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Fig 4: Shows different dermatoglyphic pattern

Results The above table shows distribution of various

finger print patterns in patients with oral squamous cell
Arches and loops were more frequent in cases
carcinoma.50% of the patients with oral squamous cell
than in controls whereas whorls were more frequent in
carcinoma have loop pattern, 30% have arch pattern and
control group.
20% have whorl pattern.
Table 1: Fingerprint pattern in patients with
Table 3:Fingerprint pattern in control group
potentially malignant disorders

Potentially Malignant PATTERN CONTROL GROUP

Pattern
Disorders
Arches 20%
Arches 40%
Loops 12%

Loops 80% Whorls 68%

The above table shows distribution of various finger
Whorls 30% print patterns in control group.68% of the control group
have whorl pattern, 20% have arch pattern and 12%
The above table shows distribution of various finger have loop pattern.
print patterns in patients with potentially malignant
disorders. 80% of the patients with potentially malignant
disorders have loop pattern, 40% of the patients has
arches and 30% have whorls.

Table 2: Fingerprint pattern in patients with oral

squamous cell carcinoma

Oral Squamous Cell

Pattern
Carcinoma

Arches 30%
Fig 5: Graph showing different fingerprint pattern in
Loops 50% potentially malignant disorder patients, oral squamous cell
carcinoma patients and control group
Whorls 20%
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 353

Discussion 11.Yet another study found an increased proportion of

ulnar loops in cancer patients.
Dermatoglyphics refers to epidermal ridges present
on the palm, sole, fingers, and toes. These epidermal The dermal ridges have various notable
ridges are formed in the same intrauterine period when characteristics which make them important, not only in
neuronal development takes place in the intrauterine personal identification, but also in human biology for
life of a fetus. Thus, dermatoglyphics is correlated with various reasons. Firstly, unlike many bodily traits the
genetic abnormalities and is useful in the diagnosis dermal ridges and configuration once formed remain
of congenital malformations and many other medical unchanged except in dimensions, i.e. they are age stable.
disorders. Since then widespread interest in epidermal The ridges are environment stable and begin to appear
ridges developed in medical field since it became apparent from 5th month of embryonic life. Although the patterns
that many patients with chromosomal aberrations had formed by ridges vary in size, shape and detailed
unusual ridge formations. Inspection of skin ridges, structures, still they can be classified into definite main
therefore seemed promising, simple, inexpensive means types. The dermatoglyphic features can thus be exploited
for determining whether a given patient had a particular quantitatively and qualitatively to be used as “genetic
chromosomal defect 9. SCC is a widespread disease marker” of a disorder.
associated with considerable amount of morbidity and
mortality. It is a major worldwide health problem and Considering the high mortality and high morbidity
the number of sufferers is increasing rapidly due to rate due to oral cancer in India, we planned to assess
more and more people embracing deleterious habits palmar dermatoglyphics in potentially malignant
such as tobacco chewing, smoking and alcohol abuse. disorders and OSCC and find whether a correlation exists
Similarly OSF is a widespread precancerous condition between potentially malignant disorders, oral squamous
especially prevalent in South East Asia. Areca nut is an cell carcinoma and palmar dermatoglyphics. Our study
important predisposing factor, but not all the patients revealed differences in the dermatoglyphic patterns
with chronic habits suffer from the disease. Conversely, among various groups which could be considered
not all the patients with OSF have a prolonged history of genetic markers for detecting those who are predisposed
areca nut or tobacco consumption. It is said that genetic to develop potentially malignant disorders and oral
susceptibility is responsible for such variations. squamous cell carcinoma.Hardly any dermatoglyphic
study has been carried out in relation to oral malignancy,
Tobacco and alcohol are established risk factors hence more studies with larger sample need to be
for oral leukoplakia, oral submucous fibrosis and Oral undertaken to conclude the results.
squamous cell carcinoma, substantial evidence also
suggest that the carcinogenic process is driven by the Conclusion
interaction between exposure to exogenous carcinogens
Arches and loops were more frequent in cases than
and inherent genetic susceptibility. In response to
in controls whereas whorls were more frequent in control
environmental exposures, genetic damage accumulates
group.This study concluded that dermatoglyphic patterns
more quickly in individuals with genetic susceptibility
may have a role in identifying individuals either with or
to DNA damage than in those without such instability
at risk for developing potentially malignant disorders
but with a similar exposure. Consequently, individuals
like leukoplakia, oral submucous fibrosis , lichen planus
with genetic instability might be at a greater risk for
etc and oral squamous cell carcinoma . Hence it can be
developing these lesions 10.
used to identify high risk group, so that early primary
In this study Arches and loops were more frequent and secondary preventive measures can be instituted in
in cases than in controls whereas whorls were more order to prevent the occurrence of these lesions.
frequent in control group. Atasu et al, in examining
Ethical Clearance – Taken from Instituitional
dermatoglyphics and cancer patients in general, one
Ethical Committee
of the studies has noted an increase in whorls and a
decrease in radial loops in 201 Turkish cancer patients8 Source of Funding- Self
which was contradictory to this study. Kindred et al,
found that ,with different cancers found more whorls to Conflict of Interest- Nil
be present and in studying high risk found more whorls
 354 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

References 6. Galton F. Finger prints. London: McMillan; 1982.

1. Cummins H, Midlo C. Fingerprints, Palms and 7. Henry ER. Classification and uses of finger prints.
Soles: An Introduction to Dermatoglyphics. New 8th ed. London: H. M. Stationary Office; 1937.
York: Dover Press; 1961. p. 319. 8. Atasu M, Telatar H. Cancer and dermatoglyphics.
2. Schaumann B, Alter M. Dermatoglyphics in Lancet 1968;20:861.
medical disorders. New York: Springer Verlag; 9. Whitelaw WA. The proceedings of the 11th annual
1976. history of medicine days. Available from: http://
3. Miller JR, Giroux J. Dermatoglyphics in pediatric www.hom.ucalgary.ca/dayspapers2002. pdf.
practice. J Pediatr. 1966;69:302–12. 10. Lynch HT, Kaplan AR, Moorhouse A, Krush
4. Cloos J, Spitz MR, Schantz SP, Hsu TC, Zhang ZF, AJ, Clifford G. Dermatoglyphic peculiarities in
Tobi H, et al. Genetic susceptibility to head and members of a high-cancer-risk kindred. Prog Exp
neck squamous cell carcinoma. J Natl Cancer Inst Tumor Res 1974;19:325-32.
1996;88:530-5. 11. Wu X, Lippman SM, Lee J, Zhu Y, Wei QV, Thomas
5. Kanematsu N, Yoshida Y, Kishi N, Kawata K, M, et al. Chromosome instability in lymphocytes:
Kaku M, Maeda K, et al. Study on abnormalities in A potential indicator of predisposition to oral
the appearance of finger and palm prints in children premalignant lesions. Cancer Res 2002;62:2813-8.
with cleft lip, alveolus, and palate. J Maxillofac
Surg. 1986;14:74–82.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 355

Evaluation of Safety and Efficay of Nifedipine in Pregnancy

Induced Hypertension: A Prospective Observational Study

Venkateswarlu K.1, T. Ram Mohan Reddy 2, B. Naveena3, E. Sneha Reddy3, A. Prithi1

1Assistant Professor, 2 Associate Professor, 3Pharm. D, Department of Pharmacy Practice,
CMR College of Pharmacy, Hyderabad

Abstract
Introduction: Pregnancy induced hypertension (PIH) is a pregnancy specific, multisystem disorder
characterized by development of edema, hypertension and proteinuria after 20 weeks of gestation. The
group of diseases includes preeclampsia and eclampsia, which are peculiar to pregnancy. Antihypertensive
treatment should be commenced in all women with a systolic blood pressure ≥170 mm Hg or a diastolic
blood pressure ≥110 mm Hg because of the risk of intracerebral hemorrhage and eclampsia.

Aim: To evaluate the safety and efficacy of nifedipine in gestational hypertension.

Methodology: A Prospective observational study was conducted in outpatient and inpatient department of
obstetrics and gynaecology of Government hospital for a period of one year (November 2017 - November
2018).Inclusion criterion of the study was to collect and analyse the case sheets of patients having Gestational
hypertension and Gestational age of >20 weeks admitted in the hospital and visited outpatient department
during one year duration. Exclusion criterion of this study was patients having chronic hypertension,
Gestational age of <20 weeks, Patients who were diagnosed with other causes of convulsions in pregnancy
like cerebral malaria and epilepsy and Patients not willing to participate in the study.

Results and Discussion: In the present study, 70(68.62%) patients were treated with nifedipine and rest
32(31.37%) patients were treated with other antihypertensive. Nifedipine showed significantly better clinical
outcomes in comparison to other anti hypertensive. Nifedipine safety profile in terms of adverse effects was
significantly better than other anti hypertensive. IUGR had greater relative risk compared to other fetal
outcomes while relative risk was significantly less for maternal outcomes in patients treated with nifedipine.

Conclusion: Our study results implicated the efficacy of nifedipine in pregnancy induced hypertension in
terms of clinical outcomes, type of delivery, maternal outcomes and fetal outcomes and incidence of adverse
effects.

Key words: Pregnancy induced hypertension, Preeclampsia, Anti hypertensive, Nifedipine.

Introduction by development of edema, hypertension and proteinuria

after 20 weeks of gestation [1]. The group of diseases
Pregnancy induced hypertension (PIH) is a
includes preeclampsia and eclampsia, which are peculiar
pregnancy specific, multisystem disorder characterized
to pregnancy [2].Hypertension in pregnancy is defined
as systolic blood pressure greater than or equal to 140
mmHg and/or diastolic blood pressure greater than or
Corresponding Author: equal to 90 mmHg. Severe hypertension in pregnancy
Dr. Venkateswarlu K. Pharm. D. is defined as a systolic blood pressure greater than or
Assistant Professor, Department of Pharmacy Practice equal to 170 mmHg and/or diastolic blood pressure
Email: [email protected] greater than or equal to 110 mmHg [3].Hypertensive
91+8106203903, CMR College of Pharmacy disorders in pregnancy include Gestational hypertension,
Hyderabad-501401 Preeclampsia – eclampsia, chronic hypertension–
 356 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

essential, secondary and white coat. Risk Factors for complications of hypertensive disorders of pregnancy.
Preeclampsia - Moderate risk: Age 40 years or more, With efficient antenatal care and early treatment of
first pregnancy, Multiple pregnancy, Interval since last pregnancy induced hypertensive disorders, the serious
pregnancy of more than 10 years, Body mass index of 35 form i.e. eclampsia has become almost a clinical rarity
or more at presentation, Family history of pre-eclampsia, in developed countries. However, in developing country
Nulliparity, Multifetal gestation, Obesity, Preeclampsia like India and in the rural population, it still continues
in a previous pregnancy and Abnormal uterine doppler to be a major obstetric problem. Moreover the disease
studies at 18 and 24 weeks [4]and High risk: Chronic not only affects pregnancy outcome but also predisposes
hypertension, Chronic kidney disease, Hypertensive mother and child to long term health complications like
disease during a previous pregnancy, Autoimmune cardiovascular diseases [8].This study attempts to look
disease, Pregestational diabetes mellitus and Presence of how these complications can be minimised/managed.
thrombophilia[4].Antihypertensive treatment should be Also this study helps to know the prevalence of
commenced in all women with a systolic blood pressure pregnancy induced hypertension and its complications.
≥170 mm Hg or a diastolic blood pressure ≥110 mm
Hg because of the risk of intracerebral hemorrhage and Methodology
eclampsia. Severe hypertension can be treated using A Prospective observational study was conducted
drugs like Nifedipine which is administered as a 10mg in outpatient and inpatient department of obstetrics
oral dose initially, with a repeat dose of 10mg if there and gynaecology of Government hospital for a period
is inadequate response after 30 minutes. Intravenous of one year (November 2017- November 2018), which
labetalol: This is administered as a 20-50 mg bolus dose provides specialized healthcare services to people.
over 2 minutes. Hydralazine: It is 3rd agent of choice Before initiation of the study, approval was obtained
administered as an IV or IM dose of 5-10 mg every 20- from Institutional Human Ethical Committee of the
30 min to control hypertension of ≥170 systolic and/ hospital. Main aim is to study the management of
or 110 diastolic. Ongoing Treatment for Hypertension: gestational hypertension. Objectives of the study include
In terms of lowering blood pressure in preeclampsia, a comparing different antihypertensive drugs given in the
number of drugs have demonstrated safety and efficacy gestational hypertension patients, identify and assess
[5].Antihypertensive treatment duration depends on
the impact of various factors that influence maternal
clinical symptoms and patients response to therapy [6]. morbidity and mortality, determining type of delivery
Medication adherence is essential to prevent PIH related and to determine different maternal and fetal outcomes
complications [7]. First line drugs include methyldopa associated with the gestational hypertension. Inclusion
and labetalol. Second line agents are Hydralazine, criterion of the study was to collect and analyse the case
Nifedipine and prazosin. Nifedipine prevents calcium sheets of patients having Gestational hypertension and
from entering cells of the heart and blood vessel walls, Gestational age of >20 weeks admitted in the hospital
resulting in lower blood pressure [8]. Angiotensin and visited outpatient department during one year
converting enzyme (ACE) inhibitors and angiotensin duration. Exclusion criterion of this study was patients
receptor blockers are contraindicated in pregnancy. having chronic hypertension, Gestational age of <20
Their use in the third trimester has been associated with weeks, Patients who were diagnosed with other causes
fetal death and neonatal renal failure. Drug of choice of convulsions in pregnancy like cerebral malaria
for the prevention of eclampsia is MgSo4. Magnesium and epilepsy and Patients not willing to participate in
sulphate therapy is recommended for use antepartum, the study. Data Analysis: The categorical variables
intrapartum and within the first 24 hours postpartum for were represented in number and percentage. Data was
severe pre-eclampsia. Need of the Study: Every year analysed using SAS version 9.1.
nearly 5, 29,000 women die globally due to pregnancy
related causes. For each death nearly 118 women suffer Results
from life threatening events or severe acute morbidity.
Hypertensive disorders of pregnancy seem to be one of the A total of 102 patients with pregnancy induced
major causes of maternal morbidity and mortality leading hypertension were identified and managed using anti-
to 10-15% of maternal deaths specially in developing hypertensive medications. In the present study, patients
world [2]. World Health Organization (WHO) estimates with age 22-25 yrs42 (41.7%) showed higher incidence
that at least one woman dies every seven minutes from of PIH followed by 18-21yrs 38 (37.25%).In this study
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 357

patients of primigravida 57 (55.88%) showed increased placental abrasion showed lower relative risk 0.85 and
risk for PIH when compared to multigravida. In the 1.14 respectively and other information was detailed
present study, clinical symptoms like pedal oedema 90 in table 3. In this study, IUGR showed relative risk
(88.2%) followed by proteinuria 49 (47.65%) showed of 1.06 compared to other fetal outcomes in patients
higher predominance in PIH. In the present study, treated with Nifedipine were mentioned in table 4. In
patients with PIH were treated using Nifedipine70 the present study, clinical outcomes in patients treated
(68.62%) and further details are given in table 1. In the with Nifedipine and other drugs group was compared
present study, low birth weight 59 (57.84%) showed using p value and their details were mentioned in the
predominance in patients diagnosed with PIH. In table 5. In the present study, incidence of adverse
this study, LSCS showed lower relative risk (0.91) in effect like pedal edema was low in patients treated with
patients treated with nifedipine and remaining details are Nifedipine 30(42.86%) when compared with other drugs
mentioned in the table 2. In terms of maternal outcomes 18(56.25%) and remaining details were mentioned in
in patients treated with Nifedipine, oligohydromnios and table 6.

Table -1: Distribution according to choice of drug

S. No Drugs No of pts Percentage

1 Nifedipine+ labetalol and others 70 68.62

2 Labetalol and other drugs without nifedipine 32 31.37

Table – 2: Assessment of type of delivery in patients treated with Nifedipine

Nifedipine

YES NO
Confidence
Relative Risk
70 32 Interval

YES 44 22
LSCS 0.91 0.68-1.22
NO 26 10

YES 28 08
NVD 1.22 0.94-1.57
NO 42 24

Table – 3: Assessment of maternal outcomes in patients treated with Nifedipine

Nifedipine

YES NO Confidence
Relative Risk
70 32 Interval

YES 43 19
Nil 1.03 0.68-1.22
NO 27 13

YES 14 09
Oligo 0.85 0.60-1.22
NO 56 23

YES 13 04
Placental 1.14 0.84-1.54
NO 57 28
 358 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table – 4: Assessment of fetal outcomes in patients treated with Nifedipine

Nifedipine

YES NO
Confidence
Relative Risk
Interval
70 32

YES 44 22
Normal 0.92 0.70-1.20
NO 26 10

YES 18 07
IUGR 1.06 0.79-1.42
NO 52 25

YES 08 04
Still birth 0.95 0.62-1.45
NO 60 26

Table - 5: Comparison of clinical outcomes in Nifedipine and other drugs group

Nifedipine Without Nifedipine P value

Systolic BP 124.81± 18.46 132.16±19.52 0.0063

Diastolic BP 79.86±10.05 85.52±11.23 0.0002

Table-6: Distribution of adverse effects in patients on nifedipine and other anti- hypertensive.

Adverse Effects Without Nifedipine Nifedipine

Pedal edema 18 (56.25%) 30 (42.86%)

Headache 16 (50%) 26 (37.14%)

Sweating 19 (59.37%) 21 (30%)

Dizziness 22 (68.75%) 27 (38.57%)

Nausea and Vomiting 20 (62.5%) 25 (35.17%)

Facial Edema 17 (53.13%) 28 (40%)

Discussion the incidence of PIH and eclampsia was higher in the

age group of 22-25 years followed closely by the age
The aim of antihypertensive therapy in the
group of 18-21 years. Similar studies were conducted
management of pregnancy induced hypertension is
by Vidyadhar et al [1]and stated that maternal age less
to prevent complications due hypertension while
than 20 years was the strongest risk factor for both
prolonging the course of pregnancy. The aim of
preeclampsia and eclampsia. Xu Xiong et al [10]concluded
antihypertensive therapy is to achieve a blood pressure
that mean maternal age for PIH was 25.8 years. The
lower than 170/110 mm of Hg but not lower than 130/90
present study revealed that, PIH was more common
mm of Hg without compromising uteroplacental blood
among primigravida when compared to secondpara
flow and placental perfusion. In the present study,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 359

and multipara. Studies conducted by Vidyadhar et al Conclusion

[1]
revealed that 65% were primigravida among the
PIH needs early diagnosis and treatment through
study conducted in PIH patients. Thus primigravida are
regular antenatal checkups to prevent it and its
under higher risk for PIH than multigravida. It is now
complications. The incidence of PIH is high among
believed that the high risk is related to the maternal first
the patients with age 22 to 25 yrs. Our study results
exposure to chorionic villi, specifically the trophoblast,
implicated the efficacy of nifedipine in pregnancy
which is of fetal origin. Maximum numbers of patients
induced hypertension in terms of clinical outcomes, type
were clinically presented with pedal edema followed
of delivery, maternal outcomes and fetal outcomes and
by proteinuria. In eclamptic patient headache, vomiting
incidence of adverse effects. Inclusion of Nifedipine
and seizures are also associated with pedal edema and
in anti hypertensive treatment is founded to be fairly
proteinuria. In the present study of the total women who
efficacious over treatment without it.
developed PIH, 68.62% were prescribed with Nifedipine
and other drugs (methyldopa, magnesium sulphate and Conflicts of Interest: There are no conflicts of
furosemide). 31.37% were prescribed with labetalol and interest.
other drugs without Nifedipine. Similar results were
supported in the study conducted by Punam D. Sachdeva Source of Funding: Self.
et al[9]. Pregnancy induced hypertension increases the
Acknowledgment: We sincerely and whole
risk of low birth weight. In our study the incidence of low
heartedly convey our regards to all doctors, nursing staff
birth weight 59(57.84%) is higher than the ideal birth
and other medical staff of gynaecology department who
weight 43 (42.15%) which supported by a study “Impact
helped us in data collection and interpretation.
of pregnancy induced hypertension on birthweight
by gestational age” conducted by Xu Xiong et al [10]. References
As PIH is one of the major maternal complications, in
order to prevent maternal and fetal mortality maximum 1. Vidyadhar BB, Purushottam AG, Aditi SM.
cases are delivered by caesarean section unless vaginal Maternal and Foetal Outcome in Pregnancy Induced
delivery is impossible, LSVD showed relative risk Hypertension: A Study from Rural Tertiary Care
lower than normal delivery concluding appropriateness Teaching Hospital in India. International Journal of
of the management. In our study the adverse maternal Biomedical Research. 2011; 2(12):595-599.
outcomes are at lower incidence implicating efficacy 2. Nusrat N, Ahson M, Nisar AS, Munir A.
of Nifedipine in PIH patients. The maternal outcomes Hypertensive Disorders of Pregnancy: Frequency,
observed in our study were oligohydromnios and Maternal and Fetal Outcomes. Pakistan Armed
placental having higher relative risk. Similar results Forces Medical Journal. 2010; (1):72-75.
were stated in the study conducted by Vidyadhar et 3. Sibai BM, Diagnosis and Management of
al[1]. In this study the observed fetal outcomes were Gestational Hypertension and Preeclampsia.
normal 66(94.28%) followed by IUGR 25(35.71%) and The American College of Obstetricians and
still birth 12(17.14%), and the relative risk is higher Gynecologists. 2003; 102(1):181-192.
for IUGR. Similar results were concluded in the study
4. Hypertension in Pregnancy–Medical Management.
conducted by Xu Xiong et al[10].Clinical outcomes of
Clinical guidelines. King Edward Medical Hospital.
Nifedipine and other antihypertensives where compared
2003:1-19.
and the p-value calculated showed significant efficacy
of Nifedipine among other antihypertensives in PIH 5. Lowe SA, Brown MA, Dekker G, Gatt S, Mclintock
treatment and outcomes. Nifedipine was concluded to C, Mcmahon L et al., Guidelines for the Management
be the effective drug in treatment of severe hypertension of Hypertensive Disorders of Pregnancy. Society of
in pregnancy and preterm labour by Patricia Smith et Obstetric Medicine of Australia and New Zealand.
al [11]in their study. Results of our study showed lower 2008; (1):1-31.
incidence of adverse effects with Nifedipine, compared 6. Kamala S, Pragathi D, Venkateswarlu K.
to other anti hypertensive drugs. A study conducted by CALCIUM CHANNEL BLOCKERS INDUCED
Chava.Jhansi et al [12] concluded similar results. PERIPHERAL EDEMA. IJPSR 2016; 7:290-3.
7. Venkateswarlu K, Ram Mohan reddy T. COMPARE
THE EFFICAY AND SAFETY OF DIPEPTIDYL
 360 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

PEPTIDASE-4 INHIBITORS WITH OTHER 10. Xiong X, Mayes D, Demianczuk N, Olso DM ,et
ORAL HYPOGLYCEMIC AGENTS IN TYPE 2 al.,. Impact of pregnancy- induced hypertension on
DIABETES MELLITUS PATIENTS. IJPSR 2018; fetal growth. Am J Obstet Gynecol.1999; 180:207-
9(11):4963-7. 13.
8. Mateti P, Koduri S, Ushkamalla S, Venkateswarlu 11. Jhansi C, Harshini MYS, Sandeep K,
K. A Study on Optimal Duration of Antibiotic ChandrasekharaRao P. et al. COMPARISON
Therapy in Various Infectious Diseases. Am. J. OF EFFICACY AND SAFETY OF ORAL
Pharm Health Res 2015; 3(8):1-8. LABETALOL AND NIFEDIPINE IN
9. Sachdeva PD, Patel BG, Bhatt MV. A Study PRE- ECLAMPSIA: A PROSPECTIVE
of Incidence and Management of Pregnancy OBSERVATIONAL STUDY. J Pharm Pharm
Induced Hypertension in Central Gujarat, India. Sci.2015; 7(9):277-80.
International Journal of Universal Pharmacy and 12. Smith P, Anthony J, Johanson R. Nifedipine
Life Sciences. 2011; 1(3):62-70. in pregnancy.British Journal of Obstretics and
Gynecology. 2000; 107(3):299-307.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 361

Comparison of Immunization Coverage Status Reported

through NFHS Coverage Evaluation Survey and HMIS in
Maharashtra

Vijay Baviskar1, Rutuja Patil2, Sudipto Roy2, Satish Doiphode3, Arun Dhongade4, Sanjay Juvekar5
1
Joint Director, Maharashtra State AIDS control society, Gov of Maharashtra, 2PRERNA Young Investigator, Vadu
Rural Health Program KEMHRC Pune, 3State Immunization Consultant, State Family Welfare Bureau Gov of
Maharashtra, 4Surveillance Manager, Vadu Rural Health Program KEMHRC Pune, 5Officer in charge, Vadu Rural
Health Program KEMHRC Pune

Abstract
Accurate health data is the most crucial factor for effective public health program evaluation, monitoring,
planning, and implementation. There are many surveys conducted in India for collating information
on the health status of the country, one of which is NFHS (National Family Health Survey). NFHS is a
representative sample survey which collects evidence of trends in population, health and nutrition indicators
including immunization status of children under five years of age. However, the public health system in
India including Maharashtra is dependent on the reports generated by HMIS for assessment of immunization
coverage status. There is a relatively large difference in immunization coverage estimates of NFHS-4 and
HMIS reports. NFHS and HMIS both have differences in the purpose, design, and interpretation between
the two. A deeper and more detailed analysis of the two systems and datasets is required to explore these
differences and make evidence-based conclusions on data triangulation.

Key words: Immunization data, NFHS, HMIS, data, comparison

Introduction surveys with overlapping goals, several gaps remain in

National health programs are highly reliant on the availability of health information in India (2)assess the
availability of health data in the public domain, and review publications resulting
accurate and usable data for successful design and from the National Family Health Survey (NFHS.
implementation, which is also crucial for identifying
programmatic gaps and planning program amendments. NFHS is a representative sample survey conducted
In India, health data is commonly sourced from public throughout India. NFHS 4 which was conducted during
health reporting system and representative surveys; 2015-16 included collection of information on health
less commonly from the private health sector. Multiple indicators from 29 states and six union territories. It
rounds of various health surveys like National Family collected evidence of trends in population, health and
Health Surveys (NFHS), District Level Household nutrition indicators. The health indicators focused on
Surveys (DLHS) and Annual Health Surveys (AHS) maternal child health and selected communicable and
have been conducted over past few years (1). These non-communicable diseases(3).
surveys provide information on health indicators in a
sample of representative individuals across the country. The recent evolution of National Health Mission
In spite of the availability of data collected from different (NHM) has provided an opportunity for the health
system to gather real-time information and has gradually
Corresponding Author: moved towards digitalization leading to the strengthened
Rutuja Patil, base of health information in Indian health system.
Young Investigator, Vadu Rural Health Program Health Management Information System (HMIS) is an
KEMHRC Pune, 3rd Floor, TDH Building, Sardaar initiative launched in 2008 by NHM which is a digital
Moodliar Road, Pune 11 [email protected] platform for monitoring of service delivery with a focus
 362 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

on reproductive, maternal and child health. It captures Cont... Table 1: District wise comparison of
70 data items at sub-centers and 117 items at Primary immunization data reported by NFHS and HMIS
Health Centres. HMIS has provided a platform for
collection and aggregation of information which can Dhule 40.0 98.39
be further analyzed and the information could be used
Gadchiroli (82.0) 95.64
for monitoring and thus better performance of health
Gondia 74.4 84.73
systems (4).
Hingoli 65.9 99.25
The HMIS portal primarily collects information Jalgaon (43.2) 93.78
related to Ante Natal Care (ANC) of pregnant women,
Jalna 70.0 94.66
deliveries and it’s outcome, reproductive health and child
care, especially the immunization status (5). Reporting Kolhapur (46.9) 101.28
of immunization is an utmost important indicator to Latur 59.4 103.17
assess the health status of the population. Both NFHS Nagpur (76.5) 99.07
and HMIS collects information on immunization from Nanded 51.1 97.14
the population.
Nandurbar 32.8 78.04
Background: Nasik 62.3 97.77
Osmanabad (62.7) 100.34
The public health systems in India including
Maharashtra are dependent on the reports generated Parbhani 51.5 103.21
by HMIS for assessment of immunization coverage. Pune (81.0) 92.22
Moreover, the information is also compared with the Raigad (47.6) 78.34
information obtained from the recent NFHS rounds. Ratnagiri (73.1) 91.84
The information present in the public domain for access
Sangli (43.4) 93.26
was used for this comparison. The total immunization
reported by NFHS-4 (2015-16) in Maharashtra state is Satara 59.2 97.57
56.3 % whereas the immunization reported by HMIS is Sindhudurga (80.3) 77.22
94.13%. Below is the district wise comparison of total Solapur 64.9 97.28
immunization reported by NFHS-4 and HMIS report Thane 40.9 88.01
of the year 2015-16 (Table 1). The full immunization
Wardha (76.5) 90.04
means vaccination with BCG, Measles, and three doses
Washim (67.9) 93.48
each of Polio and DPT/Penta in children of age-group
12-23 months. Yavatmal 61.6 94.95

Table 1: District wise comparison of immunization This relatively large difference in -reports of
data reported by NFHS and HMIS NFHS-4 and HMIS data raises several questions about
the actual proportion of children in Maharashtra who
are fully immunized. While this commentary is not
% of fully
% of fully immunized a critique of either of the two systems, here we will
District immunized as per
as per NFHS data try to explain factors that may be responsible for this
HMIS data
difference and argue that the two reports are probably
Ahmednagar 43.4 94.20 not comparable; instead, they have different purposes
Akola 50.8 105.75 and can be complementary to each other.
Amravati (64.7) 93.95
Purpose
Aurangabad 59.3 100.38
Beed 53.9 101.81 The National Family Health Surveys are nationwide
surveys conducted with a representative sample of
Bhandara (81.1) 84.09
households throughout the country. They are designed
Buldhana 64.2 88.96 to provide national, state and for the first time in NFHS-
Chandrapur (60.5) 96.53 4, district-level estimates of important indicators of
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 363

family welfare, maternal and child health, and nutrition 29,460 women as these were included in the women’s
including estimates of children that are fully immunized. questionnaire of the survey. All women were asked
The NFHS rounds use standardized questionnaires, about vaccines received by all living children in the last
sample designs, and field procedures to collect data. five years prior to the survey. To obtain this information
woman were first asked to produce vaccination cards for
The HMIS is a regular health reporting portal in the the children and data on individual vaccines along with
public health system, i.e. it reports indicators related to the date of vaccination was recorded from these cards.
maternal health, child health, communicable diseases If the card were not available, women were asked if
and other health conditions from public health facilities their children had received vaccines and thus reported
as well as private facilities. Immunization status of vaccination history was recorded. Data is collected over
children vaccinated at public health facilities is one of a period of approximately one year and primary reports
the important indicators that are regularly reported in the are published within two years of data collection.
HMIS. The HMIS has a reporting structure that builds
up from the government sub-centers to primary health The HMIS is a regularly updated portal that records
centers and further to the district and state level. The information on individual vaccines from vaccination
HMIS includes data from all public health facilities in registers maintained at government sub-centers, primary
districts and state; thus it is not sample-based. The HMIS health centers, and other public health facilities. Every
is an important tool that provides real-time data on health primary health center and sub-center are given a ‘target
indicators and is used by government program managers population’, i.e. children eligible for immunization that
as well as policymakers to understand the current health is estimated from census data and the actual number of
status of communities as well as design interventions to eligible children immunized is calculated against the
improve health programs including micro-level planning. target population. Data on children immunized at other
The HMIS is valuable in identifying lacunae in program public health facilities are recorded at the primary health
implementation and taking immediate corrective actions center where children reside. Data in HMIS is updated
for the same. every month and made available to program managers.
A critical component of the HMIS is monitoring and
Definitions evaluation. Data in the HMIS is monitored at all levels
Both NFHS and HMIS follow guidelines developed from the sub-district level to the national level. At each
by the World Health Organization wherein children are level, the data is cross-verified by respective program
considered fully vaccinated when they have received managers and only then reported, thus ensuring the
a vaccination against tuberculosis (BCG), three doses quality of the data.
of diphtheria, whooping cough (pertussis), and tetanus Critical differences between NFHS-4 and HMIS
(DPT) vaccine; three doses of the poliomyelitis (polio)
vaccine; and one dose of the measles vaccine by the age of The NFHS rounds are sample surveys, with data
12 months. While the NHHS-3 reported both proportions collected from these sample households expected to
of children fully immunized before 12 months of age as provide estimates for the complete population. Though
well as the proportion of children fully immunized at sample size calculations and sampling strategies have
any time before the survey, the NFHS-4 state fact sheet been statistically calculated to ensure adequate power
for Maharashtra reports the only proportion of fully and representativeness of the sample estimates, as with
immunized children aged 12-23 months. any sample survey, there remains an uncertainty in
projecting sample data to the larger population, in this
Method case, the complete population of the state and districts.
The NFHS rounds are conducted at intervals that are Further, there is a time-lag between a collection of data
not regular. While NFHS-1 was conducted in 1992-1993 and publishing results of the survey which can range
and NFHS-2 in 1998-1999, the NFHS-3 was conducted from one to two years; while immunization trends
in 2005-2006 and the NFHS-4 was conducted after an at the national level usually are not expected to vary
interval of 10 years in 2015-2016. The NFHS-4 round significantly, such a lag may not be useful to identify
for Maharashtra gathered information from 26,890 any acute weaknesses. The HMIS records program data
households, 29,460 women, and 4,497 men. Indicators on a real-time and regular basis. Data for all children
for child immunization was obtained from these immunized at public health facilities are recorded in
 364 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

the HMIS and monthly reports are generated from the While all these factors do not comprehensively
HMIS to facilitate calculation of number and proportion explain differences in immunization status between
of children immunized. Thus the HMIS can inform the NFHS-4 and HMIS, there is enough evidence to show
immunization program about monthly trends at all levels significant differences in the purpose, design, and
of the public health system interpretation between the two. Obviously, a deeper and
more detailed analysis of the two systems and datasets
The NFHS surveys generate estimates at a given is required to explore these differences and make
point of time and while trends in the status of child evidence-based conclusions. Thus, interpreting either
immunization can be statistically estimated from the NFHS-4 data or the HMIS data needs utmost caution
consecutive survey rounds. The HMIS, by virtue of its when estimating immunization status of the complete
regularity of data recording, can provide relatively more population. At this juncture, it is advisable to not draw
accurate estimates of trends in immunization. However, conclusions about the same before exploring further.
calculation of the ‘target population’, i.e. all eligible A direct comparison between the two datasets would
children within a given area, which forms the denominator neither be appropriate nor would it generate actionable
to calculate the proportion of children immunized, may evidence. Rather, it would be more judicious and
have inaccuracies as it is estimated from the last census efficient to consider the two datasets as complementary
and data on new births available from government to each other and apply appropriate statistical methods to
records. In addition, it is difficult to estimate in and use both to arrive at population immunization proportion
out-migration while calculating ‘target population’. estimates.
This inherent difficulty in fixing a denominator when
using HMIS data is a known weakness in the system; Conclusion
which can be corrected to a large extent using statistical
adjustments and more accurate population estimates. All these raise a question if actual information
However, a discussion on this is beyond the scope of could be compared with the estimated one. Although
this commentary. this could be one possible way to compare the actual
information, many comparisons could be done if raw
Data on individual vaccination in NFHS-4 was data of both the data sets could be made available. We
either recorded from vaccination cards or from mother`s can also independently analyze the available health
recall. Further, data were recorded for all living children systems data and publish it responsibly in peer-reviewed
in the five years prior to the survey. The accuracy of journal which would give credibility to the use of health
data in case of unavailability of vaccination cards must system data for various reasons and purposes. Probably
be viewed with caution as mother`s recall is influenced data triangulation exercises including a combination of
by many factors, especially elapsed time in case of the two datasets along with an independent verification
vaccinations given 3-5 years ago. While the NFHS-4 has would provide the most realistic estimates of
yet to publish detailed estimates, the NFHS-3 reports that immunization coverage. Thus, we could initiate by using
vaccination coverage for each type of vaccine and for available data from health systems to produce credible
full vaccination was much higher for children for whom publications to utilize the potential of such datasets for
a vaccination card was shown (76% for all vaccines) better tomorrow.
than for the children whose vaccination information is
all based on mother’s recall (24% for all vaccines). This Conflict of Interest: The Authors declare no
seems to be a significant difference in the proportion conflict of interest
of children vaccinated. However, the NFHS-3 report Source of Funding: This activity was not funded by
does not mention proportion of all respondents that had any funding agency and was self funded.
and did not have a vaccination card. If the proportion
of respondents without a vaccination card was high, Ethics: The data used are reports available in
then there is a higher likelihood of under-reporting of public domain which do not include any individual level
vaccination, based only on maternal recall. Even among datasets hence no separate ethical approval was required.
those with vaccination cards, the NFHS-3 did not report
the completeness of vaccination cards as cards with References
incomplete information do not necessarily indicate 1. Srivastava D. Health system monitoring using
incomplete immunization.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 365

Health Management Information System (HMIS) in 4. Husain; Z, Saikia; N, Bora RS. Opportunities and
India and suggested enhancements to this platform. challenges of health management information
International Journal of Scientific & Engineering system in India: a case study of Uttarakhand.
Research. 2015;6(9):1245–8. Munich Personal RePEc Archive. 2012;(40014).
2. Dandona R, Pandey A, Dandona L. A review of 5. Health Management Information System [Internet].
national health surveys in India. Bulletin of the 2016 [cited 2017 Feb 4]. Available from: https://
World Health Organization. 2016;94(4):286–296A. nrhm-mis.nic.in/hmisreports/frmstandard_reports.
3. National family Health Survey [Internet]. 2009 aspx
[cited 2017 Feb 4]. Available from: http://rchiips.
org/nfhs/nfhs4.shtml
 366 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Skin Diseases Prediction: Binary Classification Machine

Learning & Multi Model Ensemble Techniques

Vikas Chaurasia1, Saurabh Pal2

1Research Scholor, MCA Dept., VBS Purvanchal University, Jaunpur,
2
Dept. of MCA,VBS Purvanchal University, Jaunpur, UP, India

Abstract
Unlike many other diseases, the skin disease has more irritability. Dermatology sicknesses incorporates
normal skin rashes to serious skin contaminations, which happens because of scope of things, like diseases,
warm, allergens, framework issue and drugs. First regular skin issue are dermatitis. Atopic dermatitis is
relating current (perpetual) condition that causes eager, aroused skin. Most much of the time it appears as
patches on the face, neck, trunk or appendages. It will in general erupt sporadically so die down for a period.
A large portion of the dermatological sicknesses are not reparable but rather most the treatments depend on
the administration of the side effects related with it.

The focus of this research will be the Dermatology database. The problem is to determine the type of
Eryhemato-Squamous disease like psoriasis, seboreic dermatitis, lichen planus, pityriasis rosea, cronic
dermatitis and pityriasis rubra pilaris. The differential analysis of erythemato-squamous maladies is a
genuine issue in dermatology. They all offer the clinical highlights of erythema and scaling, with next to no
distinctions. Each pattern is a set of 33 numbers in the range linear values and one of them is nominal. The
80% of the dataset utilize for demonstrating and keep down 20% for approval. Objective is to accomplish
best performer algorithm which will convey in dermatology informational collection so for this reason the
gut feel recommends distance based calculations like k-Nearest Neighbors and Support Vector Machines
may progress admirably. By using 10-fold cross validation and assess calculations utilizing the accuracy
metric.

Keywords: Dermatology, Atopic dermatitis, Eryhemato-Squamous, k-Nearest Neighbors, Support Vector

Machines.

Introduction weather change, photosensitive skin issue like tanning,

color obscuring, sunburn, skin malignant growths,
Around 1500 BC a medical document on skin
and irresistible infections are expanding at a quicker
ailments Ebers Papyrus was found in ancient Egypt.
pace. A one percent decrease in ozone prompts a two
It portrays different skin maladies, including ulcers,
to four percent expansion in the occurrence of tumors.
rashes, and tumors, and recommends medical procedure
The seriousness of developing skin illnesses in India is
and balms to treat the afflictions [1, 2]. From that point
additionally underlined by the way that the World Health
to now the skin sickness portion has indicated colossal
Organization (WHO) has included skin infection under
development. The predominance of skin malady in
the most widely recognized non-transferable maladies
India is 10 to 12 percent of the all out populace with
in India. What’s more, there is an absence of offices
Eczema and Psoriasis being the significant benefactors.
that give thorough skin related medicines under one
Because of contamination, bright light, and an unnatural
rooftop.” The circumstance is additionally compounded
by the low accessibility of dermatologists in India. At
Corresponding author: present, there are around 6,000 dermatologists obliging
Saurabh Pal a populace of more than 135 crore. This implies for
Email: [email protected] each 100,000 individuals, just 0.49 dermatologists are
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 367

accessible in India when contrasted with 3.2 in numerous The different conclusions of erythema - squamous
conditions of the US.” Different tertiary consideration disease are a thorny problem in dermatology. They
private setups come up short on the capacity to treat all provide clinical highlights of erythema and scales,
incessant, hereditary and pediatric skin diseases. with little difference. The disease at this gathering was
psoriasis, sebaceous glands, lichen planus, pityriasis
Literature Survey rosea, permanent dermatitis and pityriasis of the hair
[3]
Investigating the ups and downs of the . Some tests have been carried out in consideration of
computerized skin disease conclusion system, several the discovery of erythematous squamous disease. These
available arrangements are still under research and surveys link various technologies to specific issues and
development. The difference between certain obstacles complete the unique correctness of the representation.
and shortcomings is that this arrangement subsequently In these investigations, the main work of the differential
attempts to overcome current problems in a variety of analysis of erythematous squamous disease is Table 1.
ways.

Table 1: A few investigations which have dealt with skin disease mining

Author Year Method Classification accuracy

A constrained-syntax genetic 96.64%

Bojarczuk[4] 2001
programmingC4.5 89.12%

decision tree 80.33%

Chang et.al [5] 2009
neural network 92.62%
Guvenir et al.[6] 1998 VFI5 96.2%
Ubeyli and Guler[7] 2005 ANFIS 95.5%

LSVM 97.22%
RS 97.22%
B1_5 97.5%
B1_10 98.1%
Nani[8] 2006
B1_15 97.22%
B2_5 97.5%
B2_10 97.8%
B2_15 98.3%

Polat and Gunes[9] 2009 C4.5 and one-against-all 96.71%

Ubeyli[10] 2009 CNN 97.77%
Ubeyli and Dogdu[11] 2010 K-mean clustering 94.22%
Lekka andMikhailov[12] 2010 Evolving fuzzy classification 97.55%
Xie and Wang[13] 2011 IFSFS and SVM 98.61%

AdaBoost
BayesNet 85% for Eczema
A.A.L.C. Amarathunga et al[14] 2015 J48, 95% for Impetigo
MLP 85% for Melanoma.
NaiveBayes)
 368 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Method Evaluation of Algorithms

Initially, differential expression analysis was used After the pre-processing of information collection,
to select erythema-scaly, the most informative feature we evaluated the expected execution of six well-known
of significant differential expression, and then fed into classification techniques for finding skin diseases.
the following classification process. Then, we use S-fold Specifically, we apply Logistic Regression (LR), Linear
cross-validation technology to divide the initial data into Discriminant Analysis (LDA), k-Nearest Neighbor
k groups, training and test data sets. After that, multiple (KNN), Classification and Regression Tree (CART),
algorithms used for evaluation are learned from the Gaussian Bayesian (NB), Support Vector Machine
training sets, each of which consist of k-1 of the k groups, (SVM). As the first time to arrange the classification
and then applied to the corresponding test set, which is the model. These six classification strategies are highly
remaining group of the S groups, to output the predicted accurate in practical applications.
class of the samples. Then, we will evaluate algorithms
using the accuracy metric. This is a general indicator that Ensemble Methods
quickly understands the correctness of a given model.
In this research paper ensemble method is used
We created a performance baseline on this issue and
as a method to find the accuracy of the skin disease
scrutinized many different issues of algorithms. Now we
dataset to improve the performance of algorithms. We
evaluate the same algorithms with a standardized copy
will evaluate four different ensemble machine learning
of the dataset because we have the reason to suspect
algorithms, two boosting Ada Boost (AB) and Gradient
that the differing distributions of the raw data may be
Boosting (GBM) and two bagging methods Random
negatively impacting the skill of some of the algorithms.
Forests (RF) and Extra Trees (ET).
In this section we investigate tuning the parameters for
most prominent algorithms that show promise from the General Procedure of Boosting
spot-checking in the previous section. In next section,
an ensemble model is another way to improve the The word “boost” refers to a set of algorithms
accuracy by using four different machine algorithms; that can transform weak learners into strong learners.
two boosting and two bagging methods. We will finalize Of course, weak learners are only slightly better than
the model by training it on the entire training dataset and irregular guesses, while powerful learners are very
make predictions for the hold-out validation dataset to close to perfect execution. If the appropriate response
confirm our findings. We can calculate from the entire is positive, then any weak learner can be promoted to
training data set and apply the same transformation to a strong learner, especially if it is difficult to obtain a
the input properties of the validation data set. Finally, strong learner rather than a weak learner. The promotion
the algorithm-adjusted prediction is compared with the is done by continuously preparing a large number of
aggregate model to reduce the generalization error and learners and merging them into expectations, and later
obtain more accurate results [15- 20]. learners pay more attention to the mistakes of previous
learners.

______________________________________________________________________________
Input: Distribution of sample S;
Learning base algorithm A;
Total number of learning rounds N.
Process:
1. S1 = S. # Initialization of distribution
2. for n = 1, . . . , N :
3. hn = A(Sn); # A weak learner trained from distribution Sn
4. µn = Px~Sn (hn(x) ≠ f(x)); # Evaluation of the error of hn
5. Sn+1 = Adjustment of Distribution (Sn, µn)
6. end
Output: H(x) = Combine Outputs ({h1(x), . . . , hn(x)})
______________________________________________________________________________
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 369

______________________________________________________________________________
Input: Distribution of sample S = {(x1, y1), (x2, y2), . . . , (xm, ym)};
Learning base algorithm A;
Total number of learning rounds N.
Process:
1. for n = 1, . . . , N :
2. hn = A(S, Sbr) # Sbr is the bootstrap distribution
3. end
Output: H(x) = arg max∑𝑁𝑁 𝑛𝑛−1(hn(𝑥𝑥) = 𝑦𝑦)
y∈Y
______________________________________________________________________________

Bagging Methods Table 2: Output of Evaluating Algorithms

The name Bagging originated from the contraction of
Algorithms Mean Accuracy Values
Bootstrap AGGregatING. As the name implies, the two
key elements of Bagging are bootstrap and aggregation. LR 0.979425 (0.022806)
For training information collection, one probability is to
examine various uncovered data subsets by all accounts, LDA 0.962299(0.024175)
and after this preparation is the underlying learner from KNN 0.855747 (0.051314)
each subset. In any case, because we do not have endless
CART 0.935057 (0.028180)
training data information, such a program will provide
few and non-representative examples, resulting in poor NB 0.890230 (0.072177)
implementation of the underlying learners. The bag
SVM 0.921034 (0.027220)
receives a guided loop to create a diverse base learner. It
applies a bootstrap check to get a subset of the data used
Evaluation of Algorithms with Standardize Data
to prepare the underlying learner,
We speculate that the differing distributions of
Results the raw data might be adversely affecting the ability
Here we utilized distance based algorithms like of a portion of the algorithms. How about we assess
k-Nearest Neighbors and Support Vector Machines We similar algorithms with an standardized copy of the data
have utilized 10-fold cross validation. The data set isn’t set. This is the place the data is changed with the end
excessively little and this is a decent standard test saddle goal that each attribute has a mean estimation of zero
setup. We will assess algorithms utilizing the exactness and a standard deviation of one. We likewise need to
metric. This is a gross metric that will give a fast thought maintain a strategic distance from data leakage when we
of how right a given model is. Progressively valuable change the data. A decent method to keep away from
on binary arrangement issues like this one. Making data leakage is to utilize pipelines that standardize the
a standard of act on this issue and spot-check various data and construct the model for each fold in the cross
distinctive algorithms. We will choose a suite of various validation test bridle.
algorithms fit for dealing with this classification issue.
Table 3: Output of Evaluating Algorithms on the
The algorithms all utilization defaults tuning parameters.
Scaled Dataset
On comparing the algorithms mean accuracy values are
given in following table 2. Algorithms Mean Accuracy Values
ScaledLR 0.972529(0.025776)
ScaledLDA 0.962299(0.024175)
ScaledKNN 0.969195(0.018533)
ScaledCART 0.938391(0.029970)
ScaledNB 0.869655(0.087102)
ScaledSVM 0.969310(0.023769)
 370 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

We can see that LR is as yet progressing admirably. Table 5: Output of Evaluating SVM on the
We can likewise observe that the standardization of the Validation Dataset.
data has lifted the aptitude of SVM to be the most precise
algorithm tried up until this point. See Table 3.
accuracy_score 0.9864864864864865
The outcomes propose delving further into the LR
and SVM algorithms. Almost certainly, setup past the [[11 0 0 0 0 0]
default may yield significantly increasingly precise [ 0 11 0 0 0 0]
models. [ 0 0 13 0 0 1]
confusion_matrix
[ 0 0 0 4 0 0]
Ensemble Methods [ 0 0 0 0 24 0]
[ 0 0 0 0 0 10]]
Another way that we can improve the execution of
algorithms on this issue is by utilizing ensemble strategies. precision recall f1-score support
We will utilize a similar test tackle as previously, 10- cronic dermatitis 1.00 1.00 1.00
fold cross validation. No data standardization is utilized 11
for this situation since each of the ensemble algorithms lichen planus 1.00 1.00 1.00 11
depend on decision trees that are less sensitive to pityriasis rosea 1.00 0.93 0.96 14
information distributions. See table 4. pityriasis rubra pilaris 1.00 1.00
classification_report
1.00 4
Table 4: Output of Evaluating Algorithms psoriasis 1.00 1.00 1.00 24
seboreic dermatitis 0.91 1.00
0.95 10
Algorithms Mean Accuracy Values avg / total 0.99 0.99 0.99 74

AB 0.588391 (0.062920)
Conclusion
GBM 0.959080 (0.036807)
Skin disease is a disturbing and real medical issue
RF 0.959195 (0.036403)
around the world. In spite of the fact that the machine
learning strategies have been increasingly more generally
ET 0.969310 (0.041881) utilized in disease expectation, nobody technique beats
all the others. In this paper, we exhibited six diverse order
models and multi-model ensemble way to deal with the
Finalization of Model
prediction of skin disease. The outcomes demonstrate
In view of the results, The LR demonstrated the that differential expression analysis is important to
most guarantee as a low intricacy and stable model for diminish the dimensionality of data and to choose
dermatology dataset. In this section we will conclude effective data, along these lines expanding the accuracy
the model via preparing it on the whole training dataset of the prediction and decreasing the computational
and make predictions for the hold-out validation dataset time to a substantial degree. The multi-model ensemble
to affirm our findings. A part of the findings was that method at that point uses the expectations of numerous
LR performs better when the dataset is standardized so diverse classification models as input. The classification
all characteristics have a mean estimation of zero and a technique decreases the generation error and acquires
standard deviation of one. We can ascertain this from the more data by utilizing the principal organize predictions
whole training dataset and apply the equivalent change as highlights than it is trained in isolation. Also, by
to the input properties from the validation dataset. utilizing classification techniques, the mind boggling
connections among the classifiers are found out
We can see that we accomplish an exactness of consequently, in this way empowering the order strategy
about 99% on the held-out validation dataset. A score to accomplish better prediction.
that more and improved to our desires evaluated above
amid the tuning of LR. See table 5. Ethical Clearance- No ethical clearance is needed
for this research paper.

Funding: This study was not funded by any funding

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 371

agency 11. Übeyli ED, Doğdu E. Automatic detection of

erythemato-squamous diseases using k-means
Competing Interests None declared clustering. Journal of medical systems. 2010 Apr
1;34(2):179-84.
References
12. Lekkas S, Mikhailov L. Evolving fuzzy medical
1. Mukhopadhyay AK. Dermatology in India diagnosis of Pima Indians diabetes and of
and Indian dermatology: A Medico-historical dermatological diseases. Artificial Intelligence in
perspective. Indian dermatology online journal. Medicine. 2010 Oct 1;50(2):117-26.
2016 Jul;7(4):235.
13. Xie J, Wang C. Using support vector machines
2. Hartmann A. Back to the roots–dermatology in with a novel hybrid feature selection method
ancient Egyptian medicine. JDDG: Journal der for diagnosis of erythemato-squamous diseases.
Deutschen Dermatologischen Gesellschaft. 2016 Expert Systems with Applications. 2011 May
Apr;14(4):389-96. 1;38(5):5809-15.
3. Güvenir HA, Demiröz G, Ilter N. Learning 14. Amarathunga AA, Ellawala EP, Abeysekara GN,
differential diagnosis of erythemato-squamous Amalraj CR. Expert system for diagnosis of skin
diseases using voting feature intervals. Artificial diseases. International Journal of Scientific &
intelligence in medicine. 1998 Jul 1;13(3):147-65. Technology Research. 2015 Jan;4(01):174-8.
4. Bojarczuka CC, Lopesb HS, Freitasc AA. 15. https://scikit-learn.org/stable/modules/feature_
Data mining with constrained-syntax genetic selection.html
programming: applications in medical data set.
16. Perriere G, Thioulouse J. Use of correspondence
algorithms. 2001;6:7.
discriminant analysis to predict the subcellular
5. Chang CL, Chen CH. Applying decision tree and location of bacterial proteins. Computer Methods
neural network to increase quality of dermatologic and Programs in Biomedicine. 2003 Feb 1;70(2):99-
diagnosis. Expert Systems with Applications. 2009 105.
Mar 1;36(2):4035-41.
17. Altman NS. An introduction to kernel and nearest-
6. Güvenir HA, Emeksiz N. An expert system for neighbor nonparametric regression. The American
the differential diagnosis of erythemato-squamous Statistician. 1992 Aug 1;46(3):175-85.
diseases. Expert Systems with Applications. 2000
18. Chaurasia V, Pal S, Tiwari BB. Prediction of
Jan 1;18(1):43-9.
benign and malignant breast cancer using data
7. Übeylı ED, Güler I. Automatic detection of mining techniques. Journal of Algorithms &
erythemato-squamous diseases using adaptive Computational Technology. 2018 Jun;12(2):119-
neuro-fuzzy inference systems. Computers in 26.
biology and medicine. 2005 Jun 1;35(5):421-33.
19. Chaurasia V, Pal S, Tiwari BB. Prediction of
8. Nanni L. An ensemble of classifiers for the benign and malignant breast cancer using data
diagnosis of erythemato-squamous diseases. mining techniques. Journal of Algorithms &
Neurocomputing. 2006 Mar 1;69(7-9):842-5. Computational Technology. 2018 Jun;12(2):119-
9. Polat K, Güneş S. A novel hybrid intelligent method 26.
based on C4. 5 decision tree classifier and one- 20. Yadav, D., Pal, S. To Generate an Ensemble Model
against-all approach for multi-class classification for Women Thyroid Prediction Using Data Mining
problems. Expert Systems with Applications. 2009 Techniques. Asian Pacific Journal of Cancer
Mar 1;36(2):1587-92. Prevention. 2019; 20 (4).
10. Übeyli ED. Combined neural networks for diagnosis
of erythemato-squamous diseases. Expert Systems
with Applications. 2009 Apr 1;36(3):5107-12.
 372 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Compressive Strength Evaluation Between Metal Ceramic and

Zirconia crowns. An in-vitro Study

Vikram.V1, Sanjna Nayar2, Narayana Reddy3

1Senior Lecturer, 2Head of Department, 3Professor Department of Prosthodontics,
Sree Balaji Dental College & Hospitals , Chennai

Abstract
The aim of this study is to evaluate the compressive strength of metal and zirconia cores and also the point
of chipping of the veneered porcelain to both the core materials. For the present study, full coverage crowns
were fabricated for mandibular molar. The crowns were divided into two groups. First group is five samples
of metal ceramic crowns and second group is five samples of zirconia ceramic crowns. These crowns were
subjected to static compression loading in a universal testing machine until the fracture of the veneering
porcelain. The compressive load was recorded in newton. Data were subjected to student t test analysis.
Mean compressive strength for group 1 metal ceramic crowns was 2587.80N and the mean compressive
strength for group 2 zirconia ceramic crowns was 1361.00N. The compressive strength of metal when being
used as a core material is significantly higher than zirconia. Under static compressive loading, the point of
fracture of the veneered porcelains occurred at significantly lower values for the zirconia based restorations
when compared to that of metal ceramic restorations.

Keywords: zirconia, metal ceramic, compressive strength, chipping.

Introduction introduced in Dentistry, the polycrystalline zirconium

dioxide (zirconia) resulted particularly attractive in
Fixed prosthodontic treatment involves the
prosthodontics, due to its excellent mechanical properties
replacement and restoration of teeth by artificial
and improved natural-looking appearance compared
substitutes that are not readily removed from the mouth.
to metal–ceramics. Zirconia stabilized with Y2 O3 has
Its focus is to restore function, esthetics and comfort1.
the best properties for these applications. Zirconia is a
For the past 40 years the porcelain-fused-to-metal
crystalline dioxide of zirconium10.
systems have been extensively used in fixed partial
dentures (FPDs) and still represents the gold standard. The first proposal of the use of zirconium oxide for
The advantages of the PFM systems are to combine the medical purposes was made in 196912. Zirconia exhibits
fracture resistance of the metal substructure with the a phenomenon called “transformation toughening,”
esthetic property of the porcelain2. The drawbacks of which disables the progress of crack growth and
these restorations are that the bulk of the natural tooth may increases toughness against fractures14. The tetragonal
need to be sacrificed to provide adequate space to ensure crystals of zirconium oxide are metastable and the
adequate fracture resistance and aesthetics3. However, stress applied to cracks or flaws can transform them into
recently the increasing demand for esthetic restorations larger monoclinic crystals15. Yttrium partially stabilized
as well as the questionable biocompatibility of some tetragonal zirconia poly crystal (3Y-TZP) is made of
dental metal alloys has accelerated the development and transformable t-shaped grains stabilized by the addition
improvement of metal-free restorations.4 of 3mol% yttrium-oxide (Y2O3). Such a polycrystalline
material exhibits low porosity and high density; at the
All ceramic restorations have become more widely
moment it is the most popular and frequently used
distributed due to their high esthetic potential and their
form of zirconia commercially available for dental
excellent biocompatible properties5. Zirconia (ZrO2) is
applications20.
a ceramic material with adequate mechanical properties
for manufacturing of medical devices7. Since it was COMPRESSIVE STRENGTH
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 373

In the study of strength of materials, the compressive bodied consistency (DENTSPLY) using the double mix
strength is the capacity of a material or structure technique (fig 1) . The impression was poured using
to withstand loads tending to reduce size. It can be type IV dental stone. The dies were casted in cobalt
measured by plotting applied force against deformation chromium alloy32 (fig 2).
in a testing machine21. Some material fracture at their
compressive strength limit; others deform irreversibly,
so a given amount of deformation may be considered as
the limit for compressive load.2 Compressive strength is
often measured on a universal testing machine23.

Dental ceramic materials exhibit many desirable

material properties, including biocompatibility,
esthetics, diminished plaque accumulation, low thermal
conductivity, abrasion resistance, and color stability24.
However, brittleness and low tensile strength are weak
points of ceramic materials. Therefore, the clinical
success of all-ceramic fixed partial dentures (FPD) has
been disappointing, especially for posterior FPDs when Fig. 1 - Impression of prepared Typhodont tooth model
compared with metal-ceramic restorations. Although
metal frameworks have inherent disadvantages,
studies reveal that the resistance to fatigue failure is
comparatively more for metal ceramic restorations when
compared to all ceramic restorations.25

Porcelain materials present two problems associated

with occlusal forces: fracture of the porcelain, which
is dependent upon the size and direction of the force
(e.g., normal chewing versus bruxing), the type of
porcelain (e.g., feldpathic, versus lithium disilicate,
versus zirconia), and the time of force application; and
wear of the material and its antagonist, whether natural
enamel or other restorative materials. This is dependent Fig. 2 - Cobalt chromium dies
upon the type of porcelain, quantity and timing of force,
glazed versus polished porcelain, and the nature of the
antagonist.27

Method
For the present study, full coverage crowns fabricated
for mandibular first molar were tested for compressive
strength. Materials used subjected to testing include:

1) Metal ceramic

2) Zirconia ceramic (Table 1).

In order to standardize the crowns, a conventional

tooth preparation was done on a mandibular first molar
typhodont tooth model (Nissin)29. A full arch mandibular
impression tray was used to make impression of the Fig. 3 - Fabricated crowns on the dies
prepared tooth model using Aquasil soft putty/ regular
set (DENTSPLY) and Aquasil ultra LV, type 3: light
 374 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Bonding Casts To The Crowns The load force applicator’s ball established three
point contact with the slopes of the vestibular cusps.
Once fabricated, the crowns were bonded onto the
Static compression loading was carried out until chipping
metal dies (fig 4) using dual polymerization composite
or fracture took place of the veneered porcelain to the
resin cement (Rely X U 200,3M.) and light cured for a
corresponding core material. This value was recorded
period of 20 seconds for initial setting of the material
in Newton (N). The data obtained was tabulated and
(fig 5).
analyzed using student t-test analysis.
A force of 10 N was applied for 5 minutes to ensure
even distribution of the bond material and seat the crowns
properly34. After the cement had set the excess cement
were removed from the margins of the restoration .

Fig. 6 - Static compression loading done on the samples

Fig. 4 - Crowns cemented on the stabilized dies Results

Five samples were tested for compressive strength of
metal ceramic in which chipping of veneering porcelain
was at maximum of 2908N and minimum of 2300N.

Five samples were tested for compressive strength

of zirconia ceramic in which chipping of veneering
porcelain was at a maximum of 1500N and minimum
of 1000N.

Mean values of compressive strength for metal

ceramic and zirconia crowns were 2587.80 and 1361.0
N respectively (Table 1). These values were subjected to
independent student t-test analysis (Table 2). The t-value
obtained was 7.880 with degree of freedom (df) being
Fig. 5 - Light curing done for initial setting of the cement 7.589 (Table 2). There was a statistically significant
difference between the compressive strength of metal
Compression Testing
ceramic and zirconia crowns (p=0.000) (Table 3).
The compression testing was carried out using a
universal testing machine (Instron model: WDW-100). Discussion
The load applicator (4mm metal ball) descended onto
With regard to biting forces in the oral cavity,
the samples (fig 6) exercising a continuous force with a
compressive strength of materials used in fixed
vertical cross head speed of 1mm/min, moving vertically
restorations plays a significant role in the durability and
downward perpendicular to the occlusal zone.
longevity of the prosthesis. Normal chewing cycle starts
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 375

with opening movement from centric occlusion, lateral These conditions are quite different from the conditions
movement and closure on to working side. Then finally used in this study; thus, further investigation should be
shear movement against slopes of the upper teeth to carried out using stress corrosion or corrosion fatigue
grind the food particles and bring the jaw back to centric methodology so that the long term performance of
occlusion. The para functional habits like clenching restorations can be predicted.
includes sustained amount of compressive forces in
centric occlusion, whereas bruxing include sustained The typical failure pattern of a veneering material in
compressive and shearing forces. the daily clinical practice is known as ceramic chipping.
For metal ceramics restorations, the linear coefficient
The choice of compressive test type and its of thermal expansion for metal and ceramic must
specific design used in this study is best suited to closely match to achieve a strong interfacial bond. A
study the resistance of ceramic materials. These have small mismatch between these two factors results in an
been substantiated by numerous authors (Snyder et unknown amount of residual stress at the interface. This
al, Panadero et al). The compressive testing would stress is usually confined to the veneered porcelain only.
therefore appears to be a validated method for evaluating
fracture resistance of crowns or fixed partial dentures. The bond between veneering ceramic and zirconia
Furthermore the cross head speed (1mm/min) and static framework is currently the subject of comprehensive
compressive load were established in light of a literature investigation, when compared to that of metal ceramic
review dealing these variables. restorations and this forms the basis of this study.
The results of the present study show that the point
Despite the many disadvantages of in vitro study it of chipping or fracture of the veneering porcelain for
is important to evaluate isolated mechanical properties the metal ceramic restorations ranges from 2000 to
under standardized conditions and limited influencing 3000N. Subsequently the chipping for the zirconia
parameters. Although compressive strength does based restorations ranges from 1000 to 1500N. There
not reproduce conditions in the oral environment as is a statistically significant difference between the two
faithfully as in vitro cyclic studies, the results of this groups.
type of test provide valid information, which can then be
extrapolated in clinical practice. From the present in vitro study, it may be confirmed
that porcelain veneers with the same characteristics
All-ceramic crowns are subject to fracture behave in response to static loading differently depending
during function. To minimize this common clinical on the type of core they cover. Zirconia restorations
complication, zirconium oxide is the material of choice fracture at lower static load values. Porcelain veneer
used for the framework of all-ceramic crowns. Kelly over a metal ceramic core resisted higher static loading.
suggested several recommendations for a clinically
relevant in vitro load-to-failure test for all-ceramic Conflict of Interest: Nil
restorations: use of a die material with elastic modulus Source of Funding: Self
similar to dentin, failure test under wet cyclic loading,
preparation of the teeth or dies according to clinical Ethical Clearance: Not required as it is an in-vitro
guidelines and use of all-ceramic crowns with clinically study
relevant dimensions.
References
In the current study, some experimental conditions
were different from Kelly’s recommendations. The 1. Barghi N, McKeehan-Whitmer M, Aranda.
elastic modulus of the die material in this study is higher Comparison of fracture strength of porcelain-
than that of dentin. However, natural teeth are hard to veneered-to
be standardized in size, mineralization, internal cracks, high noble and base metal alloys J Prosthet Dent. 1987
pulpal chamber dimension, and mechanical properties Jan;57(1):23-6
and would have fractured under the high compressive 2. Pröbster L Compressive strength of two modern
loads exerted during the test. Clinically, restorations all-ceramic crowns Int J Prosthodont. 1992 Sep-
are subjected to dynamic complex loading in saliva, Oct;5(5):409-14
which contains both organic and inorganic components. 3. Tinschert J, Natt G, Mautsch W, Augthun
 376 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

M, Spiekermann H Fracture resistance of lithium 15. Encke BS, Heydecke G, Wolkewitz M, Strub
disilicate-, alumina-, and zirconia-based three- JR. 2009. “Results of a prospective randomized
unit fixed partial dentures: a laboratory study. Int J controlled trial of posterior ZrSiO(4)-ceramic
Prosthodont. 2001 May-Jun;14(3):231-8. crowns.” J Oral Rehabil 36:226-235.
4. Pospiech P All-ceramic crowns: bonding or 16. Silva NR, Bonfante EA, Zavanelli RA, Thompson
cementing? Clin Oral Investig. 2002 Dec;6(4):189- VP, Ferencz JL, Coelho PG. Reliability of
97 Metalloceramic and Zirconia-based Ceramic
5. Proos KA, Swain MV, Ironside J, Steven GP Crowns. J Dent Res 2010.
Finite element analysis studies of a metal- 17. Moustafa N. Aboushelib Long Term Fatigue
ceramic crown on a first premolar tooth. Int J Behavior of Zirconia Based Dental Ceramics
Prosthodont. 2002 Nov-Dec;15(6):521-7. Materials 2010, 3, 2975-2985
6. Guazzato M, Proos K, Quach L, Swain MV. 18. López-Mollá MV, Martínez- González MA, Mañes-
“Strength, reliability and mode of fracture of Ferrer JF, Amigó-Borrás V, Bouazza-Juanes
bilayered porcelain/zirconia (Y-TZP) dental K Bond strength evaluation of the veneering-
ceramics.” Biomaterials 2004 20:5045-5052. core ceramics bonds Med Oral Patol Oral Cir
7. Edward A. mclaren, DDS*Russell A. Giordano ii, Bucal. 2010 Nov 1;15(6):e919-23
Dmd, Dmedsc** 19. Schmitt J, Wichmann M, Holst S, Reich S. 2010
Zirconia-based ceramics: material properties, esthetics, “Restoring severely compromised anterior teeth
and layering techniques of a new veneering with zirconia crowns and feather-edged margin
porcelain, VM9, QDT (2005) 99-111 preparations: A 3-year follow-up of a prospective
clinical trial.” Int J Prosthodont 23:107-109.
8. Sundh A, Molin M, Sjögren G Fracture resistance of
yttrium oxide partially-stabilized zirconia 20. Roediger M, Gersdorff N, Huels A, Rinke S. 2010.
all-ceramic bridges after veneering and “Prospective evaluation of zirconia posterior fixed
mechanical fatigue testing. Dent Mater. 2005 partial dentures: Four-year clinical results.” Int J
May;21(5):476-82 Prosthodont 23:141- 148.
9. Snyder MD, Hogg KD Load-to-fracture value of 21. Rocha EP, Anchieta RB, Freitas AC Jr, de Almeida
different all-ceramic crown systems. J Contemp EO, Cattaneo PM, Chang Ko C. Mechanical
Dent Pract. 2005 Nov 15;6(4):54-63 behavior of ceramic veneer in zirconia-based
restorations: A 3- dimensional finite element
10. Sailer I, Fehér A, Filser F, Gauckler LJ, Lüthy H,
analysis using microcomputed tomography data. (J
Hämmerle CH. 2007. “Five-year clinical results
Prosthet Dent 2010;105: 14-20)
of zirconia frameworks for posterior fixed partial
dentures.” Int J Prosthodont 20:383-388. 22. Choi YS, Kim SH, Lee JB, Han JS, Yeo IS
In vitro evaluation of fracture strength of
11. Manicone PF, Rossi Iommetti P, Raffaelli L . An
zirconia restoration veneered with
overview of zirconia ceramics: Basic properties
various ceramic materials. J Adv Prosthodont. 2012
and clinical applications. Journal of dentistry 35 (
Aug;4(3):162-9.
2007) 819 – 826.
23. Kwon TK, Pak HS, Yang JH, Han JS, Lee JB, Kim
12. Della Bona A, Kelly JR The clinical success of all-
SH, Yeo IS. Comparative fracture strength
ceramic restorations J Am Dent Assoc. 2008
analysis of Lava and Digident CAD/
Sep;139 Suppl:8S-13S.
CAM zirconia ceramic crowns. J Adv Prosthodont.
13. Choi BK, Han JS, Yang JH, Lee JB, Kim SH. 2013 May ;5(2):92-7.
Shear bond strength of veneering porcelain to
24. Ozcan M, Niedermeier W Clinical study on
zirconia and metal cores. J Adv Prosthodont. 2009
the reasons for and location of failures of metal
Nov;1(3):129-35.
ceramic restorations and survival of repairs.Int J
14. Örtorp A, Kihl ML, Carlsson GE. 2009. “A Prosthodont. 2002 May-Jun;15(3):299-302.
3-year retrospective and clinical follow-up study
25. Shadid, R. , Sadaqah, N. , Abu-Naba’a, L. and
of zirconia single crowns performed in a private
Al-Omari, W. (2013) Porcelain fracture of
practice.” J Dent 37:731-736.
metal-ceramic tooth-supported and implant-
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 377

supported restorations: A review. Open Journal of of veneer porcelain pressed on Y-TZP. J Dent
Stomatology, 3, 411-418 2010;38(4):318-24.
26. Rinke S, Gersdorff N, Lange K, Roediger M 31. Al-Dohan HM, Yaman P, Dennison JB, Razzoog
Prospective evaluation of zirconia posterior ME, Lang BR. Shear strength of core veneer
fixed partial dentures: 7-year clinical results Int J interface in bi-layered ceramics. J Prosthet Dent
Prosthodont. 2013 Mar-Apr;26(2):164-71 2004;91(4):349-55.
27. Coelho PG, Silva NR, Bonfante EA, Guess PC, 32. Guess PC, Kulis A, Witkowski S, Wolkewitz M,
Rekow ED, Thompson VP. Fatigue testing of two Zhang Y, Strub JR. Shear bond strengths between
porcelain-zirconia all- ceramic crown systems. different zirconia cores and veneering ceramics and
Dent Mater 2009;25(9):1122-7. their susceptibility to thermocycling. Dent Mater
28. Coelho PG, Bonfante EA, Silva NR, Rekow ED, 2008;24(11):1556-67.
Thompson VP. Laboratory simulation of Y-TZP 33. Van der Zel J. M. GT, De Kler M, Tsadok Hai
all-ceramic crown clinical failures. J Dent Res T. Effect of shoulder design on failure load of
2009;88(4):382-6. PTCercon crowns. IADR General Session 2004
29. Bonfante EA, Sailer I, Silva NR, Thompson VP, 2004.
Rekow ED, Coelho PG. Failure Modes of Y-TZP 34. Curtis AR, Wright AJ, Fleming GJ. The influence
Crowns at Different Cusp Inclines. J Dent 2010. of simulated masticatory loading regimes on the
30. Bonfante EA, Coelho PG, Guess PC, Thompson bi-axial flexure strength and reliability of a Y-TZP
VP, Silva NR. Fatigue and damage accumulation dental ceramic. J Dent 2006;34(5):317-25.
 378 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A Proximate Analysis of Phytochemical in Sonalum Trilobatum

after the addition to Leavened Yeast goods with Sensory
Evaluation

Manivel. K1, John R William1, Moyeenudin.HM1

1
Asst. Professor, School of Hotel and Catering Management, Vels Institute of Science, Technology & Advanced
Studies, (VISTAS), Chennai, India.

Abstract
Herbs are used as a medicine in curing various diseases, Due to many reasons in recent days the Respiratory-
related health issue has become one of the major problems faced by most developing countries. The constant
rise in pollution from vehicular traffic, factory smoke emissions and other factors have to lead to a steady
rise in global warming. As a result of these factors, certain allopathy medicines fail to have its complete
usefulness on ones Therefore to achieve the natural changes and progress a neutralised therapy will help
resolve this problem. By incorporating solanum trilobatum in bread we can gradually indicate respiratory-
related health issues effectively. Since bread is the widely used commodity all over the world. It will help in
resolving the deficit. The objective behind this study is to make over the human body in tune with nature. It
is our effort to introduce solanum trilobatum in 3 different proportions into bread by testing it on the basis of
liking, acceptance, taste, etc. It was observed that the procedure resulted in a product that can be effectively
accepted and implemented.

Key words: solanum trilobatum, bread products, anti-oxidant,

Introduction to maintain its traditional secrecy. Many of the herbal

recipes not recorded. This kind of recipes in every day
Solanum Trilobatum is one among the Indian
food or medicines when consumed more than prescribed
traditional herbs that helps to cure many diseases in
levels can cause adverse side effects. Proper knowledge
the human body. It has been elaborately used in Siddha
of right ratio before intake is most essential before using
medicines. The nature of this is, its leaves are covered
this for consumption This research was aimed at the
by thorns, the flower is purple in color, and fruit is red in
incorporation of the the solanum trilobatum in bread as
color. AS the thorn is toxic, it should be removed before
a medicine substitute to help recover from diseases 2.
using it.Solanum trilobatum is known for its nutritional
In this research, we have used solanum trilobatum for
value and numerous health benefits, such as sodium
making herb bread with different proportion ranging
potassium, phosphorous, zinc magnesium and iron.
from (10%, 20%, and 30%) in a normal bread dough
Each part of this plant can be used for various purpose.
recipe such as soup stick, bun and rusk. The sample
People in India usually use them in a powder form after
were then allowed to be examined by forty untrained
dehydrated by sun light; and stored in air tight container.
customers and were used hedonic scale asked to rank
This powder is mixed along with cooking commodities
their observation. Then the results were concluded from
or can be made as decoction and is commonly consumed
the sensory evaluation of the observation provided by
an empty stomach as per elderly advice 1. There are
the customers. The tested products were found to have
numerous home recipes are not revealed out of which
better taste, texture, aroma, and appearance observed by
the customers. Most of the multi-grains used in bakery
Corresponding author industry
Manivel. K
Email address: [email protected]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 379

Cereals used in bread: It has, however, a somewhat coarser texture than other
white loaves. Baked in a casserole, it is easy to prepare
Though the cereals are used to be cultivated in the in the oven in about an hour. When it comes out of the
Nile region and the major source of the good and best oven an hour later, brush with melted butter, sprinkle
quality bread making wheat flour and all-purpose flours. with salt and serve 6. A Middle Eastern bread these
There are many different varieties the durum wheat small loaves puff into hollow balls that can be filled with
type is best known for RYE (Secale cereal): Probably sandwich spread or butter and honey.5 Buttermilk bread
of southwest Asian Origin, rye is similar in composition has a country kitchen lilt, and this loaf has a country –
to wheat 3. In Europe, it is used mainly for making rye kitchen taste. It is light, of good texture, has a golden-
bread and crisp bread (particularly in Scandinavia). It brown crust and creamy white insides 6. It keeps for a
is also used in the manufacture of drinks: whiskey in long period deep frozen and makes delicious toast. 6Fork
America, Beer in Russia. Millet (Panicum miliaceum): bread: Bread is rich and tenders a deep, dark brown
The kernel obtained from the cultivation is widely crust surrounding a lovely yellow interior. 6Bran, the
consumed as a cereal in continents like Africa and Asia. brown, flaky outer covering of the wheat kernel, has a
It is also used as a source of starch in Russia. CORN nut-like flavor and is often mistaken for one of several
(Zea mays): which is Native to Mexico and in some breakfast portions of cereal with almost the same name.
parts of South America, The major grain commonly They are bran, too, but of different texture and form.
consumed is corn kernels and it is consumed in various Hardly as exotic in flavor or appearance as its place of
forms during their meal like tortilla made out of corn origin- Hilo, on the big island of Hawaii-this bread, from
flour. The corn flour is used in making many Mexican a recipe member of the Hilo women’s club, is a good
specialties like burritos, Tacos, Nacos, Quesadillas, and straightforward bran loaf .bran and molasses bread.
Enchiladas. This consumes additional time and liquid There is an unusual wheat flavor about this bran bread
than normal grain. that is underscored by the dark 7unsulphured molasses.
Herbs: The bran particles are believed to cut the gluten stands
which reduce the size of the loaf compared to a loaf
The herbs accessible has its bioactive parts which off-white made with the same volume of flour. Oats
help to turn away and fix any disease. The solanum bread Oats have had a plebeian upbringing, mentioned
trilobatum is an herb in like manner contains all of the as a weed by the classical writers of Rome, and used
8 principal amino acids making it one of just a bunch infrequently in medicines 7. In the early Christian era
couple of plants that give an all of protein source 4. It is they grained some stature as a foodstuff, yet despite their
well off in flavonoids, including Quercetin, Kaempferol, ability to add flavor and good texture to the bread, oats
Beta-sitosterol, caffeoylquinic destructive, and zeatin. have come down through the centuries principally as a
As well as the herb like Rosmarinus officinalis, food for livestock. Blended bread. The bread made with
generally called nursery rosemary, is a nearby to the the blended grains are coarser, denser, and darker than
Mediterranean zone. This herb is a native to mint family, most other loaves. They taste of no one grain but the
it is an evergreen bramble in like manner related to basil, meld of them all. In the seven recipes, there is a total
marjoram, and oregano. It is typically found creating by of seven different flours and cereals of French bread
the ocean, and its Latin name thinks about to “dew of the in France, bread is seldom baked in the home because
sea.” 4Oregano begins from Origanum, an assortment the boulangerie is just around the corner producing its
of the mint family. Oregano at first began from warm bounty of golden loaves, six days of the week potato
environments in western and southwestern Eurasia and bread. The potato grew wild in Peru and was taken to
the Mediterranean locale. Oregano is a suffering plant Europe by Spanish explorers in 1530.
that has the properties of herbs, green and leaf like, with
round framed leaves 5. Materials and Method
Types of Bread: The ingredient was sourced as whole grains from a
local grocery store as whole grain. It was then combined
White bread has a variety of tastes and texture that together and further milled and then stored in airtight
add delight to meals and snacks. White flour is also an containers before its actual use. The recipe was tried
important ingredient in many dark breads which would in the department of Hotel and Catering Management
not raise sufficiently Cottage bread is moist and flaky. at Vels University, Chennai during 2018-2019 in the
 380 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

month of January

Recipe

Serial
Ingredients Quantity
Number

1 Multigrain flour 200g

2 Yeast 5g

3 Salt 3g

4 Water 120ml (100ml-120ml)

5 Gingely oil 20ml

6 Sugar 20g

A percentage of 2grams, 4grams and 6grams solanium trillobatum was used in three different proportion sample.
It was observed that the dough did not crack in spite of having lesser gluten percentage 8. The dough shaped into soup
sticks, sunrise, mini buns etc. The shaped rolls were placed on a clean baking tray and further rested for 15 minutes.
It was then baked in an oven at 170*c for 18 minutes to a color of light golden brown.

Results
Sensory Evaluation

The bread prepared with the addition of solanum trilobatum in various ratios and shapes was sent for sensory
evaluation and their likes and dislikes are identified through hedonic scale.

Table: 1 Sensory Evaluation of Soup Stick

Neither
Like
Disliike Dislike Dislike Dislike Like Like Like Like
Very
Extremely Very Much Moderarely Slightly Nor Slightly Moderately Extremely
Much
Dislike

Colour 0 0 0 1 2 10 11 2 1

Taste 0 0 1 1 3 10 12 0 0

Aroma 0 0 0 3 5 11 6 2 0

Appearance 0 0 0 1 0 0 0 0 0

Texture 0 1 1 2 0 0 0 0 0

Acceptance 0 0 2 1 0 0 0 0 0
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 381

Table: 2 Sensory Evaluation of Sunrise Shape

Dislike Neither Like

Disliike Dislike Moder- Dislike Like Like Moder- Like Ex-
Very Like Nor Very
Extremely arely Slightly Slightly ately tremely
Much Dislike Much

COLOUR 1 0 1 2 3 4 3 9 3

TASTE 0 0 0 0 3 5 7 10 1

AROMA 0 0 0 0 1 9 2 11 2

APPEAR-
ANCE 0 0 2 1 1 6 6 10 1

TEXTURE 1 0 0 1 3 6 6 9 1

ACCEPTANCE 0 0 0 0 0 6 3 8 3

Table: 3 Sensory Evaluation of Bun Shape

Neither
Dislike Like
Disliike Dislike Dislike Like Like Like Like
Very Very
Extremely Moderarely Slightly Nor Slightly Moderately Extremely
Much Much
Dislike

Colour 0 0 2 3 6 4 5 3 3

Taste 0 0 0 5 4 9 4 2 2

Aroma 0 1 2 2 6 5 5 3 2

Appearance 0 0 1 2 1 6 10 2 4

Texture 0 0 2 0 5 4 6 7 2

Acceptance 0 1 0 4 1 6 3 3 4

Discussion and dislikes with the prepration methods and In the

present examination, the Multigrain Bread fused with
The bread products made with the addition of
thuthuvalai and healthful screening and capacity were
Solanum trilobatum is used as a sample, taste, texture
researched 10. The proximate, basic, phytochemical
and colour was good and found to be acceptable in this
investigation of sustenance test analyzed. The outcomes
survey through sensory evaluation in Table1, Table2,
were talked about as underneath. The real constituents in
Table3.The taste of this product shows higher percentage
the consumable bit are water, protein, sugar, lipid (fat or
in Table3 as colour and aroma also satisfactory. and
oil) and fiery remains (minerals). Investigation of these
this food is tested for its phytochemical compounds
essential constituents is frequently alluded to proximate
present after the cooking process the results shows likes
examination 11. Proximate investigations of nourishment
 382 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

test assume a pivotal job in surveying their dietary 14. These materials will go to separated supplements,
hugeness and help to get to the nature of the example nutritional enhancements with explicit weight control
(Pandey et al., 2006). Consequences of the proximate plans to hereditarily built originator sustenance’s,
sythesis in examined test materials are given in Table 4. natural items, prepared nourishments and refreshments.
Isoflavonoids, Phytochemicals present in the herb are
Table 4: Proximate configuration of Extract comprehensively depicted as phytosterols, limonoids,
terpenoids, carotenoids, phytoestrogens, polyphenols,
Content Quantity
flavonoids, anthocyanidins and glucosinolates 15. They
Moisture content (%) 8.46 have gigantic effect on the social insurance framework
and may give therapeutic medical advantages including
Ash (%) 3.41 the counteractive action and additionally treatment
of ailments and physiological issue. Lion’s share of
Crude fibre (%) 4.23
sustenances, for example, entire grains, beans, natural
Protein (%) 63.75 products, vegetables and herbs contain phytochemicals
of nutraceutical significance 16. These element of
Fat (%) 3.42 phytochemicals moreover unaided as well as in blend,
Carbohydrate have colossal restorative potential in relieving different
17.12
(%) sicknesses including malignant growth, diabetes,
stomach ulcer, Heart related infections, and blood
Minerals are gotten from the soil outside layer. pressure and so on. In the present examination, tannin,
Through the impacts of the climate, shakes that contain flavonoids, steroids, alkaloid and polyphenol were
minerals are ground into littler particles, which at that available in the tried example. The nearness of these
point become some portion of the dirt. The mineral mixes shows the beneficial outcome on the wellbeing.
substance in the dirt is consumed by developing plants
12. The plants are devoured by the two creatures and Conclusion
individuals as sustenance. This mineral turns out to
The phytochemical study of solanum trilobatum
be a piece of the natural way of life. The real minerals
herb shows that it is loaded with various minerals with
fill in as basic parts of tissues and capacity in cell and
good nutritive value and an proximate analysis of this
basal digestion and water and corrosive base parity 13.
herb states that this can be stored for a longer period
Consequences of the significant minerals are yielded
when it is prepared with a combination of all-purpose
Table 5.
flour and other yeast made ingredients like sugar, salt,
Table 5: Mineral composition of powder water, solanum trilobatum powder to make a bread 6.
The sensory evaluation of this bread on taste, texture and
appearance gave maximum satisfactory levels, also we
Sample Extract
Contents believe the tested products using it can help people with
(mg/100g)
respiratory problem as it has magnesium and iron in it.
Calcium 165.43
The popularity of bread products in the market gluten-
free bread whole meal bread rye bread Repopulation
Potassium 127 is taken place in the bakery industry due to the various
Magnesium 88 lifestyle-related diseases in the search of healthy products
with this intention multigrain bread commonly known as
Zinc 12.42
one traditional grain leaving more healthy bean used in
Iron 65.87 the bakery for making of a variety of bakery products.
Phosphorous 132.45 Ethical Clearance: Not required for this article.

Phytochemicals Study Conflicts of Interest: Conflict of interest declared

none.
The Phytochemicals has Nutraceuticals significance
of elements which support in advance wellbeing is happen Source of Funding: Self
with a convergence in sustenance of pharma businesses
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 383

References 8. Aruna Bhatia et al, Antioxidant activity of native

and micropropagated Tylophora Indica leaves
1. P. Swapna Latha and K. Kannabiran, Antimicrobial
Extract: A comparative study: JNPPB7 Journal of
activity and phytochemicals of Solanum trilobatum
Natural Production Plant Resources, 2013; 3, (1), p.
Linn, African Journal of Biotechnology December
1-7.
2006, 5, (4), p. 2402-2404.
9. Nieto G, Ros G, Castillo J. Antioxidant and
2. Doss, H. Mohammed Mubarack and R.
Antimicrobial Properties of Rosemary (Rosmarinus
Dhanabalan, “Pharmacological importance of
officinalis, L.): A Review. Medicines (Basel) 2018
Solanum trilobatum” Indian Journal of Science and
;5, (3), p. 1-13
Technology, Feb. 2009, 2 (2), p. 41-43.
10. David J.R. Fulton et al, Reactive Oxygen and
3. Reetta Holma, et al, Constipation Is Relieved More
Nitrogen Species in the Development of Pulmonary
by Rye Bread Than Wheat Bread or Laxatives
Hypertension, MDPI Antioxidants, 2017; 6, 54.
without Increased Adverse Gastrointestinal Effects,
The Journal of Nutrition, March 2010; 140, p. 534– 11. R. Nair, et al. Antibacterial Activity of Some
541. Selected Indian Medicinal Flora. Turk J Biol, 2005,
p. 41-47.
4. Evert, Alison B et al. “Nutrition therapy
recommendations for the management of adults 12. Ncube N. S. et al, Assessment techniques of
with diabetes.” Diabetes care 2013; 36 (11), p. antimicrobial properties of natural compounds of
3821-3842. plant origin: current methods and future trends.
African Journal of Biotechnology Vol. 7 (12), 17
5. Dhillon G K et al, Effect of Oregano Herb on
June, 2008; 29, pp. 1797-1806,
Dough Rheology and Bread Quality, International
Journal of Food Science, Nutrition and Dietetics, , 13. Prusti, A., et al, Antibacterial Activity of Some
2013; 2 (4) , p. 40-44 Indian Medicinal Plants. Ethnobotanical Leaflets
2008; 12, pp. 227-230
6. Dimple Singh-Ackbarali, Rohanie Maharaj,
.Sensory Evaluation as a Tool in Determining 14. Jawhar M, et al, Rapid proliferation of multiple
Acceptability of Innovative Products Developed shoots in solanum trilobatum L. Plant Tissue
by Undergraduate Students in Food Science and Culture; 2004; 14 (2) pp. 107-112.
Technology at the University of Trinidad and 15. Shahjahan M, et al, Effect of medicinal plants on
Tobago. Journal of Curriculum and Teaching. tumurogenesis Ind.J.Med.Res. 2004; 123 (5-8), pp.
2014; 3(1), p.10-27 23-27
7. Li, Xue et al. “Short- and Long-Term Effects of 16. Purushothaman Balakrishnan et al, A perspective
Wholegrain Oat Intake on Weight Management on bioactive compounds from Solanum trilobatum
and Glucolipid Metabolism in Overweight Type-2 ,Journal of Chemical and Pharmaceutical Research,
Diabetics: A Randomized Control Trial.” Nutrients, 2015; 7, (8), pp. 507-512 .
Sep. 2016; 8 (9), p. 549
 384 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A Study on Patients of Scrotal Dermatitis

Akhil Kumar Singh1, Ranjana Singh2, Parth H Thakkar3

1AssociateProfessor, Dept of Dermatology, Venereology & Leprosy, 2Professor Dept of Preventive & Social
Medicine, 3Resident, Dept of Dermatology, Venereology & Leprosy, Saraswathi Institute of Medical Sciences NH24
Anwarpur Dist Hapur, UP

Abstract
Scrotal dermatitis is among one of the very common dermatological condition that has been easily overlooked
by dermatologists ,treating physicians as well as by patients. The condition is easily mistaken for the common
skin disorders affecting the area, like Tinea and scabies. This study will try to find out the various etiological
factors and the management of the condition. 85 Male patients between the age group of 15 to 78 years
were enrolled in a study period of 8 month. Majority of patients (48.2%) were wearing jeans regularly.54%
of patients were wearing Jocky type of underwear. Medicated soaps were used by 30% of patients. 23% of
patients were using antiseptic liquids for cleaning the area. Deodorant spray was used by More than 21% of
patients. 75.6% of patients used combination creams (self medicated). On examinations 63.5% of patients
were having erythema of some grade. Thickening of scrotal skin were observed in 60% of cases.Superficial
to deep ulceration /erosion were present in 41.2% of patients. Scabies nodules were present in 22.4% of
patients. Associated Tinea cruris was observed in 32.9% of patients. However, fungus infection of scrotum
was found in 17.6% of cases.17.6 % of cases were having associated bacterial infections. Irritant reactions/
contact dermatitis was most common cause of scrotal dermatitis observed in 44.7% of cases, followed by
neurodermatitis (LSC) in 30.5% of cases.

Key words: Scrotal dermatitis, Irritant dermatitis scrotum, Scrotal pruritis

Introduction Though the condition can be treated easily, it causes

significant physical and psychological morbidity to the
Scrotal dermatitis may present in different
patient in the form of persistent or recurrent symptoms
morphological features and is characterized by severe
and social embarrassment. Also there is tendency for
itching, erythema, scaling, erosion, fissuring and
recurrence, as mostly we stress on medicines part but
lichenification of the scrotal skin. Apart from these, there
we ignore the factors behind the condition. Mostly busy
may be loss of hairs, Multiple factors are responsible for
practitioners do not explain in detail the factors behind it
the condition, the most important being psychological
and the preventive measures to be taken.
stress and contact dermatitis either allergic or irritant.
The condition has been easily diagnosed as fungal
Aims and Objectives
infection of the scrotal area. Due to wide spread use of
antiseptics ,irritant ,soaps, sprays, hygiene wash and 1. To classify the different dermatosis affecting the
many topical agents, nowthis condition has become very scrotum.
common.
2. To find out the various physical, psychological
Though very common condition, very limited and chemical factors responsible for this.
literature has been published on scrotal dermatitis either
3.To treat and to educate the patient to prevent
because of under reporting by the practitioners. Probably
future recurrences.
“scratching the balls” is considered as a common male
habit.
Material and Method
A total of 85 male patients above age of 15 years
attending dermatology OPD in Saraswathi institute
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 385

of medical Sciences, Hapur and School of Medical suspected patients KOH examination was done to rule
Sciences & research, Gr Noida were included in study. out dermatophytosis. The final diagnosis was made. The
The duration of study was from January 2019 to August patients were treated and observed for 2 months after
2019. A questionnaire was prepared and all the details successful treatment. Any recurrence was recorded. The
including socioeconomic status, personal habits, dressing patients were advised to change their habits and change
pattern, type of underwear, toiletries including perfume their toiletries and dressing pattern.
spray, hygiene wash, antiseptic lotions was also noted.
Informed consent was also taken. Proper examinations The data was recorded, tabulated and analyzed by
of the area in good day light condition was done. Any using SPSS software version 20. Percentage, mean and
sign of inflammation, thickening, lichenification, chi square test was used for statistical significance and P
ulcerations /erosions, loss of hairs were also recorded. In value <0.05 &<0.001 were considered significant.

Results
The total numbers of 85 cases were recorded in the department of dermatology were as follows:

Table 1: Characteristics of patients

Age group (Years) No. Percentage

15-29 27 31.8

30-44 30 35.3

45-59 15 17.6

60-74 10 11.8

75+ 3 3.5

Socio-economic status

High 12 14.1

Lower 13 15.3

Lower Middle 30 35.3

Middle 30 35.3

Associated Diabetes Mellitus

Yes 12 14.1

The age of patients was in the range of 15 years Out of the 85 patients, majority (41) were wearing
and 78 years with mean age of 39.6 years. Majority of jeans daily for the most of the time (48.2%). 30 patients
patients belonged to between age group of 30 to 45 years (35.3%) were wearing pant daily. Pajamas were worn
(35%) followed by age group of 15 to 29 years (31.8%). daily by 12 patients (14.1%).Only 2 patients (2.45) were
Only 3.5% patients were above age of 75 years. wearing dhoti regularly.
Out of 85 patients, highest number of patients Jocky type (V shaped) underwear were regularly
belonged middle and lower mid socioeconomic status worn by majority of patients 46(54.1%) . Loose Desi or
35.3 % each. boxer type were worn by 26 patients (30.6%). Long and
 386 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

tight underwear were worn by 13 patients (15.3%).

Except 5 patients (5.9%) all were using soaps for

cleaning the area involved and for regular bathing.
Majority of patients were using mild soaps (31, 35.3%).
Soap with chemicals were used by 26 patients (30.6%).
Herbal soaps were used by 12 patients (14.1%). While
2 patients were using detergent bars for bathing.
Surprisingly 3 patients (3.5%) were using V wash
(Female hygiene wash) over the area.
Fig 1. Clinical features
20 patients (23.6%) used liquid antiseptics like
Various grade of Mild to deep erythema were
Dettol, Savlon etc. for cleaning the area or for bathing
observed in 54 (63.5%) cases. Some grade of thickening
purposes.
of scrotal skin was observed in 51 (60%) cases.
Deodorants over the area was used by 18 patients Superficial to deep painful ulceration were observed in
(21.2 %). 35 cases (41.2%), Nine patients(10.6%) showed erosion
with serous discharge.
4 Patients (4.6%) used Dithranol (a highly irritant
ointment used in treatment of psoriasis) leading to severe Nodules over the scrotal skin (old or active scabies)
irritant contact dermatitis. were observed in 19 (22.4%) of patients.

35 (41.2%) patients were using various antifungal Associated Tenia Cruris were observed in 28
creams over the scrotum. Most commonly been patients (32.9 %). Associated Intertrigo was observed
Luliconazole and Miconazole. One patient used Zalim in 9 patients (10.6 %). Skin scrapping and KOH mount
lotion (containing salicylic acid and herbal ingredients ) tests were performed in suspected cases. 15 patients
leading to acute irritant contact dermatitis. were found positive for superficial dermatophytosis.

Antihistamines were used by majority of patients 15 patients (17.6 %) were also having associated
75(88.2%) most commonly being Cetirizine and bacterial infections like folliculitis,furunculosis and
Pheniramine Maleate. infected eczema over the scrotal skin.

Clinical Features 11 patients were having diabetes with HbA1c level

more than 7.

Table.2 Age wise distribution of non venereal dermatosis of scrotum

Age Group Chi-

15-29 30-44 45-59 60-74
Non- Venereal 75 + Total Squre P Value Result
Years Years Years Years Value
Genital Dermatosis

*Irritant / Contact
20 11 5 1 1 38
Dermatitis

Scabies 3 7 6 4 1 20

Fungal Infection 3 7 2 1 0 13
57.317 Highly
<0.004
significant
Bacterial Infection
1 1 0 3 0 5
Alone

Lichen Simplex
2 9 9 6 1 26
Chronicus
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 387

Irritant and /or contact dermatitis was most common Discussion

cause of scrotal dermatitis in 38 cases (44.7%) of cases ,
Scrotal dermatitis is among one of the very common
followed by Lichen simplex chronicus (Neurodermatitis)
dermatological condition having multifactorial origin.
was present in 26 cases (30.5%). Scabies infestation
In a study in year 2017 by Dipali Rathod et al [4] in
over scrotum was present in 20(23.5%) cases.Fungus
non-venereal dermatosis in both females and males
infection could be confirmed mycologically only in
showed scrotal dermatitis in 16 % of cases, if we take
13 cases (15.3%). Bacterial infections like folliculitis
only male patients in consideration the percentage will
were present in 5 cases (5.9%).a highly significant
come 21.3%. In another study by M Kanta Prasad Rao[7]
association was observed between type of dermatitis &
over male patients ,13 % of patients were having Scrotal
age (p<0.004).
dermatitis. The etiological factors are multifactorial &
Treatment and response can be classified as:

All the patients improved with the treatment, but in 1. Irritant or allergic reactions to soap or detergents
18 patients (21.2%) there was recurrence of symptoms
2. Topical antiseptics like Chlorxylenol, Triclosan,
after the successful treatment. Out of these 18 patients,
Cetrimide ,Chlorhexidine etc
7 did not follow the instructions.
3. Topical antibiotics like Neomycin, Gentamycin
etc

4. Topical Antifungal creams and salicylic acid /

benzoic acid based preparations.

5. Diabetes Mellitus

6. Dermatological conditions like Atopic dermatitis,

seborrheic dermatitis, lichen simplex chronicus

7. Hygiene or perfume spray

8. Occlusive dresses / tight jeans

9. Tight and hugging under wears

10. Infestations by scabies / pediculosis

Lichen Etiopathology – The scrotum is an area with

Simplex Chronicus remarkable permeability. It provides a unique
percutaneous doorway for the entrance of drugs into
the circulation and is thus uniquely susceptible to toxic
and irritant agents [4].Allergic reactions of the male
genital are most often acute. They are influenced by the
dependent position, rich vascularity and looseness of the
connective tissue in this area [1]. Further the occlusion
in form of tight hugging under wears and followed by
release of detergent remnants present in undergarments.
The detergent works as an irritant to scrotal skin. Other
contributory factors includes friction, maceration,
overwashing leads to scrotal dermatitis [12, 13].Riboflavin
and other Vit B complex deficiency occasionally produce
scrotal dermatitis [9].
Acute irritant dermatitis
 388 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Clinical features – The Scrotal dermatitis may In this study 26 patients (30.6%) were using antiseptic
present itself as severe itching with burning sensation soaps (Dettol , Savlon , lifebuoy). These soap contains
In Lichen simplex chronicus the scrotal skin shows Chlorxylenol (Dettol) and Triclosan. Chlorxylenol or 4
thickening, hypo or hyper pigmentation[2]. chloro 3,5-dimethylphenol present in various commonly
used antiseptics preparations and soaps is also an
Krishnan Ajay & Kar Sumit suggested the following important cause of dermatitis of the scrotum[11]. It also
classification[1] depending upon clinical features. causes the removal of normal microbial flora of the skin
Type 1- Mild & acute type: In it there is severe and facilitates the colonization by pathogenic groups[1].
burning and itching. Heals with mild desquamation after Twenty patients (23.6%) were using antiseptics liquids
some days or weeks. either directly over area or mixing with water for
bathing. Cetrimide is one of the most common cause of
Type 2- Severe chronic dry: Scrotum looks bright contact sensitivity [11]. Deodorants were used over the
red and hypopigmented with severe itching. area by 17 patients (20%) . Irritant reactions can occur
from fluorinated hydrocarbon propellants sprayed too
Type 3 –Chronic wet: Whole of scrotum and inner close to the genitals.[15]
thighs become macerated with oozing Fetid odor and
telangiectasia may present. Surprisingly 3 patients were using V wash ( vaginal
Wash containing Lactic acid & having pH of 2.5) over
Type 4 -Ulcerated and edematous: The scrotal skin the area . 2 patients were using highly irritant detergent
is edematous with fluid or pus discharge, associated with bar for bathing. To treat itching combination creams
severe pain. containing steroids, antibiotics and antifungals were
The majority of patients(57)in our study were young used by majority of patients 66 (75.6%). 35 patients
in age group of 15 to 44 years (67.1%) this is the age (41.2%) were using antifungal creams over the scrotum.
when most of the persons were wearing jeans, tight Since the inflamed skin has a higher permeability, the
pants etc. also this is the age when the teenager ,students various over the counter products applied over the
and young adult try various toiletries and perfumes. lesions further aggravate the condition[1].

In this study 42 % of patients belong to middle and Four patients had used Dithranol ointment which
high income group. These group usually have enough led to development of acute irritant erosive contact
surplus money to spend on expensive jeans, toiletries, dermatitis over the scrotum and surrounding skin.
deodorant and perfume etc. In our study only 12 patients In this study mild to deep erythema was observed
were having Diabetes as shown by blood sugar levels in majority of patients 54 (63.5%). Various grade of
and HbA1C levels. thickening in 51 patients (60%).
Jeans were regularly worn by 41 patients (48.2%). Superficial to deep painful ulceration were observed
The pants were worn regularly by 30 patients (35.3%). in 35 cases (41.2%), leading to difficulty in walking.
The students and young men wear jeans most of the 9 patients(10.6%) showed painful erosion with serous
time, wearing the same jeans for days together without discharge.
washing or drying. The jeans and tight synthetic
pants act as occlusive dress preventing evaporation of Nodules are very common over genital areas in case
moisture, increasing local temperature thereby making of scabies . Scabies nodules in treated or untreated cases
the environment conducive for growth of bacteria and were found in 20 cases (23.5%). In a study by M. Kanka
fungus. It also facilitate transcutaneous absorption of Prasad Rao Genital scabies was present in 18.33% of
irritants. cases of nonvenereal dermatosis [7].

The jockey type of tight and hugging underwears An intact skin barrier prevents the penetration of
were worn regularly by majority of patients 46 (54.1%) harmful substances into the skin. Irritants and allergens
. these underwears covers scrotum all around and are that stay on the skin surface and come into contact with
constantly in contact with scrotal skin. Any remnant of the stratum corneum only do not harm the skin [8].
detergent, feces & urine acts as an irritant to scrotal skin.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 389

Associated Tenia cruris was present in 28 cases 2013 Sep; 28(5):302–05.

(32.9%).However presence of dermatophytes was 2. Rajashekhar N, Thippeswamy C, Prasanna N B.
demonstrated microscopically in 15 cases (17.6%) Lichen simplex chronicus of scrotum. Indian J
by skin scraping and KOH examination. Tenia cruris Dermatol VenereolLeprol [serial online] 1999
cases are very common but spread over the scrotum is [cited 2019 Oct 30]; 65:91-92
rare. Decreased scrotal skin barrier function facilitating
3.  Bhatia MS, Gautam RK, Bedi GK. Psychiatric
permeation of antifungal factors into the stratum corneum
profile of patients with neurodermatitis. J Indian
and decreased eccrine sweat secretion in the penile skin
Med Assoc 1996. Dec; 94(12):445-46.
resulting in lowered skin hydration have been proposed
as the mechanism of the relative resistance, but neither 4. Fisher AA. Unique reactions of scrotal skin to
has any rigorous proof [14]. topical agents.Cutis 1989. Dec; 44(6):445-47
5. Woskoff A, Carabelli S, Hoffman M. Dermatitis
Acute and chronic contact / irritant dermatitis of the scrotum. Med CutanIbero Lat Am.1982;
were observed in 38 patients (44.7%).Lichen simplex 10(1):37-40
chronicus were diagnosed in 26 (30.6%) patients. In
6. Hogade AS, Mishra S.A study of pattern of
a study by Bhatia et al over cases of Neuro dermatitis
nonvenereal genital dermatoses of male attending
scrotal involvement was present in 12% of cases [3].
skin OPD of tertiary centre in Kalaburagi. Int J Res
15 patients were also having associated or only Dermatol.2017; 3: 407-10
bacterial infections. In a study by Woskoff A et al it 7. Dr.M.KanakaPrasadaRao. A Study Of Pattern of
was found that Candida and Staphylococcus were most various non venereal Genital Dermatosis In Male
commonly involved [5]. Patients Attending to Skin & STD OPD, RIMS
General Hospital,Srikakulam, Andhrapradesh.
All the patients were counselled and treated. Most IOSR Journal of Dental and Medical Sciences.
of them were advised to change detergents, soaps, 2018; 17:01-09
underwear etc. They were also advised not to use
combinations creams and antiseptics soap/liquids. Mild 8. Proksch E, Brasch J.Abnormal epidermal barrier
steroid creams were given for short periods, in cases of in the pathogenesis of contact dermatitis.Clin
Dermatitis and Lichen simplex chronicus (LSC) along Dermatol. 2012 May-Jun;30(3):335-44
with advice to shun itching. Sedating antihistamines were
9. Nath D K. Dry, scaly dermatitis of scrotum.Indian J
given at night in cases of LSC. All the patients improved
Dermatol VenereolLeprol. 1999; 65:49-50
with medicines and changing the toiletries and clothes.
However, in 18(21.2) patients there were recurrence 10. Dipali Rathod et al., A Cross Sectional Descriptive
of symptoms within two months of completing the Study of Non-Venereal Dermatoses affecting the
treatment. Male and Female Genitalia at A Tertiary Care
Hospital of South India .Sch. J. App. Med. Sci.,
Conclusion Dec 2017; 5(12D): 5099-5108
11.  Calnan CD. Contact dermatitis from drugs. Proc R
Though scrotal dermatitis is a very common
Soc Med 1962. Jan; 55:39-42
condition, still it is underreported and underrated
condition. For successful treatment, apart from 12. Ramam M, Khaitan BK, Singh MK, Gupta SD
medicines, lifestyle changes are also required. Frictional sweat dermatitis.Contact Dermatitis.
1998; 38:49.
Source of Support – Nil
13 . Bauer A, Geier J, Elsner P.Allergic contact
Conflict of Interest – None declared dermatitis in patients with anogenital complaints. J
Reprod Med. 2000; 45:649-54
Ethical Clearance- Taken from Institutional Ethics 14. Pielop J, Rosen T. Penile dermatophytosis. J Am A
Committee Dermatol 2001; 44:864-7.
15. Marfatia YS, Patel D, Menon DS, Naswa S.
References
Genital contact allergy: A diagnosis missed. Indian
1. Krishnan Ajay, Kar Sumit ,Scrotal Dermatitis - Can J Sex Transm Dis AIDS. 2016; 37(1):1–6
we Consider it as a Separate Entity?Oman Med J. doi:10.4103/0253-7184.180286
 390 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Health Status of Children in Assam

Chayanika Goswami
PhD Research Scholar, Dept of Economics, Gauhati University, Assam

Abstract
Children are the most valuable asset of a nation; their good health is the cornerstone for survival and
development for current and succeeding generations which guarantee the sound and sustained economic
development. Child health is a state of social, emotional, intellectual, mental and physical well- being which
does not merely represent the absence of disease or infirmity. The term nutrition refers to a process of
attaining necessary food for proper health and growth of human being. The nutritional status of children
impacts their health, cognition and educational achievements. But underweight and malnutrition are most
prominent health indicators in India and also in Assam (According to NFHS-3 & NFHS-4). Assam is situated
in the North-East of India, bearing a considerable percentage of its population under the poverty line. Assam
does not have shown much improvement in its health and nutrition indicators. Almost 36.4 percent children
under age 5 are stunted and Infant Mortality Rate as high as 48( NFHS-4). The health status of children in
rural areas of Assam is very pathetic. 55 percent children are stunting in rural areas. Various reports states
that though Assam has made progress in its health indicators, still there is a great need to strengthen its
existing health care services especially in the rural areas. The present study has made an attempt to study
the health status of children in Assam. This study may be able to provide a base line information and need
for effective implementation of various schemes and programmes for the improvement of health status of
children in future.

Keywords: Assam, Child, Economic Development, Health Care, Health Indicators, Nutrition.

Introduction the poverty line. Assam does not have shown much
improvement in its health and nutrition indicators.
Childhood is a significant phase of life and Almost 36.4 percent children under age 5 are stunted
deprivation during this period can have long term adverse and Infant Mortality Rate as high as 48 (NFHS). Various
impact on the well being of children1. Child health is research article and study has reported that children in the
a state of social, emotional, intellectual, mental and developing country are most vulnerable as 50 percent of
physical well- being which does not merely represent the all deaths were occurring during the first 5 years of life.
absence of disease or infirmity. The term nutrition refers Despite inclusive efforts for improving malnutrition like
to a process of attaining necessary food for proper health ICDS programme, malnutrition among children remains
and growth of human being. According to World Health a significant problem in India as well as in Assam.
Organization (WHO), “Malnutrition means the cellular
imbalance between, supply of nutrients and energy The most common method used to assess the health
and the body’s demand for them to ensure growth, status of children is given by World Health Organization
maintenance and specific functions.2” (WHO). WHO growth standard can be used to assess
whether children are growing and developing. It can
Healthy children have the fullest potentialities to also be used to observe whether efforts to reduce child
attain proper weight in relation to height and resistance to mortality and disease are effective. According to WHO,
diseases. Thus, it may increase life expectancy and help growth standard are:-
human beings to enjoy life fully, may also increase work
capacity that results in increased productivity of nation • If < -1 to > -2 Z-score implies Mild Malnutrition
and it enhances economic growth and development.
Assam is situated in the North-East of India, bearing • If < -2 to > -3 Z-score implies Moderate
a considerable percentage of its population under Malnutrition and
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 391

• If < -3 Z-score implies Severe Malnutrition Results and Discussions

On the basis of the above growth standard, three Assam happens to be one of the worst performers
common anthropometric indicators are used to measure in reducing child’s nutritional status. A scrutiny of the
the nutritional status are - nutritional status of the children, the adults of tomorrow,
is important to assess the wellbeing and health3. Detailed
1. Height-for-age (HAZ). HAZ is used to denote studies were prepared by NFHS-3 and NFHS-4 and the
“stunting”- or low height for age, main findings shows that stunted rate is 46.5 percent,
wasted rate is 13.7 percent, severely wasted rate is 4.0
which is an indicator of chronic form of under-
percent and underweight rate is 36.4 percent. However,
nutrition. It is caused by long-term
according to NFHS-4, stunted rate has reduced to 36.4
insufficient nutrition intake and frequent percent and underweight rate also reduced to 29.8
infections. percent. On the other hand, wasted rate and severely
wasted rate has increased to 17.0percent and 6.2 percent
2. Weight-for-height (WHZ). WAZ or low respectively. Again in Assam, the infant mortality rate
weight corresponding to height stands and under 5 mortality rates is 48 and 56 respectively
which is 66 and 844.
for “wasting” or more acute or current form of under
nutrition. It is a strong The following table shows the percentage of
malnourished children in Assam –
predictor of mortality among children under five. It
is usually the result of acute Table-1: Child Malnutrition Status in Assam
significant food shortage or disease.
ASSAM
3. Weight-for-age (WAZ). The WHZ, low
weight for age, is an indicator of chronic form of under- INDICATORS NFHS-3 (2005-6) NFHS-4(2015-16)
nutrition, denoting “under-weight.”

Objective: Stunted 46.5 36.4

1. To study the health status of children in Assam.

Wasted 13.7 17.0

Methodology
Severely Wasted 4.0 6.2
The present study is based on the secondary data
that are collected from different government reports and Under-weight 36.4 29.8
organizations. The sources of secondary data are:-
Infant Mortality Rate 66 48
i. The Department of Social Welfare, Government
of Assam;
Under Five Mortality
84 56
Rate
ii. National Family Health Survey -3 (NFHS-3)
Source: NFHS - 3 & NFHS - 4
iii. National Family Health Survey - 4 (NFHS-4)
In Assam, the percentage of stunted children has
iv. Census reports, Govt. of India. decreased from 46.5 percent to 36.4 percent whereas
wasted and severely wasted children are increased from
v. Health and family welfare reports.
13.5 percent to 17 percent and 4 percent to 6.2 percent
vi. Statistical Handbook of Govt. of Assam. respectively. But the percentage of underweight children
has reduced from 36.4 percent to 29.8 percent.
vii. Nutrition Policy reports of Govt. of India,
etc. The district wise nutritional status of children in
Assam is shown in table 1.2. It can be seen from table
1.2 that that Dhubri district has the highest number of
 392 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

“stunting” children with 47.4 per cent. Goalpara district has the highest number of “under-weight” children with 39.5
per cent. Cachar district on the other hand, has the highest number of “wasting” children with 30.6 per cent.

Table 2: Child Nutritional Status in Various Districts of Assam (In percentage)

District Stunted Wasted Severely Wasted Under Weight

KOKRAJHAR 30.6 15.7 6.1 27.1

DHUBRI 47.4 22.2 9.5 39.0

GOALPARA 42.7 22.1 8.9 39.5

BARPETA 41.7 16.6 5.8 33.1

MARIGAON 38.4 10.3 0.9 25.8

NAGAON 38.4 13.3 4.4 31.3

SONITPUR 28.7 21.5 10.9 26.9

LAKHIMPUR 29.3 11.2 4.4 24.2

DHEMAJI 35.5 6.2 0.8 15.8

TINSUKIA 36.0 14.8 2.2 32.7

DIBRUGARH 33.3 22.4 8.2 33.0

SIVSAGAR 35.5 8.3 1.5 22.2

JORHAT 25.5 14.8 5.4 18.1

GOLAGHAT 32.6 13.9 6.5 20.2

KARBI ANGLONG 28.1 18.7 11.0 23.7

DIMA HASAO 34.7 6.3 1.3 18.2

CACHAR 36.3 30.6 11.3 36.3

KARIMGANJ 42.3 17.6 6.1 35.6

HAILAKANDI 38.1 19.1 6.3 32.5

BONGAIGAON 39.1 23.6 12.7 32.9

CHIRANG 40.1 13.0 4.4 24.7

KAMRUP (R) 33.3 18.8 5.3 29.6

KAMRUP (M) 24.6 11.0 2.4 23.2

NALBARI 26.8 15.3 6.2 20.0

BAKSA 32.4 10.5 2.7 22.4

DARRANG 43.5 19.2 5.3 37.9

UDALGURI 39.1 18.3 8.1 31.8

Source: NFHS-4
If we look at the table of health status of children Reports (HDR) Assam- 2014, the multiple diversity
of Assam in the geographical diversity category, it was areas and border areas are more vulnerable to “under-
found that the number of “stunting” children is highest weight” and “wasting” children. Number of wasting and
in general area (66.1 per cent) followed by Char areas under-weight children is highest in multiple diversity
(61.8 per cent). According to the Human Development
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 393

areas (24.6 percent and 45.8 per cent) followed by border areas (22.3 percent and 39.8 per cent). The following table
shows the health status of children according to geographical diversity-

Table-3: Health Status of Children in Geographically Diverse Area of Assam

GEOGRAPHICAL DIVERSITY STUNTING WASTING UNDERWEIGHT

Char areas 61.8 14.7 37.9

Flood affected areas 49.7 17.3 33.7

Hills 36.6 4.9 28.3

Tea-garden area 46.8 18.2 33.6

Border areas 47.8 22.3 39.8

Multiple diversity 55.1 24.6 45.8

General 66.1 12.6 37.7

Source: Assam HDR, 2014

The HDR Assam-2014 studied the male-female break up regarding the nutritional status of children under age
five and it was found that 55 per cent male children against 52.9 per cent female children are “stunting”, 17.7 per cent
male against 16.1 per cent is “wasting”, 39 per cent male children against 35.7 per cent female children are “under-
weight.” Again, the rural-urban break up has shown that 55 per cent rural children against 44.3 percent urban children
are “stunting”; 17.1 per cent rural children against 15.6 urban children are “wasting” and 38.2 rural children against
30.4 urban children are “under-weight.” The following table shows male-female and rural-urban break up in the three
category of nutritional status of children in Assam:-

Table - 4: Malnutrition in Assam

ATTRIBUTORS STUNTING WASTING UNDERWEIGHT

Male 55 17.7 39

Female 52.9 16.1 35.7

Rural 55 17.1 38.2

Urban 44.3 15.6 3.4

Sour Source: Assam HDR, 2014

Conclusion may be attributed to lack of proper nutritious foods,

illiteracy among parents, lack of proper sanitization
From the above, we can conclude that Assam has
facilities, irregular heath checkup, food scarcity and
made progress in its health indicators, but it is most urgent
various socio economics factors that affect the nutritional
to strengthen its existing health care services especially
status of children. Under National Rural Health Mission
in the rural areas. The percentage of proper nourished
(NRHM) various quality development programme has
children in rural Assam is not very satisfactory. 55
been launched and under the Ministry of Social Welfare,
percent children are stunting in rural areas. According
ICDS programme has been introduced to facilitate
to National Family Health Survey- 4, the health profile
regular health check-up, immunization, health education
of Assam shows that about 29.8% children below the
and other child health education programme.
age of 5 years are underweight. Besides, 35.7% children
between the age group of 6-59 months are anemic and Ethical Clearance: It is a review article.
about 25.7% women have body mass index (BMI) below
normal. It indicates the state of acute malnutrition which Source of Fund: Self
 394 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Conflict of Interest: Nil 3. Assam Human Development Report (AHDR),

2014. Social Welfare Department, Govt. of Assam.
References 2014.
1. Das B, Talukdar M, Bharali AJ. Child Health in 4. Ministry of Health and Welfare, GOI. NFHS-
India,( Book style). Omsons Publications. ISBN: 4. International institute of Population Sciences,
9789381981153,9381981159. Edition: 1:2017; pp. Mumbai. 2015-16.
10-22.
2. WHO. “Malnutrition - The Global Picture, World
Health Organization”. Available at https:/ /www.
who- int/home -page.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 395

Relationship of Character Strengths to Influence Psychological

Well-Being During Adolescence

Mallika Vohra1, Neelam Pandey2

1Research Scholar, 2Assistant Professor, Amity Institute of Psychology & Allied Sciences, AUUP, Noida

Abstract
The primary research study examined the association and influence of VIA Character strengths on satisfaction,
efficiency, sociability, mental health, interpersonal relations and above all the overall well- being. Research
showed that (for n=300 adolescents who participated in the study), several character strengths (e.g., self-
regulation, prudence, honesty, social intelligence, hope, courage and curiosity) are highly significantly
positively correlated with measures of subjective well-being and its overall formation. Acknowledgment
of the requirement for programs for positive youth advancement makes the evaluation and improvement of
character qualities an exceptionally significant exercise in the present situation. An investigation of character
qualities and their applications during adolescence period along these lines expect high significance because
of its suggestions for prosperity of the young generation just as for psychological overall well-being
advancement. In the above setting, the present examination of the profile of character qualities in Indian
adolescent’s as planned revealed featuring qualities that are most supported by them to advance well-being
and bring prosperity.

Keywords: character strengths, well-being, adolescence, satisfaction, mental health, positive psychology

Introduction qualities may create situations of friendships and

At the point when parents, guardians and teachers increment the social help individuals get from others,
talk about the characteristics they most would like to which thusly could expand positive encounters that lead
develop in children, they frequently notice character to enjoyment, harmony, satisfaction and mental health.
qualities such as, honesty, prudence, teamwork, love Numerous examinations have analyzed co-relationship
of learning.1These ethical characteristics are esteemed and indicators of subjective wellbeing in grown-ups, yet
in their own right, despite the fact that they are there is less research on emotional prosperity, especially
additionally accountable to profit society and the people positive records of prosperity and its indices, in young
who have them. We expect that youngsters who build children’s. 3&4 The study investigates whether young
up these characteristics will add to society and have people’s character qualities toward the middle school
satisfying lives. Ongoing examination in positive brain would foresee their downturn, bliss, and life fulfillment.
research demonstrates that many character qualities Research suggests that building character strengths
are related with momentum levels of prosperity.2 Only can increase well-being. For example, interventions
a few researches look at whether character qualities that promote social intelligence and self-regulation can
anticipate or advance future prosperity, nonetheless. The reduce substance abuse, aggression and other behavioral
significant discussion was to look at whether character problems among children, and increase the likelihood
qualities foresee consequent prosperity during pre- that youth will graduate from school.5&6
adulthood. Character qualities are impacted by family, The primary reason for this investigation was to look
network, environmental, cultural, and other relevant at whether character qualities relate and foresee mental
elements. From a certain perspective, character qualities prosperity during youthfulness. We inspected whether
are pliant; they can be educated and obtained through adolescents’ character qualities toward the middle
training. There are numerous courses through which school would foresee their satisfaction, efficiency,
character qualities could advance positive results and sociability, mental health and interpersonal relations;
avoid psychopathology. For instance, coordinated
 396 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

joined together their abstract prosperity. Character Measures

qualities are the subset of personality attributes that are
ethically esteemed. Like other personality attributes, The Values in Action Inventory (VIA) Classification
character qualities are airs that show in individuals’ describes 24 Character strengths that are thought to be
musings, feelings and practices. 4,7&8Demeanor, nature the fundamental building blocks of character. These
and personality styles may encourage qualities and building blocks are universally considered to be qualities
facilitate strengths. For instance, personality styles, such that define and lead people being their best. Character
as, amiability and approach (rather than withdrawal) strengths are defined as capacities for thinking, feeling
may encourage character qualities, such as, kindness and behaving. Every person possesses each of these 24
and courage. Though demeanor, nature and personality Character strengths in different degrees, resulting in
styles are not ethically esteemed, be that as it may, unique profiles that constitute the rich array of human
character qualities have an ethical importance and the personalities we observe. Adolescents completed the
vast majority of these characteristics are esteemed Revised Values in Action Inventory of Strengths for
crosswise over societies and from the beginning of Youth (VIA Youth; Park & Peterson, 2006), designed for
time.9Psychological well-being alludes to individuals’ young people (ages 10–17). The questionnaire consists of
cognitive and enthusiastic assessments of their lives. 198 items that adolescent’s rate on a Likert scale ranging
It incorporates decisions eg. life fulfillment, pleasance from 1 (‘Not like me at all’) to 5 (‘Very much like me’).
feelings and less unsavory passionate encounters like Sample items on the VIA-Youth include ‘I often tell my
discouragement.10As we learn we create inward qualities friends and family members that I love them’ (love), ‘I
and qualities which furnish us with a solid inner locus am very careful at whatever I do’ (prudence),and ‘I like
of control and assembles our confidence. Studies have to tell jokes or funny stories’ (humor). The VIA Youth
demonstrated that youngsters who experience a more strength scales have been standardized and justified for
significant level of emotional prosperity have improved the Indian adolescents under study demonstrated good
inward locus of control. It has been said that adolescence internal consistency (with Cronbach alpha ‘s ranging
is the time of “growing up” and early adulthood is the from 0.72 to 0.93)
ideal opportunity for “settling down”. The psychological Well-being (PWB) scale
comprises of 50 statements developed by Dr. Devendra
Materials and Method Singh Sisodia with a view to measure several aspects
Participants and Procedure of well-being vis. Satisfaction, Efficiency, Sociability,
Mental Health and Interpersonal Relations. All
This study examined the profile of character strengths statements are of positive manner developed using
and well-being of adolescents enrolled in a school in Likert criteria wherein the ratings are described as 1
National Capital Region of India and who participated ‘(Strongly Disagree)’ to 5 ‘(Strongly Agree)’.This scale
in a psychological study for middle school students. is useful in a variety of research and applied settings such
The data was obtained from 300 adolescents, 100 each as quality of life index, a mental health status appraisal
from class 6, class 7 and class 8, further comprising 50 and a measure of psychotherapy outcome evaluation and
boys and 50 girls from each grade class. This study was a social indicator of measuring population changes in
approved by the school board of the participating school. sense of well-being over time.
Students are represented by various regional, religious,
cultural, environmental differences. In general, it Statistics
was ensured that student participation depends on the
availability of permission from parents and the sole Descriptive Analysis was used to summarize which
interest of the student to participate. All the participants direction whether Disagree or Agree targeted students
and their parents/ guardians were informed about the representing the population under study, are concluding
purpose of the study and were enrolled after obtaining their opinions. Internal consistency was examined for
their written informed consent. The questionnaires were scale and subscale’s using Cronbach alpha. Due to the
mostly administered in groups of sizes varying between nature of the study and moreover since Likert scale is
10 and 30, under the supervision of the research staff. used for self-assessment of both character strength
and well-being dimensions non-parametric correlation
analysis was performed using Spearman’s rho to explore
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 397

the strength of relationship between them. Findings state that the character strength measures
vis. Prudence, Honesty, Self-Regulation, Forgiveness,
Results Curiosity, Courage, Leadership, Social Intelligence,
The current research was conducted to study Humility, Teamwork, Hope, Judgment and Gratitude have
subjective well-being and character strength among a positive and significant correlation with satisfaction,
Indian youth. Internal consistency reliabilities and efficiency, sociability, mental health, interpersonal
descriptive statistics for the study variables are relations and overall with the formation subjective well-
presented in Table 1 and Table 2. The results of being at 0.01 level. However, Perspective, Creativity and
correlational examination are presented in Table 3. The Appreciation of Beauty have a positive and significant
self-assessment of VIA character strengths amongst correlation with fewer of the well-being measures.
adolescents revealed that topmost virtues are Humor, Opposing the dimensions Spirituality, Zest, Love of
Fairness, Kindness, Perseverance and Love. Likewise, Learning, Humor, Fairness, Kindness, Perseverance and
the bottom most virtues are found to be Prudence, Love showed no relationship with subjective well-being
Honesty, Self-Regulation, Forgiveness and Curiosity. and it’s formative measures.

Table. 1: Reliability, Mean and SD of character strengths for adolescent school students (n=300), under
study

Measure N Items Cronbach’s Alpha (α) M SD

Prudence 8 .739 1.74 .59
Honesty 8 .733 1.77 .58
Self-Regulation 9 .744 1.83 .58
Forgiveness 7 .811 1.84 .68
Curiosity 8 .759 1.87 .61
Courage 8 .751 1.88 .62
Leadership 8 .791 1.94 .65
Social Intelligence 8 .747 1.95 .62
Humility 9 .841 1.99 .76
Teamwork 8 .831 2.00 .76
Perspective 8 .892 2.07 .94
Hope 8 .825 2.09 .75
Judgment 8 .861 2.13 .83
Gratitude 8 .878 2.18 .96
Creativity 8 .861 2.24 .93
Beauty 8 .790 2.35 .85
Spirituality 8 .805 2.47 .89
Zest 8 .771 2.60 .86
Love of Learning 8 .755 2.79 .83
Humor 9 .933 2.98 1.08
Fairness 9 .865 3.19 .98
Kindness 9 .815 3.39 .85
Perseverance 9 .740 3.59 .76
Love 9 .727 3.71 .68
 398 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table. 2: Reliability, Mean and SD of Well-Being and it’s measures for adolescent school students (n=300),
under study

Measure
N Items Cronbach’s Alpha (α) M SD
Scale and Subscales
Well Being 50 .923 1.99 .49

Satisfaction 10 .825 1.91 .62

Efficiency 10 .782 1.96 .59

Sociability 10 .708 2.02 .59

Mental Health 10 .651 2.03 .53

Interpersonal Relations 10 .690 2.00 .56

Table. 3: Correlation Examination using Spearman’s rho of Character Strengths and Well Being for the
adolescent school students (n = 300), under study

Character Interpersonal
Well -Being Satisfaction Efficiency Sociability Mental Health
Strengths Relations

Prudence .579** .508** .581** .483** .303** .290**

Honesty .502** .571** .484** .397** .213** .251**
Self-Regulation .656** .622** .660** .458** .387** .360**
Forgiveness .587** .506** .581** .420** .366** .305**
Curiosity .665** .783** .640** .487** .313** .273**
Courage .469** .551** .400** .405** .287** .156**
Leadership .632** .979** .594** .309** .239** .302**
Social Intelligence .682** .730** .655** .526** .312** .350**
Humility .588** .511** .560** .504** .269** .353**
Teamwork .560** .375** .485** .547** .338** .326**
Perspective .179** .172** .132* .245** .163** .027
Hope .548** .768** .579** .279** .222** .259**
Judgment .490** .706** .485** .255** .235** .167**
Gratitude .292** .244** .234** .259** .182** .229**
Creativity .154** .219** .165** .092 .133* .033
Beauty .120* .198** .120* .025 .104 .115*
Spirituality .066 .109 .052 .036 .055 .059
Zest -.006 .055 -.006 .005 .041 .019
Love of Learning -.009 .064 .004 .064 -.003 .023
Humor -.043 -.087 -.094 .072 .033 -.006
Fairness -.085 -.115* -.029 -.025 -.025 -.055
Kindness -.141* -.113 -.069 -.089 -.099 -.079
Perseverance -.030 .016 -.027 .003 -.056 -.011
Love -.147* -.030 -.088 -.092 -.120* -.112

** Correlations are significant at p< .01 level

* Correlations are significant at p< .05 level
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 399

Discussion Future Implications

As far as we could possibly know, youthful to Future research will recognize the systems by
adulthood transition has been a sacked process in the which the VIA character qualities increment well-being.
formation stages of their character qualities. Recognizing Such research is probably going to have significant
the importance of its association with well-being, ramifications for intercession and counteractive action
determining virtues that promote such developmental work. Implementing character strength development in
process is deemed significant and integral. Youthful turn well-being interventions and programs in the school
adulthood might be described as the period that is set curriculum not only increase subjective feelings of
apart by solidification of one’s personality on one hand happiness among students, but also protect them against
and the accentuation on dominance of various ecological the negative effects of stress and the development
requests on the other. The developing acknowledgment of psychopathological problems.1 &15Research has
of the requirement for programs for positive youth demonstrated that certain strengths of character are
advancement makes the evaluation and improvement of linked with increased life satisfaction, decreased
character qualities an exceptionally significant exercise psychopathology, fewer internalizing and externalizing
in the present situation. The positive youth improvement behavior problems and academic achievement.16 A
approach underlines on enabling youth to be the specialist promising approach to increase well-being among
of their own development with grown-ups propelling adolescents is through positive psychology interventions
the revelation of their possibilities.11 An investigation – that is, intentional activities that aim to cultivate
of character qualities and their applications during positive feelings, behaviors, or cognitions.17 Moreover,
this period along these lines expect high significance, strengths can be clearly cultivated and strengthened
because of its suggestions for prosperity of the young, through regular activity and application in life.18Along
just as for psychological well-being advancement. In these lines, advancement of positive mental character
the above setting, the present examination as planned qualities based interventions that can be used as a major
and determined for looking at the profile of character aspect of the school educational plan is an auspicious
qualities in Indian youth, featuring the qualities that are interest.
most supported by them. Encounters containing positive
feelings in this manner prompts higher life fulfillment. Conflicts of Interest: Authors declare no conflict
Diener (2000) clarified well-being as “peoples’ of interest.
evaluations that are both affective and cognitive”.12
Funding: Self
In positive brain science (psychology), pleasure is
communicated utilizing the term ‘well-being’ which is Ethical Clearance: This study was based entirely
a multi-dimensional construct. Character strengths form on the interest of the student to participate. Formal
the foundation where a person’s personality that grows permission was taken from the parents and school to
step by step with time. Previous researches expresses conduct research procedures.
that high psychological well-being correlates with the
absence of mental and social issues like state of mind References
issue and useless family connections, and such people
1. Seligman, M.E.P., Ernst, R., Gillham, J., Reivich,
are in every case better at critical thinking, execution at
K., &Linkins, M. Positive education: Positive
work, opposing pressure and more beneficial in contrast
psychology and classroom interventions. Oxford
with others.13&14Utilizing correlational investigation,
Review of Education 2009; 35: 293–311.
the present examination supported and found that
psychological well-being is noticeable among youth. 2. Peterson, C. A primer in positive psychology. New
The finding can be credited to the formative parts of a York: Oxford University Press 2006
person with respect to constructive mental development. 3. Huebner, E.S., & Diener, C. Research on life
Maturing is identical to development that prompts satisfaction of children and youth: Implications for
development. Development creates, with various the delivery of school-related services. New York:
encounters which people experience during their life Guilford Press 2008; In M. Eid & R.J. Larsen (Eds.),
span. Maturing is identical to development and is framed The science of subjective well-being: 376–392
on a person’s characteristic qualities. 4. Park, N., & Peterson, C. The values in action
 400 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

inventory of character strengths for youth. New 11. Larson, R. Positive youth development, willful
York: Springer 2005; In K.A. Moore & L.H. adolescents, and mentoring. Journal of Community
Lippman (Eds.), What do children need to flourish? Psychology 2006; 34(6): 677–689
Conceptualizing and measuring indicators of 12. Diener, E., & Suh, E. M. Culture and subjective
positive development:13–23 well-being. MIT press 2000
5. Greenberg, M.T., Weissberg, R.P., O’Brien, M.U., 13. Frisch, M. B. Improving mental and physical health
Zins, J.E., Fredericks, L., Resnik, H., & Elias, M.J. care through quality of life therapy and assessment.
Enhancing school-based prevention and youth 2000
development through coordinated social, emotional,
14. Veenhoven, R. National wealth and individual
and academic learning. American Psychologist
happiness. Springer Netherlands 1989; In
2003; 58: 466–474
Understanding economic behavior: 9-32
6. Weissberg, R.P., & O’Brien, M.U. What works
15. Park, N. Character strengths and positive youth
in school-based social and emotional learning
development. The Annals of the American Academy
programs for positive youth development. The
of Political and Social Science 2004; 591: 40–54
Annals of the American Academy of Political and
Social Science 2004; 591: 86–97 16. Park, N., & Peterson, C. Strengths of character in
schools. New York: Routledge 2009; In R. Gilman,
7. Park, N., & Peterson, C. Positive psychology and
E.S. Huebner, & M.J. Furlong (Eds.), Handbook of
character strengths: Application to strengths-based
positive psychology in schools: 65–76
school counseling. Professional School Counseling
2008; 12: 85–92 17. Sin, N.L., & Lyubomirsky, S. Enhancing well-being
and alleviating depressive symptoms with positive
8. Peterson, C., & Seligman, M.E.P. Character strengths
psychology interventions: A practice-friendly meta-
and virtues: A handbook and classification. New
analysis. Journal of Clinical Psychology 2009; 65:
York: Oxford University Press 2004; Washington,
467–487
DC: American Psychological Association
18. Seligman, M.E.P., Steen, T.A., Park, N., & Peterson,
9. Dahlsgaard, K., Peterson, C., & Seligman, M.E.P.
C. Positive psychology progress: Empirical
Shared virtue: The convergence of valued human
validation of interventions. American Psychologist
strengths across culture and history. Review of
2005; 60: 410–421
General Psychology 2005; 9: 203–213
10. Diener, E., Suh, E., & Oishi, S. Recent findings on
subjective well-being. Indian Journal of Clinical
Psychology 1997; 24: 25–41
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 401

Dental Health Handbook as Parents Monitoring in the

Formation of Independence for Brushing Teeth in Early
Childhood

Ngatemi1, Tedi Purnama1

1
Lecturer Departement of Dental Health, Ministry of Health Polytechnic Jakarta I, South Jakarta, Indonesia

Abstract
Oral health problems that many have encountered are dental caries and periodontal disease where the
prevalence of dental caries of children aged 5-6 years by 93% with def-t index of 8.43. Such conditions
do not meet the WHO target and FDI is 50% of children aged 5-6 years free of dental caries, it is because
children are not capable of independent activity in brushing teeth. Proper behavior change strategies can be
done by providing dental health education by parents. Dental health handbook could be a learning brushing
teeth in efforts to establish the independence of brushing their teeth in early childhood. This study aims
to effectiveness of dental health handbook as monitoring the parents in the formation of independence of
brushing teeth in early childhood. Method: This study uses quasy experiment with pretest and posttest design
with one group, by providing dental health guide books and training to parents. This research was conducted
in PAUD Fatahillah Pangkalan Jati Depok. The independent variables: dental health guide books, variable
between: knowledge and attitudes of parents and the dependent variable: the skills brushing teeth free of
plaque and score early childhood. Data were tested using a paired sample test and wilcoxon. Result: the
provision of dental health handbook effectively improve the knowledge and attitudes of parents (p <0.001)
and effectively to the improvement of skills brushing teeth and a decrease in plaque score (p <0.001).
Conclusion: effective dental health handbook as monitoring the parents in the formation of independence of
brushing teeth in early childhood.

Keywords: dental health handbook, independence brushing teeth, early childhood

Introduction Jl. Wijayakusuma No. 47-48 South Jakarta Email:

[email protected]
Oral health is for general health, meaning that if
someone toothache then general health will be disturbed. periodontal pathogens are inflammatory mediators
Oral health problems that many have encountered are which then enter the bloodstream, causing systemic
dental caries and periodontal disease.1-3 disease, such as: increasing the risk of heart attack,
stroke risk, increase the severity of diabetes, respiratory
Dental caries is a disease in hard tissue of teeth
diseases, preterm labor, rheumatoid arthritis, osteoporosis,
that is characterized by the breakdown of enamel and
pancreatic cancer, kidney disease and interfere with the
dentin caused by the metabolic activity of bacteria in
system digestion, especially in children. Dental caries
plaque that causes demineralization. Dental caries if left
in preschool children is commonly known as early
untreated will cause periodontal infection. Bacteria
childhood caries, because the enamel of primary teeth is
Corresponding Author: thinner than permanent teeth, so it is more susceptible to
dental caries.4-7
Tedi Purnama
Dental caries in Western Australian Aboriginal
Departement of Dental Health, Poltekkes Kemenkes children aged 1-4 years especially preschool disease is
Jakarta I, number 5 of the disease to be treated from the hospital.
According to Kwan in Santoso (2017), more than 50
 402 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

million hours of school per year is lost as a result caused parents who have young children in maintaining their
by toothache in children who have an impact until the oral health. The use of guide books can also be motivated
life of an adult, meaning that dental caries in preschool to instill a sense of responsibility for the maintenance of
years greatly affect the quality of life of children and oral health of their children. This is evidenced research
growth.8, 9 Darwis et al (2011) that the use of guide books can
improve the status of early childhood dental hygiene.17,
Riskesdas in 2018 proved that the prevalence of 18
dental health of children aged 5-6 years by 93% with
def-t index of 8.43. Such conditions do not meet the Based on this background, researchers interested
WHO target and FDI is 50% of children aged 5-6 years in proving that the administration of dental health
free of dental caries.9, 10 handbook as monitoring the parents in the formation of
independence of brushing teeth in early childhood.
One cause of the high prevalence of dental caries
for dental health maintenance behaviors are less than the Method
maximum, this is evidenced Indonesia’s population had
brushed his teeth with the categories of behavior really This research is an observational study of analytical
only reached 2.8% and by 2.8 West Java Province.10, epidemiology. Case control study design was conducted
11
Efforts to prevent the occurrence of dental caries from November 2016 until January 2017 in
can be done through the behavior of most major dental The method used in this study is quasy experiment
maintenance and recommended by way of brushing your with the design of pre- and post-test with one group
teeth. That is the simple act of brushing teeth to remove design. The experiment was conducted in PAUD
plaque and food debris with a toothbrush and toothpaste, Fatahillah Pangkalan Jati Depok during September and
because plaque and leftover food is a major cause of October 2019. Samples were taken with total sampling,
dental caries, therefore it is necessary to build a habit of as many as 46 students and 46 parents. The independent
brushing their teeth at an early age.12,13 variable in this study are dental health handbook, the
Early childhood is a “golden age period”, meaning between variable is parents’ dental health behavior
the golden period for all aspects of human development, (knowledge and attitude) and the dependent variable
whether physical, emotional and social cognition, where is the independence of brushing and plaque score early
the development of intelligence in this period increased childhood.
by 50%. Early childhood is the ideal time for a child’s Data collection knowledge and attitudes of parents
motor skills, including brushing teeth, so that will cause measured the questionnaire with the following activities:
a sense of responsibility for the cleanliness of himself.14 pre-test, training and provision of health handbooks in
Changes in a child’s behavior depends on the the elderly and post-test. In early childhood intervention
ability of adaptation to the stimulus response beyond for 10 days with details of activities as follows: pre-
himself. It fits in the Roy adaptation theory (Sari et test, intervention by parents and post-test measurement
al, 2012) suggests that changes in a person’s behavior tool is a checklist sheet brushing and plaque index
depends on the incoming stimulus and adaptability of measurement sheets. The research data using a ratio
the person, that is to say through the right stimulus and scale statistical test, if normal data using a paired sample
the appropriate development of children, will help in test, while not normal using wilcoxon test.
entering the next phase of development is well. It is also
affecting the child’s behavior change is a stimulus from
Results
the environment, namely the involvement of family Research result shows that the respondents to the
members. Through the active participation of parents it age of 4 years as many as 4 children (8.7%), aged 5 years
will be better the child’s behavior in brushing teeth and as many as 18 children (39.1%) and the age of 6 years
guidance of parents in brushing teeth to prevent dental sebnyak 24 children (52.2%). While respondents male
caries.13, 15, 16 sex as many as 18 children (39.1%) and female gender
of respondents were 28 people (60.9%), he explained in
Dental health guide books selected as the media for the following table 1.
dental health education because it can accommodate
writing and drawing in large numbers so as to help
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 403

Table 1. Characteristics of respondents

No Variables Total Percentage

1 Age

4 years 4 8.7

5 years 18 39.1

6 years 24 52.2

2 Gender

Male 18 39.1

Femele 28 60.9

Table 2. The mean value of plaque index of children, knowledge and attitudes of parents

No Variables Mean SD Min-Max

1 Tooth brushing skills

Pre-test 4.37 1.142 3-7

Post-test 8.48 1.110 6-10

2 Children’s plaque index

Pre-test 36.22 10:50 12-60

Post-test 26.83 9291 10-48

3 Knowledge parents

Pre-test 7:28 1.760 5-11

Post-test 10:07 1.806 7-13

4 Attitude parents

Pre-test 36.41 8.798 25-35

Post-test 50.33 9.031 55-65

Table 2 shows the average value of the value of the skills children brushing their teeth increased from 4.37
became 8.48. The value of the index on the child plaque scores decreased from 36.22 into 26.83. The average value
of the knowledge of parents has increased from 7.28 into 10.07, and the average value of parents’ attitudes also
increased from 36.41 into 50.33.

Table 3. Test of normality

No Variables Pre-test Post-test

1 Tooth brushing skills of child 0.000 0.001

2 Plaque index of child 0.184 0.067

3 Knowledge of parents 0.001 0.008

4 Attitude of parents 0.001 0.008

* Shapiro-Wilk
 404 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 3 shows the results of the normality test Discussions

for the plaque index score of children with normal
Provision of dental health guide books and training
distribution because the p-value >0.05 then proceed
to parents do to improve the knowledge and attitudes of
parametric test, while for the results of the child’s teeth
parents in the maintenance of oral hygiene. According to
rub skills, knowledge and attitudes of parents are not
Santoso (2017), is a dental health maintenance training
normal distribution because the p-value of <0.05 so non-
activities planned through the learning process that aims
parametric test.
to provide knowledge, inculcate and practice the skills
Table 4. Test the effectiveness of the knowledge until someone can independently perform maintenance
and attitudes of parents and after intervention actions oral hygiene.9

The result of the effectiveness of variable data and

Variables Mean ± SD P-value
knowledge of dental health maintenance attitude of
Pre-test 7.28 + 1.760 parents shows that the p-value 0.001 (P <0.05) means
Knowledge 0.001 that dental health guide books effectively improve
Post-test 10.07 + 1.806 the knowledge and attitudes of parents in raising their
children’s oral health. Improved knowledge and attitudes
Pre-test 36.41 + 8.798 caused by the guidebooks can be learned in time at any
Attitude 0.001 time, parents can actively learn independently so that
Post-test 50.33 + 9.031 the retention of material oral hygiene maintenance can
* Wilcoxon easily catch. Health education is essentially a business
activity or health messages to the community, group
The results of the effectiveness test given knowledge or individual. With the training given, respondents get
before and after treatment showed that the p-value was the learning that results in a change from the previously
0.001 (p <0.05) means that the provision of dental health unknown becomes known, the former did not understand
handbook effectively improve the knowledge of parents being understood. This study is also consistent with the
and the p-value the attitude of parents is 0.001 (p <0, results of research Amin (2014) found a positive effect
05) means that the provision of dental health handbook of dental health education to changes in values, attitudes
effectively improve the attitudes of parents. and actions of parents to maintain their children’s oral
health.19, 20
Table 5. Test effectiveness skills brushing teeth
plaque index scores before and after intervention Besides given a guide book, parents who have given
their dental health maintenance training because then
Variables Mean ± SD P-value parents will be monitoring the activities of brushing
Pre-test 4.37 + 1142 teeth as efforts to establish the independence of children
Tooth brushing brushing their teeth. According Subekti (2017) assisting
0001
skills *
Post-test 8.48 + 1.110 parents in toothbrushing influence behavioral change
brushing and dental hygiene level of the child.21
Pre-test 36.22 + 10.50
Plaque index ** 0001
Post-test 26.83 + 9.291 The results of the effectiveness test the skills of data
brushing teeth showed p-value was 0.001 (p <0.05),
* Wilcoxon ** Paired Sample Test
meaning that the provision of dental health guide books
The results of the effectiveness test of skills brushing in older people brushing their teeth effectively improve
teeth before and after treatment showed that given the the skills of early childhood. Intervention during 10 days
p-value was 0.001 (p <0.05) means that the provision of brushing teeth effectively improve the skills of young
of dental health handbook in older people effectively children because parents provide mentoring children in
improve the skills of early childhood brushing teeth and the learning process of brushing his teeth, parents and
plaque index score of p- value is 0.001 (p <0.05) means children directly involved in how to brush their teeth
that the provision of dental health handbook in older properly. This is in line with research Purnama (2019)
people effectively lower the score the plaque index in mentoring brushing teeth for 10 days by a parent can
early childhood. shape the behavior of preschool children brushing their
teeth. This success has also seen an increase in plaque
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 405

free scores of children. The results of the effectiveness oral conditions in 1990-2010: a systematic analysis.
test data indicate that the p-value was 0.001 (p <0.05), Journal of dental research. 2013;92(7):592-7.
meaning that the provision of dental health guide books 4. Rasinta T. Karies gigi. EGC. 2013.
to parents free of plaque effectively improve the scores
5. Colak H, Dulgergil CT, Dalli M, Hamidi M. Early
of children. Score plaque free early childhood has
childhood caries update: A review of causes,
increased since the sample has been taught to understand
diagnoses, and treatments. Journal of natural
the practice to brush their teeth. Practice brush their
science biology medicine. 2013;4(1):29.
teeth will be able to remove plaque. Research Raj
(2013), proving that brushing your teeth with the correct 6. Ezer MS, Swoboda N, Farkouh DJOH. Early
technique will improve oral hygiene preschoolers.22, 23 childhood caries: The dental disease of infants.
Journal Oral Health. 2010;100(1).
Conclusions 7. Pizzo G, Guiglia R, Russo LL, Campisi GJEjoim.
Dentistry and internal medicine: from the focal
Based on the results research, it can be concluded
infection theory to the periodontal medicine
that:
concept. European journal of internal medicine.
1. Dental health handbook is effective in increasing 2010;21(6):496-502.
knowledge of parents’ oral health maintenance. This 8. Dogar F, Kruger E, Dyson K, Tennant M. Oral
was proven significantly health of pre-school children in rural and remote
Western Australia. Journal Rural Remote Health.
2. Dental health handbook is effective in increasing
2011;11(4):1869.
the attitude of maintaining oral health of parents. This
was proven significantly 9. Santoso Bedjo T, Gejir Nyoman , Fatmasari
Diyah Information System Monitoring Model
3. Dental health handbook is effective as a Implemented in School Health Dental Unit. ARC
monitoring for parents in the formation of independence Journal of Dental Science. 2017;Volume 2, Issue 4,
in brushing teeth at early childhood. This was proven 2017,: PP 8-11
significantly 10. Kemenetrian Kesehatan RI. Hasil Utama Riskesdas
2018. Badan Penelitian Kesehatan. 2018:179-217
4. Dental health handbook is effective as
monitoring of parents in reducing index plaque scores in 11. Ghani L. Status dan Kesehatan Gigi dan Mulut
early childhood. This was proven significantly Ditinjuau dari Faktor Individu Pengunjung
Puskesmas DKI Jakarta Tahun 2007. Buletin
Acknowledgement: This study was funded by Penelitian Kesehatan. 2010;38(2 Jun):52-66.
Ministry of Health Polytechnic Jakarta I. The authors 12. Pullishery F, Panchmal GS, Shenoy R. Parental
thank to all partisipants and research assistans. attitudes and tooth brushing habits in preschool
Conflict of Interest: The authors reported no children in Mangalore, Karnataka: A cross-
conflict of interest. sectional study. International Journal of Clinical
Pediatric Dentistry. 2013;6(3):156.
Ethical Clearance: All participants were signed the 13. Sari EK, Ulfiana E, Dian P. Pengaruh pendidikan
informed consent prior to the data collection. kesehatan gosok gigi dengan metode permainan
simulasi ular tangga terhadap perubahan
References pengetahuan, sikap, dan aplikasi tindakan gosok
1. Organization WH. Oral health surveys: basic gigi anak usia sekolah di SD wilayah Paron Ngawi.
methods: World Health Organization; 2013. Indonesian Journal of Community Health Nursing.
2. Jackson SL, Vann Jr WF, Kotch JB, Pahel BT, Lee 2012;Volume 1, Issue 1.
J. Impact of poor oral health on children’s school 14. Martani W. Metode stimulasi dan perkembangan
attendance and performance. Journal American emosi anak usia dini. Jurnal Psikologi.
journal of public health. 2011;101(10):1900-6. 2012;39(1):112-20.
3. Marcenes W, Kassebaum NJ, Bernabé E, Flaxman 15. Husna A. Peranan Orang Tua dan Perilaku Anak
A, Naghavi M, Lopez A, et al. Global burden of dalam Menyikat Gigi dengan Kejadian Karies
 406 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Anak. Jurnal Vokasi Kesehatan. 2016;2(1):17-23. immigrants. Journal of Oral Diseases. 2014.
16. Riolina A. Peran guru dalam meningkatkan 21. Subekti A, Donasari EN, Sutomo B, Sukendro SJ.
kesehatan gigi dan mulut siswa di sekolah dasar. The parents-designed program to support tooth
Jurnal Ilmu Kedokteran Gigi. 2018;1(2):51-4. brushing during 7, 21, 35 days of young children
17. Ahn HY, Yi G. Application of Dental Health in PAUD Pandega SiwI, Tlogosari, Pedurungan,
Program for Elementary School Children. Journal Semarang City. Jurnal Kesehatan Gigi. 2017;4(2):1-
of Korean Academy of Child Health Nursing. 6.
2010;16(1):49-55. 22. Raj S, Goel S, Sharma VL, Goel NK. Short-
18. Darwis EW. Evaluasi Penggunaan Buku term impact of oral hygiene training package to
Pemeliharaan Kesehatan Gigi dan Mulut dapat Anganwadi workers on improving oral hygiene of
Meningkatkan Status Kebersihan Gigi dan Mulut. preschool children in North Indian City. BMC Oral
Quality Jurnal Kesehatan. 2011;4(2). Health. 2013;13(1):67.
19. Notoatmodjo S. Promosi Kesehatan Teori dan 23. Purnama T, Rasipin R, Santoso B. Pengaruh
Aplikasi. PT Rineka Cipta: Jakarta. 2010. Pelatihan Tedi’s Behavior Change Model pada
Guru dan Orang Tua terhadap Keterampilan
20. Amin M, Nyachhyon P, Elyasi M, Al-Nuaimi
Menggosok Gigi Anak Prasekolah. Jurnal Quality
M. Impact of an oral health education workshop
Kesehatan. 2019;13(2):75-81.
on parents’ oral health knowledge, attitude, and
perceived behavioral control among African
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 407

Women’s Mental Health in India : An Analysis through the

Gender Lens

Parismita Bhagawati
Designation: PhD Research Scholar, Political Science, Cotton University, Panbazar, Guwahati, Assam

Abstract
As opposed to the traditional biomedical view of health, the social model of health defines it essentially, as
a positive concept which significantly hinges on and is impacted by the social settings, personality of the
individual , as well as physical capacities.’ It is in this context, mental health issues among women in general
and Indian women in particular, as a subset of the larger corpus of health concerns needs to be inevitably
understood and contextualised in the societal and cultural milieu within which women operate. One of
such important societal constructs that seems to have a significant impact on mental and emotional health
and experience of women is the the construct of gender and its corollaries like gender roles, expectations,
demeanour, stereotypes etc. The social construct of gender engineers a woman’s position in the social
hierarchy and also has a prominent bearing on her social and personal life experiences. Consequently,
socio-cultural context and gender need to be understood as powerful decisive factors of one’s mental and
emotional make-up that colludes with other variables like age, family, educational attainment, occupational
structure, income and social support etc. The paper attempts to study the mental health concerns among
women in India by especially, trying to locate its causes in the socio-cultural factors amid which the women
live. Conclusively, the paper tries to highlight various suggestions for developing holistic solutions towards
the improvement of mental health of women.

Keywords: Mental health, gender, domestic violence, social model of health

Introduction The inevitable foremost step towards sculpting

a socially-rooted and contextualised model for
The World Health Organization’s Ottawa Charter for
improvement of women’s mental health is figuring
Health Promotion (1986) sees health as multidimensional
out a definition of mental health that can be usefully
and espouses a social model of health. It defines health
applied to women. The 1981 WHO report on the social
as ‘a positive concept emphasising social and personal
dimensions of mental health, states that: ‘Mental health
resources, as well as physical capacities.’ In the social
is the capacity of the individual, the group and the
model of health, while human biology, physiology
environment to interact with one another in ways that
and health care are considered as important elements,
promote subjective well-being, the optimal development
besides these, it incorporates within its purview a variety
and use of mental abilities (cognitive, affective and
of other variables and factors that have the potential to
relational), the achievement of individual and collective
impact the health of an individual. These factors range
goals consistent with justice and the attainment and
from social and cultural attributes, political environment,
preservation of conditions of fundamental equality.’
economic and financial factors, psycho-social factors to
various other inter-personal and environmental factors This definition is apt for a holistic understanding of
as well as their reciprocal communications that might women’s mental health because it:
lead to health or illness. Therefore, the concept of health
is definitely not unidimensional, it is multifaceted and • emphasises the intricacies of mutuality and
involves multiple causal factors and similarly, the interrelations among a host of variables that that
concept of women’s mental health is no exception. determine mental health and that the determinants of
health function at multiple stages.
 408 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

• looks and reaches beyond the ‘biological’ and and gender identities and positionalities of women as a
‘individual’ concedes the significance of the society and determinant. In the final analysis, on the basis of various
the ‘social’ suggestions as presented by credible health organisations
and reports that might prove beneficial in improving
• Acknowledges the primal importance of values mental health of women, a future roadmap to a holistic
and principles of justice and equality in configuring solution to the mental health crisis among women has
mental and emotional well-being. been forwarded.
The social construct of gender engineers a woman’s The Indian social reality and women’s mental health
position in the social hierarchy and also has a prominent
bearing on her social and personal life experiences. It has been evident that women in modern India face
Consequently, socio-cultural context and gender need a paradoxical situation1. While women are increasingly
to be understood as powerful decisive factors of one’s making inroads into erstwhile male-dominated
mental and emotional make-up that colludes with other professions and admirably hiking up the corporate
variables like age, family, educational attainment, hierarchy, there is still a sizeable section of Indian
occupational structure, income and social support etc. women languishing without any sense of their identity
or any form of human rights. Although, the government
Objective and Method is striving hard to bring in women-centric legislations
The primary motive of the paper is to study the and devise policies for women empowerment and uplift,
present scenario of women’s health in India. This what is happening in ground reality remains unaffected;
research paper whilst trying to enquire into the status women still in a very large number and in variegated
of women’s health, particularly, tries to understand and ways receive systemic discrimination in society.
highlight the role of the contextual socio-cultural factors Patriarchy as the basis of India’s social functioning
and gender constructs that operate in society; in serving operates within a web of norms that possess an inherent
as determinants of women’s mental health. To this tendency to disempower and control women’s every
effect, a predominantly qualitative research approach has aspect of life. The women in India having to survive
been adopted to critically inquire into the topic at hand. and grow up in such an environment and simultaneously
Data at all stages are secondary in nature and garnered having to do their best and live up to their own best
from a variety of published sources. A thorough study potential as well society’s expectations from her, proves
of journal articles, newspaper and government health to be a burdensome toil for all women throughout their
reports, books relevant to the topic has been undertaken. life-cycle. This can often lead to emotionally explosive
The methodology of data analysis is descriptive, situations wherein women start experiencing mental
explorative and analytical whereby observations, facts health problems. Indian society is in an indecisive
and ideas relating to women’s mental health indices and phase of passage from traditional to modernity, while
conditions corresponding to the socio-cultural patterns new modern liberal values are being circulated and are
and process of gender socialisation operating in the afloat in the socio-cultural milieu, they have not been
society are recorded and systematically presented in the able to completely eradicate and displace certain old
prescribed format. parochial traditional values that are endemically gender
discriminatory; This kind of gender discrimination
Findings and Discussions reinforces women’s feeling of social disadvantage and
further aggravates their psychological conditions1.
The findings of the study have been presented and
discussed in various sections dealing with various related Gender –specific risk factors featuring in women’s
observations and ideas. The first concrete finding of the mental health scenario.
study is the inevitable relationship shared by the social
realities and indicators of women’s mental health . The Gender plays an important role when it comes to
next section discusses exclusively the gender specific deciding women’s mental health. Gender also determines
risk factors that have a significant bearing on women’s one’s ability and capacity to avail various resources and
mental health. The subsequent sections deal with mental facilitates. Self evaluation, self concept, self image, styles
health issues like prevalence of suicide among women of interpersonal interactions, spirituality, mechanisms of
with special emphasis on locating the socio-economic coping with stress, needs, expectations and all the other
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 409

individual differences are, up to some extent determined which is a common occurrence in India cumulate to act
by gender. as catalysts for mental diseases.

The mental health issues of women are a result Women and suicide
various gender based risk factors like; violence, low
income, income inequality, care giving responsibility, There appears to be deeper connexion between
role stereotyping and etc. Mental disorders commonly gender and suicidal behaviour. Factors like childhood
seen in women are depression, anxiety, somatic abuse, marital rape, domestic atrocities play a significant
complaints and eating disorders. The various atrocities role in goading suicidal behaviour among women. A
faced by women like sexual violence, domestic violence socio-cultural variable responsible for female suicide
and issues of multiple roles, overwork fairly contribute typical to Indian society is the practice of dowry in
to mental disorders they suffer from, resulting in poor marriages. There are legislations in place that prohibit
mental health. A positive correlation has been established dowry dealings in marriages in India. In spite of this,
between the scales of these social variables and the the practice of dowry-related disputes still remains a
occurrence of mental disorders in women.. However, the leading cause of women’s atrocities and death. Failure
taboos related to mental health issues and the differential to meet dowry demands in many cases, leads the bride
treatment of genders stand as an obstacle in stimulating to be forced to commit suicide or even killed by the
adequate mental health development and care amongst in-laws. “The precipitants for suicide, according to
women. Indian government statistics, among women compared
to men are as follows: Dowry disputes (2.9% versus
Gender and Depression 0.2%); love affairs (15.4% versus 10.9%); illegitimate
pregnancies (10.3 versus 8.2); and quarrels with spouse
“In 1977 Weissman and Klerman reviewed the or parents‑in‑law (10.3% versus 8.2%). The common
evidence for differing rates of depression between the causes for suicide in India are disturbed interpersonal
sexes, in the United States and elsewhere, during the relationships followed by psychiatric disorders and
previous forty years. They found that studies showed physical illnesses”7.
women experienced depression at rates much higher than
men,”12 The higher occurrence of depression in women Gender-violence
cannot be solely attributed to biological factors. The
social and culturally dictated mores and gender roles too “According to an eye‑opening United Nations
have a part to play in propelling depression in women. report, around two‑third of married women in India
The unequal power status cemented by the prevailing were victims of domestic violence and one incident
patriarchal social system has resulted in women reeling of violence translated into women losing 7 working
under a vicious circle of feminisation of poverty where days in the country. Furthermore, as many as 70% of
women more often find themselves stuck in a state of married women between the ages of 15 and 49 years are
economic deprivation inciting feelings of helplessness victims of beating, rape or coerced sex.”9 Female Indian
and hopelessness. Due to the advantages bestowed psychiatric patients share a serious concern of sexual
upon by globalisation and acceptance of liberal values, coercion. “Sexual coercion was reported by 30% of the
women now are able to make inroads into the public 146 women in an Indian study. The most commonly
sphere breaking the patriarchal shackles ordaining them reported experience was sexual intercourse involving
to relegate and confine themselves to the domestic sector threatened or actual physical force (reported by 14% of
only. While women are moving up the corporate ladder women), and the most commonly identified perpetrator
and marking their place in the public sphere, this does was the woman’s husband or intimate partner (15%), or
not necessarily entail that they have been liberated a person in a position of authority in their community
from the confines of domesticity. The perplexity reality (10%).”11
is that the educated and working women today end up Gender-based violence can cause untold sufferings
shouldering an excessive double burden of both work and permanent damage to one’s emotional and
and domestic chores whisking away all of their personal psychological well-being. Resultantly, women as victims
time and energy, finally taking a toll on their emotional of violence, suffer from emotions despondence and
well-being. Additionally, gender crimes like sexual stress, post-traumatic stress disorders, fertility problems
violence, domestic violence, eve-teasing , stalking and other variants of psychosomatic diseases etc
 410 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Suggestions for promotion of mental health among women in terms of the differential social roles they play
women along. Gender-mainstreaming in health care services is a
pre-requisite for offering timely and effective remedies
Women make up half of the human resource against women’s mental health concerns.
repository in India. Therefore, ensuring good mental
health and emotional well-being of the women is Conclusion
quintessential to the country’s progress and development.
As we have been discussing, societal impositions, Therefore, it has been made inarguably clear that
expectations, bindings, control, gender roles and women’s mental health is not a lone impervious variable,
stereotypes in Indian society impacts significantly on the it has to be considered in association with their socio-
emotional and mental well-being of a woman throughout cultural context and gender roles . Any policy or mere
her life-cycle- as a young girl, teenager, adult, married discussion on women’s health concern should involve
woman, mother and also as an older woman. Therefore, her emotional and mental well-being along with her
it is very important to undertake efficient intervention physical health at all stages of her life. It is a common
and assistive strategies to promote and sustain women’s occurrence where policies in India view women’s health
mental health under the prevailing social conditions. very narrowly in terms of reproductive and maternal
health solely. Such a constricted policy worldview in
Various suggestions for a preventive, protective, India has greatly contributed towards reinforcing the
remedial and promotional framework for women’s idea that women only exist as mothers and procreators.
health in India can be advocated as follows: Moreover, when an individual woman suffering from a
certain mental health concern is focused in isolation as
• constructing evidence-based knowledge on the a singular independent biological entity divorcing her
causative factors and extant of women’s mental health condition from her sociological realities, it runs a risk of
issues as well as on the interceding and defensive factors. placing the burden of reformation on the women alone.
; But as we would agree that change for women is well
• Policy stage interventions to efficiently sculpt beyond their control and is possible only with a bigger
policies that are sensitive and responds to women’s positive social transformation. Given these realities,
mental health needs from childhood to old age and take it becomes imperative to undertake stratagems and
steps for speedy and effective implementation. schemes that would target the social factors responsible
for having a degrading impact on women’s health. Such
• Calibrate and strengthen the capacities of strategies may involves social policies to reduce gender
primary healthcare providers enabling them to address gaps in all fields of social existence, enhance women’s
and cure mental health consequences in victims of status in society by giving them their due or at least
domestic violence, abuse, sexual assault. empower and educate them enough that they are able
to voice out their demands and grasp their rights for
• Promoting action research initiatives in the field
themselves. Although a large portion of the responsibility
of women’s mental health.
of change lies on the policy makers but women in India
• Promoting awareness of mental health issues too must speak up to bring about the change they want in
and its curability among women to de-emphasise and their lives. There are ample instances where women have
eradicate its taboo nature in Indian society. taken on a social-acvitist vesture to fight off their own
devils, for instance, the anti-arrack movement in Andhra
• Disseminating useful information of health care Pradesh where they fruitfully succeeded in fighting off
services and legal consequences and the various rights liquor addiction in their husbands and wife battering.
available to women against evils of rapes, sexual assault, Movements on the same line for fighting evils of sexual
domestic violence, stalking and other such crimes. abuse, rape etc can go a long way in remedying the
unjust social circumstances under which women live in
• “collaborating with international agencies and
India. “In summary, concerted efforts at social, political,
organizations to reduce/eliminate intimate partner and
economic, and legal levels can bring change in the lives
sexual violence globally.”10
of Indian women and contribute to the improvement of
The health care services available to women need to the mental health of these women.”4
gender sensitive taking cognisance of the special needs of
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 411

Source of Fund: Self. 6. Women and mental health [Internet]. www.

mentalhealth.org.uk. [cited 2019Dec28]. Available
Conflict of Interest: Nil from: https://www.mentalhealth.org.uk/a-to-z/w/
Ethical Clearance: Data has been collected from women-and-mental-health
medical journals, books, newspaper reports and WHO 7. Rao V. Suicidology: The Indian context. In:
databases and reports which is related to the topic of Agarwal SP, editor. Mental Health: An Indian
women’s mental health. Perspective 1946‑2003. New Delhi: Directorate
General of Health Services/Ministry of Health and
References Family Welfare Nirman Bhawan; 2004. p. 279‑84.
1. Basu S. Mental Health Concerns for Indian Women. 8. Biswas S, Roy S, Debnath C, Sengupta SB. A study
Indian Journal of Gender Studies. 2012;19(1):127– of attempted suicidein adolescents in west Bengal.
36. Indian J Psychiatry 1997;39:54‑5.
2. Davar BV. Mental health of Indian women: a 9. Press Trust of India. Two‑Third Married Indian
feminist agenda. New Delhi: Sage Publications; Women Victims of Domestic Violence: UN. Posted
1999. Online; Thursday, October 13, 2005. Available
from: http://www.expressindia.com/fullstory.
3. World Health Organization. Women’s Mental
php?newsid=56501.
Health: An Evidence Based Review. Geneva:
World Health Organization; 2000. 10. Gomel MK. A Focus on Women. Geneva: World
Health Organization;1997.
4. Malhotra S, Shah R. Women and mental health
in India: An overview. Indian J Psychiatry. 2015 11. Chandra PS, Carey MP, Carey KB, Shalinianant
Jul;57(Suppl 2):S205-11. doi: 10.4103/0019- A, Thomas T. Sexual coercion and abuse among
5545.161479. PMID: 26330636; PMCID: women with a severe mental illness in India: An
PMC4539863. exploratory investigation. Compr Psychiatry
2003;44:205‑12
5. World Health Organization. Gender and women’s
mental health. Gender disparities and mental health: 12. Depression: Gender Matters: Module 3 [Internet].
The Facts. Geneva: World Health Organization; ATrain Education.. Available from: https://www.
2001. atrainceu.com/course-module/1473440-82_
depression-gender-matters-module-3
 412 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Transmission of Actinobacillus Actinomycetemcomitans &

Porphyromonas Gingivalis in Periodontal Diseases

Prabhu Manickam Natarajan

Associate Professor & Specialist Periodontist, College of Dentistry, Gulf Medical University, UAE

Abstract
Periodontitis is one of the most common bacterial infections in humans. The disease is a consequence
of destructive host immune responses to pathogenic bacterial species resulting from the dysbiosis of oral
microbiota. Criteria for defining periodontal pathogens have been developed and include association,
elimination, host response, virulence factors, animal studies and risk assessment. The bacteria associated
with periodontal diseases are predominantly gram-negative anaerobic bacteria and may include A.
actinomycetemcomitans, P. gingivalis, P. intermedia, B. forsythus, C. rectus, E. nodatum, P. micros, S.
intermedius and Treponema sp. The bacterial numbers associated with disease are up to 10(5) times larger
than those associated with health. The transmission of A. actinomycetemcomitans and P. gingivalis is
discussed in this article.

Key words: Transmission, bacteria, A. actinomycetemcomitans, P. gingivalis, periodontal disease.

Introduction Fusobacterium nucleatum, Capnocytophaga, Niesseria

Bacteria inhabit the oral cavity in various and Veillonella species are also found most frequently
concentrations. They colonize the soft tissues including in the subgingival areas. Microscopic studies prove the
the gingiva, cheeks, tongue and in the presence of teeth, presence of a few spirochetes and motile rods in these
bacteria colonize them both supra and sub gingivally. It diseased areas. The ratio of non-motile forms to motile
is estimated that between 300-400 different species can forms in health is 40:1.
colonize the oral cavity and an individual may typically Periodontal disease has been proved to have
harbor 150-200 different species. In the subgingival a complex etiology. When the microbial etiology
areas, bacterial concentrations range from about 103 is concerned, the obligatory anaerobic species
in healthy shallow sulci to >10 8 in deep periodontal Porphyromonas gingivalis (Pg), Prevotella intermedia
pockets. Among these microorganisms, about ten to 80 and Peptostreptococcus micros and the facultatively
different species are capable of inducing or initiating anaerobic species Actinobacillus actinomycetemcomitans
periodontal disease. (Aa) and Campylobacter rectus are regarded as principal
The healthy and diseased clinical areas have periodontal pathogens today. Most individuals have
been examined for the presence of microorganisms. acquired strains of suspected periodontal pathogens at
Many researches have been done in this regard. It was some time in their lives which may or may not lead to
found that in clinically healthy sites, streptococci, periodontal disease. The progress of the disease depends
facultative species of Actinomycetes [esp. A.viscosus on the resistance offered by the host. It has been quoted
& A. naeslundi], Rothia dentocariosa account for about that the subgingival species found in humans are unique
85% of the total cultivable flora. Small proportions of to that environment.
gram-negative species including Prevotella intermedia, Transmission of periodontal pathogens occurs
through various means which are to be discussed in this
Corresponding author: article. The typical pattern requires the transmission
Dr. Prabhu Manickam Natarajan of periodontal pathogens from the oral cavity of one
Associate Professor & Specialist Periodontist, College individual to the oral cavity of another. Α major focus
of Dentistry, Gulf Medical University, UAE of this article is to provide a critical review of selected
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 413

studies on the transmission of A. actinomycetemcomitans chain reaction), serotyping, ribotyping, etc. The DNA is
and P. gingivalis which are the prime periodontal cut with restriction endonucleases, run on agarose gel
pathogens of a chronic periodontitis. The information electrophoresis and the resulting fingerprint patterns
may be used in the future to decrease the susceptibility are compared either directly or with the help of various
to oral infection by A. actinomycetemcomitans and P. DNA probes. Through DNA probing technique.
gingivalis and to arrest transmission of these pathogens
to uninfected individuals. A. actinomycetemcomitans and P. gingivalis
frequently occur as monoclonal infections in the oral
Transmission of Periodontal Microbes cavity. Other periodontal bacteria may show extensive
genetic diversity. It was found that nearly 67%-80%
During recent decades, it has become evident that of Aa species and 75%-85% of Pg species from most
gingivitis and chronic periodontitis are the most common infected people are monoclonal in nature.
form of periodontal diseases seen in the population. This
might be due to various reason including hereditary, Transmission of Actinobacillus
habits, oral hygiene maintenance, susceptibility to Actinomycetemcomitans
infections and the presence of systemic diseases. Apart
from this, environmental factors have been documented Actinobacillus actinomycetumcomitans (Aa) is a
to influence the development of periodontitis. Besides gram- negative, facultative, capnophilic coccobacillus
plaque, it is proposed that the development of periodontal suggested as playing a key role in the pathogenesis
disease and its severity depends on the presence of a of several forms of periodontal diseases. Its possible
critical number of more putative periodontal pathogens. exogenous origin has also been discussed recently. The
It is well established that periodontal pathogens cluster evidence pointing to Aa as an exogenous pathogen in
in families. This suggests that bacteria are transmitted humans indicates the importance of understanding its
between family members or that family members share mechanism of transmission.
susceptibility to colonization by these bacteria. Keeping This bacterium and elevated serum antibody titers
the above statement in mind, two types of transmission against it have been associated with periodontal diseases
are recognized including vertical transmission between including prepubertal, juvenile and adult periodontitis
parents and children2,4 and horizontal transmission and refractory cases. However, this bacterium can also
between siblings and between spouses. The latter may be detected rather frequently in periodontally healthy
have consequences for the periodontal condition of a teenagers and even in children with primary dentition. Aa.
subject who marries a periodontitis patient harboring A. may belong to the normal oral microflora. The occasional
actinomycetemcomitans and P. gingivalis. If the spouse recovery of the organism in low proportions of the flora
has poor oral hygiene and gingivitis, transmission of from healthy gingival sites and in periodontally healthy
these bacteria may lead to conversion of gingivitis to individuals supports the view of the opportunistic nature
periodontitis. This hypothesis is supported by the results of infections associated with Aa.
of a recent study, which showed that spouses of severe
periodontitis patients had a worse periodontal condition Aa is acquired early in life from one or the other
in comparison to spouses of periodontally healthy parent and is less likely to colonize the subject after
subjects.9 reaching a certain age. Transmission of Aa to an
established flora may be difficult in a healthy person
Techniques to Study the Transmission of where protective immune mechanisms and microbial
Pathogens: antagonistic process are intact. However, it is possible
The mechanism of transmission of microorganisms that once anti-infective therapy is instituted, a new
has been studied thoroughly for generations. Different microbial ecology may be established in the oral cavity,
concepts of periodontal disease progression had been which will more easily allow transmission of Aa.
hypothesized and data had been published about When the resistance offered by the host decreases,
the same. Evidence for both forms of transmission bacterial transmission happens at a faster pace. It
has been provided using molecular epidemiology results from a combination of a sufficiently large
techniques like REA (Restriction Endonuclease and concentrated inoculum of the bacterial species
Analysis), AP-PCR (Arbitrary Primer-Polymerase enabling its survival during colonization, combined
 414 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

along with the environment where the recipient’s patients are in general colonized with one predominant
macro and microenvironment accepts the intrusion clone of Pg. It is not clearly known whether periodontal
of an microorganism; or in other words, the intruding break down in spouses favored the transmission of Pg
microorganism evades the host defense and proceeds to or the transmission of Pg from the spouses had initiated
infect the organism. These factors are again dependent the disease process or had an aggravating effect on the
on the behavioral patterns of the family members (i.e.) present status.8
hygiene, proximity and differences in these practices
among different family members. Therefore, theoretically In untreated periodontitis, an increasing prevalence
any combination of acquisition or transmission between of Pg with increasing age of the patients was found.
spouses and between parents and children exists. There Though transmission of Pg is not a common phenomenon,
are phases like periods of stress, when adults are more it is suggested that the suspected periodontal pathogen
susceptible to bacterial infections, and when local Pg can be transmitted between spouses. Further research
changes promote the acquisition of the disease-causing will be necessary to determine whether spouses of
bacterium because of decreased resistance, which periodontitis patients are at risk for getting periodontal
enables bacterial transmission to occur. destruction and delayed wound healing following
surgical management, because of transmission of Pg12.
Disease progression is most commonly seen in
populations with low socio economic and educational Clinical Significance of Transmission
levels as they in general maintain lower standards of oral It is well known that Aa and Pg play a major role
hygiene as sprove din study by Preus et al (1994) and in the etiology of periodontal diseases. The transmission
Tinoco et al 19887. Although intra familial transmission rate of Aa appeared to be 14 – 60 % and Pg is 30 – 75%
of Aa has been demonstrated by Zamben et al it appears of the bacterium positive spouses pair studied. A seven-
likely that transmission of pathogens also occurs between year longitudinal study of the periodontal condition of
unrelated individuals Socransky & Haffajee described young Indonesian couples who had been married for an
the transmission of ANUG both within troops in trenches average of ten years was conducted.13 Results suggested
in world war I and in communities outside the war zone, that transmission of Aa and Pg were uncommon between
after world war I. If such reports are accurate, then it spouses regarding the intimate cohabitee of several years.
appears that periodontal pathogens can be transmitted Based on the results, it was found that the transmission
rather readily, perhaps even on casual contact. Thus, occurred more frequently but did not lead to persistent
while there has been an intuitive feeling that the oral colonization or detectable levels of the organism. Also,
microbiota is relatively stable within an individual, it it was found that bacterial colonization is host dependent
seems likely that new species or different clonal types and depends on the characteristics of the strain. The
of the same species can be introduced into an individual numbers of bacteria in the transfer inoculum were too
at various stages of his on her life. If the newly acquired low or exposure to infection occurred too rarely. Based
strain is more virulent than the preexisting strain of that on the study, it was inferred that the older or established
species, then a change in disease pattern could occur. microbiota did not easily accept new bacterial invaders.
Transmission of Porphyromonas Gingivalis This result contrasts with those of Von Troil linden et al
19959 & Asikainen et al 19976 who found that spouses
Porphyromonas gingivalis (Pg) is a bacterial of patients with periodontitis had significantly more
species, which is specifically associated with severe gingival suppuration, supra gingival and sub gingival
periodontitis lesion in adults. In subgingival areas calculus and deeper periodontal pockets than the spouses
harboring Pg, it often comprises a relatively large part of patients without periodontitis. Therefore, it seems that
of the microbial flora. In healthy sites and in gingivitis not only were periodontal pathogens transmitted between
sites, the isolation frequency of this species is low. The the same spouses, but also the transmission resulted in
microorganism is quite uncommon in children although periodontitis in the recipient spouse. This possibility
it can be seen in children with aggressive type of needs to be further analyzed and the prophylactic
periodontitis. It was demonstrated recently that chronic consequences still need to be determined.
periodontitis patients can be infected with more than one
clonal type of Pg. Most often only one clonal type has Source of Pathogens & Route of Infection
been recovered, suggesting that chronic periodontitis In humans, the highest frequencies and levels of
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 415

Aa and Pg are usually seen in periodontal pockets numbers associated with disease are up to 10(5) times
subgingivally, although the organisms can be larger than those associated with health. Data on the rare
recovered from supra gingival plaque, oral mucosal presence of multiple Aa clones within a single person
surfaces, dorsum of the tongue and pharynx. These indicate that an additional Aa clone or replacement of a
two microorganisms play a major role in the initiation previous clone is difficult. This hypothesis is supported
and progression of periodontal diseases. While Aa can by the finding that fewer than half of the married couples
colonize a healthy and clean oral cavity, Pg does not in whom both spouses harbored Aa, shared identical Aa
seem to colonize clean tooth surfaces but prefers sites genotype6. While human subgingival plaque harbors
showing inflammation due to poor oral hygiene and sites more than 500 bacterial species, considerable research
harboring gram positive dental plaque bacteria. has shown that Porphyromonas gingivalis, a Gram-
negative anaerobic bacterium, is the major etiologic
Saliva play a role in the prevention and transmission agent which contributes to chronic periodontitis. This
of periodontal diseases. It was found that high salivary black-pigmented bacterium produces a myriad of
levels of periodontal pathogens are seen in patients virulence factors that cause destruction to periodontal
with advanced periodontitis and in relation to patients tissues either directly or indirectly by modulating the
with initial periodontal destruction.9 These findings host inflammatory response15. Chronic periodontal
underscore the potential of saliva as transmission diseases involve major pathogens like Porphyromonas
vehicle of periodontal pathogens. The role of saliva as gingivalis, Treponema denticola, and Tannerella
a transport vehicle has been supported by the findings forsythia, which have an immune armoury that can
that Aa and Pg could be cultured from salivary samples, circumvent host’s immune surveillance to create and
which indicates that these bacteria are able to survive maintain an inflammatory mediator rich and toxic
in saliva during transportation to a new host. It can environment to grow and survive. A full understanding of
be said that the higher their load in saliva, the greater the microbial factors, their pathogenicity as well as host
their risk of colonization of the recipient. Therefore, the factors are of the essential importance for pathogenesis
suppression of the pathogens in saliva may prevent this of periodontal disease. In this way it could be possible to
spread among individuals. treat the periodontal patients adequately.

Summary & Conclusion Ethical Clearance- Not applicable as it is a review

The periodontal disease is confirmed by a group article
of illnesses affecting the gingiva and dental support Source of Funding- Not applicable as it is a review
structures. They are caused by certain bacteria found in article       
the bacterial plaque. These bacteria are essential to the
onset of illness; however, there are predisposing factors in Conflict of Interest - Nil
both the host and the microorganisms that will influence
the pathogenesis of the illness. Periodontopathogenic References
bacterial microbiota is needed, but by itself, it is not 1. Muller HP, Lange DE & Muller RF: Actinobacillus
enough to cause the illness, requiring the presence of a actinomycetem comitans contamination of
susceptible host. toothbrushes from patients harboring the organisms.
Bacteria have been seen to play a leading role in the J Clin Periodontal 1989; 16: 388 – 390.
onset and subsequent development of these illnesses. 2. Petit MDA, Van Steenbergen TJM, DeGraff
Therefore, when it comes to treatment of these diseases, J et al: Transmission of Actinobacillus
coadjuvant antimicrobial treatment will be needed, since actinomycetemcomitans in families of adult
we already know that scaling and root planing alone will periodontitis patients. J Periodont Res. 1993; 28:
be insufficient to eliminate the periodontal pathogens14. 335-345
The bacteria associated with periodontal diseases are 3. Preus HR, Zambon JJ, Dunford RG et al: The
predominantly gram-negative anaerobic bacteria and distribution and transmission of Actinobacillus
may include A. actinomycetemcomitans, P. gingivalis, actinomycetemcomitans in families with
P. intermedia, B. forsythus, C. rectus, E. nodatum, P. established adult periodontitis. J Periodontol 1994;
micros, S. intermedius and Treponema sp. The bacterial 65: 2 – 7.
 416 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

4. Alaluusua S, Asikainen S & Chen Hsiung 10. Von Troil – Linden B, Saarela M, Matto J et al:
Lai: Intra familial transmission Actinobacillus Source of suspected periodontal pathogens re-
actinomycetemcomitans. J Periodontol 1991; 62: emerging after periodontal treatment.J Clin
207 – 210. Periodontol 1996; 23: 601-607.
5. Asikainen S & Chen C: Oral ecology and person-to- 11. Von Troil – Linden B, Alaluusua S, Wolf J et al:
person transmission of Intra familial transmission Periodontitis patient and the spouse: Periodontal
Actinobacillus actinomycetemcomitans and bacteria before and after treatment. J Clin
Porphyromonas gingivalis. Periodontology 2000- Periodontol 1997; 24: 893 – 899.
1999; 20: 65 – 81. 12. Priyavadhana P, et al. Wound Healing in
6. Asikainen S, Chen C, Alaluusua S et al: Can one Periodontics. Biosciences Biotechnology Research
acquire periodontal bacteria and periodontitis from Asia, August 2014. Vol. 11(2), 791-796.
a family member? JADA 1997; 128: 1263 – 1271. 13. VanderVelden, U, Van Winkelhoff AJ, Abbas A
7. Tinoco EMB, Sivakumar M, Preus HR: The et al: Longitudinal evaluation of the development
distribution and transmission of Actinobacillus of periodontal destruction in spouses. J Clin
actinomycetemcomitans in families with localized Periodontol 1996; 23: 1014 – 1010.
Juvenile Periodontitis. J Clin Periodontol 1998; 25: 14. Bascones Martínez A, Figuero Ruiz E. Periodontal
99 – 105. diseases as bacterial infection. Av Periodon
8. Van Steenbergen TJM, Petit MDA, Scholte LHM Implantol. 2005; 17, 3: 111-118.
et al: Transmission of Porphyromonas gingivalis 15. How KY, Song KP, Chan KG. Porphyromonas
between spouses. J Clin Periodontol 1993; 20: 340 gingivalis: An Overview of Periodontopathic
– 345. Pathogen below the Gum Line. Front Microbiol.
9. Von Troil – Linden B, Torkka H, Alaluusua S et 2016; 7:53.
al: Periodontal findings in spouses. A clinical,
radiographic and microbiologic study.J Clin
Periodontol 1995; 2: 93-99
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 417

Application of a Health Belief Model to Hypertension within

Rural India

Rajkumar E1, Romate J2

1Assistant Professor, Central University of Karnataka; 2Professor, Central University of Karnataka

Abstract
Cardiovascular diseases are the principal cause of mortality among adults across the globe as well as in India.
Hypertension is one of the leading factors contributing to cardiovascular disease; and its prevalence rate in
India is 23% among urban population and 22.6% among rural populations. Beliefs play a significant role
in managing and controlling health problems and depend in part on knowledge about the illness or disease.
The present study uses the Health Belief Model framework to enhance understanding of the relationships of
health beliefs with knowledge, risk factors for hypertension and hypertension. The present study focused on a
south western state of India from which a taluk with one of the lowest socio-economic ratings was identified.
A total of 263 participants were selected by multi-stage random sampling technique. The measures for data
collection were comprised of a demographic data sheet, the WHO Steps tool, a hypertension knowledge
questionnaire, hypertension belief scale, and physical assessments. Results were analysed using descriptive
statistics, Pearson correlation, Independent sample t test, and binary logistic regression. Findings revealed
that health belief model constructs, perceived susceptibility, severity, benefits, barriers, cues to action, and
self-efficacy were significantly correlated with hypertension knowledge. Further it was observed that the
health belief construct perceived severity was correlated with a risk factor and there was no significant
association found between health belief constructs perceived susceptibility, severity, benefits, barriers, cues
to action, and self-efficacy and hypertension.

Key words: Health beliefs, Hypertension, Knowledge, Rural, India

Introduction Hypertension is a public health problem that results

in 1.1 million deaths every year in India. It is deemed
Changes in life style and economic progression lead
to be conducive to 10.8% of all deaths and 4.6% of
to epidemiological health transition with high rates of
all disability-adjusted life years in India 4. Gupta,
adaptation to urbanization. The shift from communicable
Brahmbhatt, Sharma, & Halappanavar 5 reported that
to non- communicable diseases in the disease spectrum
the prevalence of hypertension in India is 23% for urban
is seen as one of the major consequences of economic
and 22.6% among rural populations and is directly
progression. Globally there has been a gradual increase
responsible for 42% of coronary heart disease deaths and
in the burden of non-communicable diseases. According
57% of all stroke deaths 6.
to WHO 2, 67% of the 56 million deaths in 2012 were
due to non-communicable diseases; among these, 46.2% The Health Belief Model, Rosenstock 7 predicts
were due to cardiovascular diseases. Hypertension ranks health-related behaviours with four constructs of
among the most salient risk factors for cardiovascular perception, namely susceptibility of the health problem,
diseases. It is estimated that it affects more than one- the severity of the health problem, benefits of taking
third of adults aged 25 and above, and thus one billion action, and barriers to taking action. These four constructs
people worldwide suffer from this disease and contribute account for the readiness to act by people. In addition
to nearly 9.4 million deaths from cardiovascular to these four original constructs, another element which
diseases each year Further, it is estimated that 23 million prompted action seemed necessary hence cue for action
cardiovascular deaths will occur due to hypertension by was subsequently added to the model 7. Finally, self-
2030 3. efficacy, which is the belief in one’s own ability to
 418 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

complete a task successfully, was a recent addition to the applicability within a South Asian context. The model
model 8. This was done to better connect the interpersonal purports that an individual would need to believe that
challenges of changing unhealthy behaviours with the one was personally at risk of developing the disease to
model. The model postulates that for an individual to take appropriate preventive actions. Beliefs serve an
avoid a disease, the person should believe that he/she is integral part in determining the management and control
personally susceptible to it, the occurrence of the disease of health problems and depend in part on knowledge
will have at least a moderate level of severity on some about the illness or disease. Knowledge and perceived
aspects of the individual’s life, undertaking a particular susceptibility to disease are considered as an important
action would be beneficial by reducing its severity, and factors that change the behavior of individuals. 16.
the action would overcome the barriers such as cost, The present study aims to enhance understanding
convenience, pain, or embarrassment 9. Cues to action of the relationships between health beliefs model
then act as a trigger for protective health behaviour. The constructs, knowledge, risk factors for hypertension and
cues can be internal like the bodily states of a person hypertension.
or external such as the impact of mass media. Lastly,
the individual ought to have credence in his/her ability Method
to complete an action with success. Newell, Modeste, This study utilized a cross-sectional survey to
Marshak, & Wilson 10 examined the role of beliefs in describe the relations between health belief model
the prevention of hypertension; their findings have constructs (perceived susceptibility, perceived severity,
shown that there was a significant negative association cues to action, perceived benefits, perceived barriers,
between perceived severity and systolic or diastolic and self-efficacy), knowledge about hypertension, risk
blood pressure. Self-efficacy was negatively associated factors for hypertension, and hypertension.
with risk scores. Most respondents thought that adopting
strategies to reduce the risk of hypertension was useful Study Area and Sample:
and believed that their self-efficacy could help in
changing these behaviors. Rosenstock 7 reported that The present study focused on a south western state
self-efficacy; perceived susceptibility and severity of of India. This community-based study was located in
an illness or disease are partly dependent on knowledge Jewargi taluk, which ranks 174th out of 175 taluks in the
about the illness or disease. state of Karnataka on various socio-economic indicators
17. Based on the 2011 Census data, there were 159 total

Appropriate knowledge about hypertension and number of villages in Jewargi taluk.

its related consequences can motivate individuals to
modify their lifestyle, such as weight loss 11 , restricting A multi-stage random sampling method was
alcohol consumption, engaging in regular exercise 12 and used to recruit 263 study participants. Initially, the
increased intake of fruits and vegetables 13 Individuals researcher selected 3 villages randomly from Jewargi
with little or no knowledge about hypertension will most taluka by lottery method; after selecting the villages,
likely believe that they are neither at risk of becoming a unique number was given to each household in the
hypertensive, nor will they believe hypertension to have three villages and another random draw was made to
emotional, social or medical consequences to themselves select sample households. A final lottery process was
or others. Gammage &amp; Klentrou 14 employed conducted to select the study participant among those
Health Belief Model to analyse the perceptions and in the household who were 18 years or older. Of 318
behaviors surrounding osteoporosis, and he reported that selected individuals, 263 consented to participate in the
persons of all ages lacked knowledge about osteoporosis; study. The main reason given for non-participation was
their knowledge and expertise to understand the risk a busy work schedule. Ethical clearance to conduct the
factors, protective factors, and the insidious nature of study was obtained from the department and permission
osteoporosis which was related to reduced perceived to conduct the study was obtained from the district health
vulnerability for osteoporosis and practices aiming at officer and taluka health officer.
preventing osteoporosis, were inadequate 15. Measures:
While the health belief model has shown to Health Beliefs Model:
help and explain behaviour related to hypertension
among western populations, less is known about its A six subscale measure developed by Robinson
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 419
18 assessed the constructs within the Health Beliefs diagnosis of hypertension, or receiving antihypertensive
Model. Thirty-one items on a five-point Likert scale medication and captured in a dichotomous coded
assess six subscales namely perceived susceptibility variable.
(4 items), perceived severity (5 items), cues to action
(4 items), perceived benefits (7 items), perceived Demographics: Six items were taken from the
barriers (5 items), and self-efficacy (6 items). Subscale WHO Steps Tool 20 to assess age, gender, education,
mean scores were calculated and inter-item reliability income, occupation, and marital status.
analyses were conducted. Alpha reliability scores for Data Collection:
each subscale were as follows: perceived susceptibility
0.357, perceived severity 0.687, and cues to action The written questionnaire was first translated from
0.639, perceived benefits 0.81, perceived barriers 0.795, English to Kannada which is the most popular language
and self-efficacy 0.602. Sub-scales were created by in Karnataka. Three research assistants trained by the
calculating an average score. principal investigator conducted the in-person structured
interviews.
Hypertension Knowledge: the level of knowledge
regarding hypertension was explored by asking questions Data Analysis
about the reasons (high salt intake, family history,
obesity, smoking, alcohol intake, high fat diet, stress, All data were entered into SPSS 20th version.
physical inactivity and unknown reasons), consequences Initially scales were created and alpha reliability analyses
(stroke, heart disease, kidney problem, eye problems and completed. Descriptive statistics were performed along
diabetes) and preventive measures (reduce salt intake, with correlations and independent sample t test to
reduce weight, reduce intake of fatty food, exercise examine the relationships and assess the differences
regularly, start medicine, quit smoking, stop drinking between scales. Lastly a binary logistic regression was
alcohol and regular check-up) of high blood pressure conducted to examine the contribution of health belief
and recorded all the responses from the participants. model constructs and hypertension knowledge on
Response options are dichotomous (Yes/No) 19. A single hypertension status
summed index score was calculated for knowledge of
consequences, and knowledge of preventive measures.
Results
Table 1 shows comparison of demographic
Behavioural Risk Factor Index: The WHO information between the hypertensive and non-
Steps Tool 20 was used to assess behavioural risk hypertensive group. From the results it was observed
factors, namely smoking, alcohol consumption, dietary that majority of the hypertensives were males 51.56% as
behaviour, physical activity, and obesity. Obesity via a compare to the females 48.43%. When the participants
body mass index calculation was derived from height were compared according to the educational qualification
and weight measurements taken at the time of the majority of the hypertensives had no formal schooling
interview by the researchers. Each risk factor was coded 67.18% followed by less than primary school 12.5%
0/1 to represent the presence of behaviour categorized by When the participants were compared according to
the Steps Tool, for example, being a current smoker, if occupation, majority of the participants were daily wage
physical activity less than WHO guidelines, if fruit and labourers 28.12% followed by unemployed and unable
or vegetable consumption was lower than five servings/ to work 26.6% and self-employed 20.31% respectively.
day, and being obese. Subsequently, a risk factor index Majority of the hypertensives were married 78.12%.
was created by summing up across factors. When the participants were compared according to the
Hypertension: Blood pressure was measured three age, majority of the hypertensives were above the age
times with a minimum of 5 minute rest period in between group of 46, 64.06; p<0.001
each reading; participants were in a sitting position with Table 2 shows Differences in Health Belief
the measurement on their right arm and taken over loose constructs between hypertensive and non- hypertensive.
clothing using a portable digital blood pressure device. Using independent sample t test it was revealed that in
Hypertension is defined as a systolic blood pressure 140 the sub scales perceived susceptibility, severity cues to
mm Hg or higher; or diastolic blood pressure 90 mm action and self-efficacy hypertensive group had higher
Hg for average of the three readings; t h e history of average score as compare to the non-hypertensive groups
 420 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

which indicates hypertensives have more perceived correlated with one another. All significant correlations
threat and readiness to action as compare to the non- are positive, in other words, the greater the beliefs the
hypertensives but in the subscale perceived barriers and greater the knowledge with the exception of perceived
benefits non hypertensive groups score higher average barriers which was negatively significantly related with
score which indicates non hypertensive groups were the other constructs of health belief scale.
able to overcome barriers and perceive more benefits
from healthy behaviour. Further there was no significant Table 5 shows the association of health belief
difference was found between hypertensive and non- constructs, hypertension knowledge, and socio-
hypertensives in all the subscales of health belief model demographics with hypertension. Findings revealed
that preventive knowledge of hypertension and age
Table 3 shows the relationship between health belief significantly associated with the odds of hypertension
constructs and the risk factors index. Perceived severity (OR=1.96.; CI: 1.22-3.14) p<0.05 and (OR=1.02;
was positively correlated with the risk factor index CI 1.02-1.07) p<0.01 respectively. From the table it
(r= .156, p<0.05) suggesting that those participants is observed that none of the health belief constructs
categorized with more behavioural risk factors are perceived susceptibility, severity, benefits, barriers, cues
related to higher perceived severity of the disease. Other to action, self-efficacy were significantly associated with
health beliefs constructs were not significantly related to odds of hypertension. The knowledge about reasons and
the risk factor index. consequences of hypertension efficacy were also not
significantly associated with odds of hypertension.
From table 4, it was observed that all of the belief
sub-scales and knowledge index are significantly

Table 1 Comparison of demographic information between hypertensive and non-hypertensive

Demographic variable Non Hypertensive Hypertensive Total df p

Male 90(45.22) 33(51.56) 123 (46.76) 1 0.23
Gender
Female 109(54.77) 31(48.43) 140(53.23)
No Formal Schooling 122(61.30) 43(67.18) 165(62.73) 6 0.70
Less than Primary 33(16.58) 8(12.5) 41(15.58)
School
Primary School 13(6.53) 3(4.68) 16(6.0)
Completed
Secondary School
1(0.5) 1(1.56) 2(0.76)
Education Completed
High School 12(60.30) 6(9.37) 18(6.84)
Completed
College/Graduation 17(8.54) 3(4.68) 20(7.60)
Completed
Post-Graduation and 1(0.5) 0(0) 1(0.38)
Above
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 421

Cont... Table 1: Comparison of demographic information between hypertensive and non-hypertensive

Government 2(1) 0(0) 2(0.76) 8 0.71

Employee
Non-Government 3(1.5) 4(6.25) 7(2.66)
Employment
Self Employed 44(22.11) 13(20.31) 57(21.67)
Non Paid 6(3.0) 2(3.12) 8(3.04)
Occupation Student 5(5.12) 1(1.56) 6(2.28)
Home Maker 30(15.07) 7(10.93) 37(14.06)
Unemployed able to 4(0.20) 2(3.12) 6(2.28)
work
Unemployed unable to 24(12.06) 17(26.56) 41(15.58)
work
Daily wage labourer 81(40.70) 18(28.12) 99(37.64)
Never Married 18(9.04) 4(6.25) 22(8.36) 3 0.057

Marital Currently Married 168(84.42) 50(78.12) 218(82.88)

status Separated 2(1) 0(0) 2(0.76)
Widowed 11(5.52) 10(15.62) 21(7.98)
Age 18- 30 62(31.15) 8(12.5) 70(26.61) 2 0.001
Age Age 31-45 65(32.66) 15(23.43) 80(30.410
Age 46 and above 72(36.18) 41(64.06) 123(46.76)

Table 2: Differences in Health Belief subscales between hypertensive and non- hypertensive category

Health Belief Sub scales Hypertension status M SD t p

Non Hypertensive 3.36 0.49 1.81

Perceived Susceptibility 0.239(NS)
Hypertensive 3.45 0.58

Non Hypertensive 3.64 0.45 1.03

Perceived Severity 0.303(NS)
Hypertensive 3.71 0.4

Non Hypertensive 1.77 0.81 1.07

Cues to action 0.282(NS)
Hypertensive 1.9 0.85

Non Hypertensive 3.58 0.36 1.14

Perceived benefits 0.252(NS)
Hypertensive 3.52 0.34

Perceived Barriers Non Hypertensive 2.63 0.54 1.32

0.186(NS)
Hypertensive 2.53 0.56

Self-efficacy Non Hypertensive 3.15 0.45 1.01

0.312(NS)
Hypertensive 3.22 0.44

NS= Not Significant

 422 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 3 Relationship between Health belief Subscales and Risk Factor Index

Health Belief model subscale Risk factor index (r)

Perceived Susceptibility 0.323
Perceived Severity 0.156*
Perceived benefits 0.032
Perceived barriers -0.051
Cues to action -0.116
Self-efficacy 0.032
*(p<0.05)

Table 4: Relationship between Health Belief Subscales and hypertension Knowledge

Variables 1 2 3 4 5 6 7 8 9

1 Perceived susceptibility _

2 Perceived severity -0.012 _

3 Perceived benefits -0.069 .395** _
4 Perceived barriers .251** 0.059 .213** _
5 Cues to action .280** 0.122 .129* .322** _

6 Perceived self efficacy .135* .190** .249** .172** 0.104 _

7 Knowledge of reasons .230** .208** .180** .265** .419** .271** _

Knowledge of
8 .135* .313** .424** .243** .263** .291** .643** _
consequences
Knowledge of preventive
9 .294** .186** .139* .248** .478** .302** .861** .598** _
measures

Table 5 Logistic Regression of Health Beliefs and Knowledge Subscales and socio demographics with
Hypertensive Status as Outcome

Variables OR (95%CI) p

Perceived Susceptibility 0.706 (.331 1.506) 0.36

Perceived Severity 1.389 (.435-4.437) 0.58

Perceived benefits .288 (.073 1.139) 0.07

Perceived barriers .738 (.337 -1.614) 0.44

Cues to action 1.212 ( .715- 2.053) 0.47

Self-efficacy 1.410 (.560- 3.546) 0.46

Knowledge of Reasons .632 (.388-1.030) 0.06

Knowledge of Consequences 1.433 (.905- 2.269) 0.12

Knowledge of Prevention 1.964 (1.226-3.148) 0.05

Sex .994 (.466-2.117) 0.98

Age 1.049 (1.024-1.075) 0.01

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 423

Discussion management strategies, involving in physical activity,

and not smoking in hypertensive patients. Similarly
Hypertension is considered as a major public health
in another study conducted by Kamaran, Ahari,
problem in India leading 1.1 million deaths per year 4.
Biria, Malpour & Hyedri 25 reported that adhering to
Literature suggests that health beliefs and knowledge
medicines decreases with lower perception of disease
have a vital role in the prevention and control of
severity. These contradictory results might be due to the
health conditions. There is a paucity of evidence
reason that, in the present study most of the participants
examining these health constructs among rural Indian
62.3% were with low health literacy, patients with low
populations. The present study aimed at investigating
literacy tend to feel less confident in their capability to
relationships between health beliefs, knowledge related
execute self-care behaviours and also may have less
to hypertension, risk factors, and hypertensive status.
motivation for performing self-care tasks. Subsequently,
Health belief and Hypertension knowledge: it is required to increase confidence among uneducated
people to select appropriate behaviours which help
It was observed that all the health belief constructs them to engage in healthy behaviours. The concept of
and hypertension knowledge are significantly correlated perceived susceptibility was introduced by Dehghani-
with one another. All significant correlations are positive, Taftiet.,al 26 as an pertinent component in behavioural
in other words, the greater the beliefs the greater the change among diabetic patients.
knowledge with the exception of perceived barriers
which was negatively significantly related to the other To adopt self-care behaviour, health care providers
constructs. From the findings, it could be inferred that need to involve themselves to increase the level of
higher the knowledge the greater the perception of threat awareness about the hypertension and improve the
and taking preventive actions and minimizing barriers to proficiency to modify beliefs of the patients so that they
follow healthy behaviours. Our findings are consistent accept that they were susceptibile to get these diseases.
with those reported by Rashrash, Maneno, Ettiene,
Hence, providing awareness related to hypertension
&amp; Daftary 21 to assess the relationship between
to persons with low level of information will help
Hepatitis C knowledge and health belief model constructs
in developing beliefs to know the danger of high
wherein they found that Hepatitis C Knowledge was
blood pressure which helps them to engage in healthy
positively correlated with perceived benefits and
behaviours.
perceived severity. Similarly, Midi &amp; Tsai 22 found
that among South Asian women participants, who were Health Beliefs, hypertension knowledge and
unaware of osteoporosis did not consider themselves to hypertension:
be susceptible to it and did not consider osteoporosis to
be a severe disease. Elsabagh, Aldeib, Atlam & Saied Form the findings it was observed that the health
23 reported osteoporosis knowledge was negatively belief constructs perceived susceptibility, severity,
correlated with barriers to calcium intake and barriers benefits, barriers, cues to action, self-efficacy were
to exercise. On the other hand, there was a significant not significantly associated with odds of hypertension.
positive correlation between knowledge and the benefits As the findings show, health belief subscales were
of exercise with a higher knowledge level associated not associated with hypertension this may be due to
with positive beliefs of exercise benefits. the reason that constructs of health model alone is
not sufficient to predict the hypertension, there might
Health beliefs and Risk factors be some other factors such as socio-demographic
characteristics, psychosocial factors, personal factors,
From the findings it was observed that the health
and cultural beliefs all of which will have to be present
belief constructs, perceived susceptibility, benefits,
to activate the beliefs and follow healthy behaviours 27
barriers, cues to action, self-efficacy were not & 28.
significantly correlated with risk factor index which is
the sum of all the risk factors. Present study findings Knowledge about reasons and consequences of
are in contradiction to the study conducted by Larki, hypertension were not associated with the odds of
Tahmasebi &amp; Resisi 24 found that self- efficacy and hypertension but the knowledge about preventive
perceived susceptibility were associated with holding measures has been associated with the odds of
on to low salt diet, making use of common weight hypertension. It could be attributed to the reason that,
 424 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

the person who is diagnosed with the disease frequently Conflict of Interest: The authors declare no conflict
visit to hospitals and try to get the knowledge about the of interest.
preventive measures from doctors, nurses and family
and friends this might have been raised the knowledge Funding: This study was not supported by any
about the preventive measures of hypertension. funding agency; it was a self funded study

Conclusion References

Findings of the present study indicate that strong 1. Mohan, V., & Deepa, R. Risk factors for coronary
correlations between health beliefs and knowledge of artery disease in Indians. Journal of the Association
the hypertension. In the present study except perceived of Physicians India. 2004; 52:95-7
severity none of the health belief constructs correlated 2. World Health Organization. (2014). Global
with the risk behaviours this might be due to the Status Report on no communicable diseases.
reason that in the present study most of the participants Available at http: //apps.who.int/iris/bitstream/
62.67% were without formal schooling. Perhaps, the handle/ 10665/148114/9789241564854 eng.
poor health literacy might have been the reason for pdf?sequence=1
the people to have less knowledge about hypertension 3. World Health Organization. A global brief on
and its complications. Finally, health belief constructs Hypertension Silent killer, global public health
perceived susceptibility, severity, benefits, barriers, crisis. 2013; Avialble at: http://is world.com/
cues to action, self-efficacy have not been significantly downloads/pdf/global_brief_ hypertension.
associated with odds of hypertension this may be due to 4. Institute for health metrics and evaluation. India
the reason that constructs of health belief model alone is high blood pressure. 2014. Available from: http://
not sufficient to manage the hypertension. www.Healthmetricsandevaluation.org/search-gbd-
Limitation: data.
5. Gupta A., Brahmbhatt K., Sharma P. K., &
In the present study the values of perceived benefits Halappanavar, A. B.. Prevalence and correlates of
and knowledge preventive measures are closer to the hypertension in the rural community of Dakshina
association but significant association was not found this Kannada, Karnataka, India. International journal of
might be due to small sample size. While the present medical science and public health. 2016; 5:241-245
study utilized a random sampling methodology on rural
6. Gupta, R.. Rethinking diseases of affluence;
participants, its findings cannot be generalized outside
coronary heart disease in developing countries.
its rural sample. The study may also have been under
South Asian Journal of Preventive Cardiology.
powered with its sample size particularly when the
2006; 10(2):65–78. Retrieved from Gupta A.,
sub-categories of hypertensive and non-hypertensive
Brahmbhatt K., Sharma P K & Halappanavar A B.
participants were examined. The health belief subscale
Prevalence and correlates of hypertension in the
for susceptibility had a low alpha reliability though
rural community of Dakshina Kannada, Karnataka,
still was significantly related to the three knowledge
India; International journal of medical science and
subscales. Regardless this may have impacted its
public health. 5:241-245
performance in the logistic regression model examining
hypertension status. Overall these limitations to not over 7. Rosenstock, I.M., Historical origins of the health
shadow the conclusions that were drawn from the study belief model. Health Education and behaviour.
1974; 2(4), 328-335
Future direction 8. Rosenstock, I. M., Strecher V, & Becker J. Social
learning theory and the health belief model. Health
In the future study could be extended to the
Education Quarterly. 1988; 15(2):175-83.
different parts of India including urban areas with more
sample size. Future studies, should emphasize on other 9. Becker, M. (The health belief model and personal
behaviour models with emphasis on socio-demographic health behavior. Heal education monographs. 1974;
characteristics, literacy, psychosocial factors, personal 2(4), 324–353
factors, and cultural beliefs. 10. Newell, M., Modeste, N., Marshak, H. H., &
Amp Wilson C. Health beliefs and the prevention
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 425

of hypertension in a black population living in 21. Rashrash, M. E., Maneno, M. K., Wutoh, A. K.,
London. Ethnicity & and disease. 2009; 19(1), 35- Ettienne, E. B., & Daftary, M. N., An evaluation of
41 hepatitis C knowledge and correlations with health
11. Pierce, G. L., Beske, S. D., Lawson, B. R., Southall, belief model constructs among African American
K. L., Benay, F. J., & Donato A. J., et al. (2008) “baby boomers” Journal of Infection and Public
Weight loss alone improves conduit and resistance Health. 2016; 9(4):436-42.
artery endothelial function in young andolder 22. Midi & Tasi. The Relationship Between
overweight/obese adults. Hypertension. 2008; Osteoporosis Knowledge, Beliefs and Dietary
52(1):72-9. Calcium Intake Among South Asian Women in
12. Xin, X., He, J., Frontini, M. G., Ogden, L. G., Auckland: A Thesis Presented in Partial Fulfilment
Motsamai, O. I., & Whelton P. K.,. Effects of alcohol of the Requirements for the Degree of Master of
reduction on blood pressure: a meta-analysis of Science in Human Nutrition at Massey University,
randomized controlled trials. Hypertension. 2001 Auckland, New Zealand, Massey University,
38(5):1112-7. Albany; 2008;. p163
13. Whelton, S. P., Chin, A., Xin, X., & He, J.,. The 23. Elsabagh, H. M., Aldeib, A. F., Atlam, S. A., &
effect of aerobic exercise on blood pressure: a met Saied, S. M. Osteoporosis knowledge and health
analysis of randomised, controlled trials. Annals of beliefs among employees of Tanta University.
internal medicine: 2002: 136;493–503 American Journal of Research Communication:
2015; 3(12), 62-77.
14. Gammage, K., & Klentrou, P., “Predicting
osteoporosis prevention behaviors: health beliefs 24. Azam Larki, Rahim Tahmasebi, & Mahnoush
and knowledge,” American Journal of Health Reisi.. Factors Predicting Self-Care Behaviors
Behavior: 2011; 35; (3), 371–382 among Low Health Literacy Hypertensive
Patients Based on Health Belief Model in Bushehr
15. Ediriweera de Silva et al.. A descriptive study
District, South of Iran. International Journal of
of knowledge, beliefs and practices regarding
Hypertension. 2018; Article ID 9752736, https://
osteoporosis among female medical school entrants
doi.org/10.1155/2018/9752736
in Sri Lanka. Asia Pacific Family Medicine. 2014.
13:1. 25. Kamran, A., Sadeghieh Ahari, S., Biria, M.,
Malepou,r A., Heydari, H. Determinants of
16. Abood, D.A., Black, D.R., & Feral, D. Nutrition
Patient’s Adherence to Hypertension Medications:
education worksite intervention for university staff
Application of Health Belief Model Among Rural
application of the health belief model. Nutrition
Patient. Annals of Medical and Health Science
Education Behavior: 2003; 35 (5), 260-7
Research: 2014; (6):922-7
17. Institute for Human Development. Baseline survey
26. Dehghani-Tafti, A., Mahmoodabad, S. S. M.,
of minority concentration districts of India Gulbarga.
Morowatisharifabad, M. A., Ardakani, M. A.,
2008. Available at h t t p : / / 1 4 . 1 3 9 . 6 0 . 1 5 3 /
Rezaeipandari, H., & Lotfi ,M. H.. Determinants
bitstream/123456789/3890/1/A%2
of Self-Care in Diabetic Patients Based on Health
18. Robinson, T.. Hypertension beliefs and behaviors Belief Model. Global Journal of Health Science;
of African Americans in selected Cleveland public 2015; 7(5):p33
housing. (Doctoral dissertation). 2012. Kent State
27. Williams, N. J., Whittle, J. G., Gatrell, A. C.,
University
The relationship between socio- demographic
19. Karmacharya, B. M., Epidemiology of characteristics and dental health knowledge and
Cardiovascular Diseases Risk Factors and attitudes of parents with young children. British
Hypertension in a Community-Based Suburban Dental Journal: 2002; 193; 651-6
Population in Nepal (Doctoral dissertation). 2015.
28. Arndt, V., Stürmer, T., Stegmaier, C., Ziegler, H.,
University of Washington
Dhom, G., & Brenner, H., (Socio- demographic
20. WHO STEPS Surveillance Manual. The WHO factors, health behavior and late-stage diagnosis
STEP wise Approach to Chronic Disease Risk of breast cancer in Germany: A population-based
Factor Surveillance. Geneva, Switzerland: 2005; study. Journal of Clinical Epidemiology: 2001; 54;
World Health Organization. 719-727.
 426 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Clinico-Mycological Profile of Dermatophytosis in a Tertiary

Care Hospital in North India

Sachin Sharma1, MeghaMaheshwari2, ShobhaBroor3, Paramjit Singh4,

RameshwariThakur5, Anita Chakravarti6
1PhD Scholar, Department of Microbiology, SGT deemed to be university, Gurugarm, 2*Professor and Head, Dr
Baba Saheb Ambedkar Medical College & Hospital Rohini, Delhi, 3Emeritus Prof, Department of Microbiology,
SGT deemed to be university, Gurugram, 4Professor and Head, 5Ex Professor, Department of Microbiology, MMC,
Muzaffarnagar, 6Professor and Head, Department of Microbiology, SGT deemed to be university, Gurugram

Abstract
Introduction: - Dermatophytosiscomprise approximately 15- 75% of all the mycological infections. It is
common in tropical and subtropical countries including India where high temperature and humidity play an
important role in the pathogenesis. Dermatophytes are closely related keratinolytic fungi with the ability to
degrade keratin and invade the skin, hair and nails causing dermatophytosis.

Objective: - To find out the distribution of various dermatophytefungi responsible for the different clinical
types of dermatophyte infections.

Methods: - KOH mount were prepared from the skin scrapings, nail clippings, and hair bits to look for
fungal elements. The specimens were also inoculated on Mycosal media and Sabourauds dextrose agar with
chloramphenicol. The dermatophytes were identified on the basis of colony characteristics, lactophenol
cotton blue mount, nutritional requirement, temperature tolerance, urease production, and in vitro hair
perforation test.

Result: - A total of 245 patients were included in the study. Tinea corporis was most common clinical
type with 102(41.6%) cases followed by T. facei[15 (6.1%)]. T. corporis +T. cruris [88(35.9%)] was most
common mixed clinical type. Out of 245 patients, fungal hyphae were seen in 162(66.1%) samples and the
rest 83(33.9%) were negative by KOH mount. In the 162 KOH positive samples, 151(91.5%) samples were
culture positive and 11(13.7%) were culture negative. In 83(58.9%) KOH negative samples, 14(8.5%) were
culture positive and rest 69(86.3%) were culture negative. A total of 165 samples were culture positive, of
which T. mentagraphyteswas isolated in 153(92.7%) followed by T. rubrum in 5(3.03%), T. violaceum in
3(1.8%), T.tonsurans in 2(1.2%) and M.canis in 2(1.2%) samples.

Keyworgds:- Dermatophytosis, Fungal Culture, Mycosal media, Taenia corporis, Trichophyton, Microsporum

Introduction involving the arms, trunk and legs, tineacapitis

involving the scalp, and tineapedis involving the foot,
Dermatophytosis is the term given to infections
etc. Dermatophytes are distributed into three closely
caused by dermatophytes; also called tinea according to
related genera: Epidermophyton, Trichophyton and
the site of infection as for example tineacorporis
Microsporum. These fungi can be classified on the basis
of their normal habitat: geophilic dermatophytes are
Corresponding author: naturally present in the soil, zoophilic in animals, and
Dr Megha Maheshwari, anthropophilic in humans.1
Professor and Head, Dr Baba SahebAmbedkarMedical
Zoophilic andanthropophilic dermatophytes
College & Hospital Rohini,Delhi.
evolved from a geophilic origin, with the anthropophilic
Email id: [email protected]
dermatophytes being the most highly specialized
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 427

groups. They seldom infect other animals and they are treatment were excluded from the study. Wet mount
additionally limited to some body parts. Anthropophilic of different samples e.g., skin scrapings, hair and nail
fungi are responsible for most superficial fungal clipping were prepared using 10-20% KOH. This
infections. Transmission can happen by direct preparation was examined under the microscope to look
contact or from introduction to desquamated cells. for the presence of dermatophytic fungi which appear as
Direct inoculation through breaks in the skin happens thin branching fungal hyphae. The presence of fungal
moreregularly in persons with depressed cell-mediated hyphae in clinical material was not enough to identify
immunity. Once organism enter the skin, they germinate the organisms with certainty. Samples were culturedon
and invade the superficial skin layers.2 Sabouraud’s dextrose agar with chloramphenicol and
Mycosel agar. Plates were incubated at 250C for up to
This infection is typicallynot life threatening, 4 weeks. The characteristic features of the colony that
happens even in immunocompetent hosts, and in several were considered were rate of growth, texture, topography
cases is long lasting, recurrent and troublesome to and color of the colony, and the production of pigment
cure. Superficial mycoses are among the most frequent on the reverse of the colony. Microscopic morphology
types of human infections, being estimated to effect was examined by lacto phenol cotton blue mount of
over 20-25% of the world’s population, and their the colonies and Slide culture. Further identification of
incidence is constantly increasing.3,4The distribution of dermatophytes included:
dermatophyteinfectionsand their causative agents varies
with geographical region and is influenced by a wide • nutritional requirement (such as vitamin and
range of factors likeclimatic factors, lifestyle, migration amino acid utilization) on Bactotrichophyton agar
of population, cultural practices,socioeconomic
conditions, incidence of strange comorbidities and drug • temperature tolerance
therapy.4, 5This study was therefore undertaken to find • urease production
out the distribution of causative dermatophyte species
from clinically suspected cases of dermatophytosis. • In vitro hair perforation test.

Material and Method Result: - A total of 245 samples were taken, of which
189 (77.1%) were from male patients and 56(22.9%)
This Study was conducted in the Department Of were from female patients. The commonest age group
Microbiology, SGT University, Gurgaon, Haryana was 16-30 (59.2%) followed by 31-45 (19.6%), 46-60
and Muzaffarnagar Medical College and Hospital, (8.6%), <15(7.8%) and 61-75 (4.9%) years. (Table 1)
Muzaffarnagar. The study was done from January 2017
to December 2018 over a time of a year.All consecutive Table 1: Distribution of study population
cases of dermatophytosis were included in the study. according to age and gender

Specimen Collection Variables Number Percentage

The patients who presented to the dermatology Age (years)

outpatient department with lesions on skin/ hair/ nails < 15 19 7.8
(vesicles, scaleson skin and nails and breakdown of
hairs) suggestive of dermatophytosis were refered to 16-30 145 59.2
the mycology laboratory where samples were collected 31-45 48 19.6
from the patients.A total of 245 samples were collected,
46-60 21 8.6
depending upon the site of infection, samples were:
61-75 12 4.9
• Skin scrapings
Sex
• Nail scrapings and clipping Male 189 77.1
• Hair plucking and scales scrapings Female 56 22.9

Cases of dermatophytosis with secondary bacterial Total 245 100

infections and patients already on antifungal drug
 428 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Out of 245 cases, T. corporis was commonest T.corporis+ T.facei was found in 5(2.04%) patients;
clinical type and was seen in 102(41.6%) patients. T.corporis+T.cruris+T.mannum were found in
Maximum number of cases of T.corporis were seen in 2(0.81%) patients. Rest of mixed clinical types, T.facei
the age group of 16-30 years[61(59.8%)].T.corporis + +T.mannum, T.corporis +T.pedis and T.facei+T.cruris
T.cruris were the commonest mixed clinical type with was seen in 1(0.4%) patient each. Most of these infections
88(35.9%) cases; out of which 51(57.9%) caseswere were more common in 16-30 years age group except for
in the age group 16-30 years. Second most common T. pedis and T. capitis which were more common in <15
single clinical type seen was T. facei with 15 (6.1%) years age group.
cases; followed by T.mannumin 7(2.9%) cases,T.cruris
and T.ungiumin 5(2.04%) cases each, T. pedis and T. In general Males were 3 times more commonly
capitisin 3(1.2%) cases each. effected than females by almost all the Tinea infections
except for T. ungium which was more common in
Second commonest mixed clinical type seen females. Variance of clinical condition with sex was not
was T.corporis+T.cruris+T.facei in 7(2.8%) patients; found statistically significance. (Table 2)

Table 2: Association of clinical condition with gender

Sex n (%)
Clinical condition Total (%) p-value
Male Female

T.corporis 77 (75.5) 25(24.5) 102(41.6)

T.facei 9(60) 6(40) 15(6.1)

T.mannum 6(85.7) 1(14.2) 7(2.9)

T.cruris 5(100) 0 5(2.04)

T.ungium 2(40) 3(60) 5(2.04)

T.pedis 2(66.7) 1(33.3) 3(1.2)

T.capitis 3(100) 0 3(1.2)

0.593
T.corporis+T.cruris 71(80.7) 17(19.3) 88(35.9)

T.corporis+T.cruris+T.facei 6(85.7) 1(14.3) 7(2.9)

T.corporis+T.facei 3(60) 2(40) 5(2.04)

T.corporis+T.cruris+T.mannum 2(100) 0 2(.81%)

T.facei+T.mannum 1(100) 0 1(0.40)

T.corporis+Tpedis 1(100) 0 1(0.40)

T.facei+T.cruris 1(100) 0 1(0.40)

Total 189(75.9) 56(22.8) 245

Out of 245 samples, 162 were KOH positive samples, out of which 151 (91.5%) were culture positive and 11
(13.8%) samples were culture negative. In 83 (33.9%) KOH negative samples, 14 (8.5%) were culture positive and
rest 69 (86.2%) were negative by culture. (Table 3)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 429

Table 3: Comparison of KOH mount and culture in identification of fungus

Culture negative Culture positive Total

N (%) N (%) N (%)

KOH negative 69 (86.2) 14 (8.5) 83 (33.9)

KOH positive 11 (13.8) 151 (92.6) 162 (66.1)

Total 80 (37.7) 165 (67.3) 245 (100)

From the 165 culture positive samples; T of T.facei was 10 cases (5%) effecting 4 male and 6
mentagraphytes was the most commonly isolated female.This could be because of sharing of common
dermatophyte with 153 (%) isolates, followed by T. or contaminated face products, rough scrubbing and
rubrum from 5(3.03%), T. violaceum from 3(1.81%), contaminated objects such as Towel and by increased
T. tonsurans and Microsporum canis from 2(1.21%) exposure to harsh detergents while doing household
samples each. work.T. ungium was also more commonly seen in
females.9contrary to our study, Karmakar et al showed a
Majority (68/153) of cases of T mentagrophytes preponderance of cases in 0-11 years age group11.
were isolated from cases of T corporis, whereas 3/5 cases
of T. rubrum were isolated from mixed infection of T. In the present study out of 245 patients, T.corporis
corporis +T. cruris. All T. violaceum were isolated from was commonest clinical type and was seen in 102
cases of T. capitis, all (2/2) isolates of T. tonsurans were (41.6%) patients followed by T.corporis+T.cruriswith
from cases of T. corporis+ T. cruris, and both isolates of 88(35.9%) cases. In studies by Singh et al, Noronha et
M. canis were from mixed infections with T. corporis. al and Bindu et al, also T. corporis was the main clinical
presentation observed6,10,12,.
Discussion
Only 3(1.2%) cases in our study had T. capitis.
Dermatophytes fungi are the etiologic agents of T.capitis has been reported to be rare entity from some
skin infection commonly referred to as ringworm. These other studies also in northern India13, 14, 15.Whereas in
infections are not dangerous but as chronic cutaneous studies by Siddappa et al, Janardhan et al and Karmakar
infections they may be difficult to treat and can also et al,and the prevalence of T. capitis was reported to be
cause physical discomfort for patients. 18%, 9% and 6.93% respectively which was higher than
our study8,9,11.Similar to our study,in studies by Sidappa
In the present study, out of the 245 cases, 189 (77%)
et al, Janardhan et al T capitis was more commonly seen
were male and 56 (22.9%) were female. The commonest
in males8, 9. Higher incidencein males may be due to
age group was 16-30 years (59.2%) followed by 31-45
visit to saloons where they use contaminated razors and
years (19.6%). Other studies done by Singh et al, Kaur
combs.
et al, Siddappa et al andJanardhan et al have similar
findings6,7,8,9.They also saw a male preponderance and In the present study, most of clinical presentations
the age group most commonly affected was 16-30 years were seen in the age group of 16-30 years followed by
in these studies as well.The reason for this could be due to 31-45 years while T.capitis was found most common in
increased outdoor physical work and increased chances the age group <15 years.
for contact infection than female. Noronha et al reported
T.corporis was more common clinical presentation with The incidence of T.mannumin our study was 2.8%
37 cases (24.7%) which was affecting more common in which is in concordance with studies of Vena et al
female with 20 cases (54%) compared with male with (1.7%)and Janardhan et al (3%).3,9 Occupational trauma
17 cases (45.9%) 10.Higher incidence may be due to may act as a precipitating factor.
common practice of sharing cloths, bathing towel and
In the present study the prevalence of T.pedis
overcrowding. Janardan et al showed the incidence
was1.2% which is very less as compared to studies
 430 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

by Janardhan et al, Bindu et al and Huda et al who In the present study T.violaceum was isolated from
reported incidence of T.pedis as4%, 7% and 3.3% 3 cases, all the cases being T.capitis. Similarly Madhavi
respectively9,12,16. et al showed 2(6.9%) isolates of T.violacium, all cases
being T.capitis. Noronha et al showed T.violaceum
The most common mixed clinical infection seen in 3(5%) were isolated from mixed clinical types with
the study was T.corporis+T.crurisin35.9% patientswhich 2(6.9%) and T.capitis with 1(20%) 10.
was similar to a study by Noranha et al (35.3% prevalence
of T corporis + T. cruris)10. However, Janardhan et al In the present study, only 2(1.2%) isolates of
showed the incidence of mixed types of infection to T.tonsurans were found and both were isolated from
be only 2% which is far less than these studies9. The mixed clinical infection ofT.corporis+T.cruris.Similarly
higherprevalence of multiple site involvement showed in a study by Pulariet al 2 (1.2%) isolates of T.tonsurans
in our study may be due poor hygiene and delay in 2(1.2%) were cultured; 1 each from T.corporis+T.cruris
seeking treatment.The role of fomitesin the spread of and T.capitis18.
dermatophytosiscannot be undermined in dermatophytic
infection because sharing of beds, linen, and clothing is In our study 2(1.2%) isolates of M. canis were seen;
all too common in family. 1 each from T.corporis+T.cruris and T.corporis+T.
cruris+T.facei.In a study by Sundaram etal only one
In the present study out of 245 samples, 162 were isolate ofM.canis 1(0.5%) was isolated from a case
KOH positive samples, out of which 151 (91.5%) of T.corporis19. Generally dermatophytes exhibits a
sample culture positive and 11(13.8%) samples were cosmopolitan profile, that is they found in different
culture negative. The positivity of KOH in different region of the world with variations in the frequency of
studies ranges from 53% to as high as 90%. (Table 6).In particular species as geoclimatic and social conditions
83(33.9%) KOH negative samples, 14 (8.5%) were interfere with the distribution of dermatophytes species.
culture positive and rest of 69 (85.2%) were negative
by culture.The handiness involved in these techniques Conclusion
of sampling and in examining the KOH mount might be T corporis was the most common clinical presentation
different at different places, which might account for the and T.mentagraphytes was the most common species
difference in microscopic and culture finding makingit isolated from the samples. The infections were more
essential that all the KOH negative samples should be common in 16-30 years age group and in males. There
cultured. are variations in the distribution of the clinical infection
In the present study, among the total of 165 and the isolates in different studies.
isolates; majority were [153(92.7%)]T.metagraphytes, Ethical Clearance: - Ethical clearance taken from
68(66.7%) of which were isolated from T.corporis. Ethical Committee of SGT University and Muzaffarnagar
There was no T. mentagraphyte isolate from cases of Medical College.
T.capitis. Noronha et al showed that among 29(48.3%)
isolates ofT.mentagraphytes, majority [9(45%)] were Source of Funding:- Self
isolated fromT.corporis.In a study by Madhavi S
et al majority of [5(55.5%)] T.mentagraphyteswere Conflict of Interest:- Nil
isolated from T.corporis, however,T.rubrum was the
predominant isolate in their study comprising 51.7%of
References
the total isolates17. 1. Hayette MP,Sacheli R. Dermatophytosis, Trends
in Epidemiology andDiagnostic Approach.Curr
Among the 5(3.1%)isolates of T.rubrum, majority Fungal Infect Rep. 2015;9:164–79.
[3(60%)] were isolated from mixed clinical types
2. Barry LH.Dermatophyte Infections.Am Fam Phys.
T.corporis+T.cruris. Among the 15(51.7%) T.rubrum
2003;67:101-8.
isolates, majority [5(33.3%)] wereisolated from
T.corporis followed by T.cruris.Similar to our study 3. Vena GA, Chieco P, Posa F, Garofalo A, Bosco A,
Noronha et al showed T.rubrum was second most Cassano N. Epidemiology Of Dermatophytoses:
common isolate in the study comprising 23(38.3%) of Retrospective Analysis From 2005 To 2010 And
the total isolates10. Comparison With Previous Data From 1975.
NewMicrobio. 2012;35:207-13,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 431

4. Havlickova B, Czaika VA,Friedrich M. 12. Bindu V. ClinicomycologicalStudyof

Epidemiological Trends in Skin Mycoses Dermatophytosis in Calicut. Ind J DermVenLep,
Worldwide. Mycoses. 2008;51:2-15. 2002;68:259-61.
5. Ameen M. Epidemiology of Superficial 13. Kandhari KC, Sethi KK. Dermatopriytosis in Delhi
Fungalinfections. Clin. Dermatol. 2010;28:197- area. J Ind Med Assoc. 1964; 42:324-6.
201. 14. Hajini GH, Kandhari KC, Mohapatra L N,
6. SinghS, BeenaPM.Profile of Dermatophyte Bhutani L K. Tineacapitis in North India.
Infections inBaroda. Indian J Derma VenLep. Sabouraudia.1970;8:170-3.
2003;69:281-283. 15. Desai SC, Bhatt MLA. Dermatomycosis in Bombay,
7. Kaur R, Panda PS, Sardana K, Khan S. Mycological A study on the incidence clinical dermetophytes and
Pattern of Dermatomycoses in ATertiary Care their epidemicity. .Ind J Med Res.1961; 49:662-71.
Hospital. J of Trop Med. 2015;1-5. 16. Huda MM, Chakraborty N, Sharma BJN.A
8. Siddappa K, Mahipal OA. Dermatophytes Clinicomycological Study of Superficial Mycoses
inDavangere.Ind J DermVenLepa. 1982;48:254- in Upper Assam. Ind J DermVenLel. 1995; 61:329-
259. 30.
9. Janardhan B, Vani V.ClinicoMycological Study 17. Madhavi S, Rama Rao MV, Jyothsna K.
ofDermatophytosis.Int J Res Med Sci. 2017; 5:31- Mycological Study of Dermatophytosis in Rural
3. Population. Ann Biol Res.2011;2:88‑93.
10. Noronha TM, Tophakhane RS, Nadiger 18. Poluri LV, Indugula JP, Kondapaneni SL.
S.Clinico‑Microbiological Study of Clinicomycological study of Dermatophytosis in
Dermatophytosisina Tertiary‑Care Hospital in South India. J Lab Phy.2015;7:84-9.
North Karnataka. IndDerm Online J. 2016;7:264- 19. Sundaram BM, BadrinathS. SubramanianS.
271. Clinico-Mycological study ofDermatomycoses
11. Karmakar S, Kalla G, Joshi KR, Karmakar S. inMadras (India). Mykosen 1986;29:230-4.
Dermatophytoses in a desert district ofWestern
Rajasthan. Ind J DermVenLep. 1995; 61:280-283.
 432 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Early Childhood Caries and Its Prevalence among the

Preschool Children’s Attending the Anganwadi’s at Ukkali
Vijayapura District, Karnataka India

Shardha Bai Rathod1, Padmashree S2, Sanjeev Khanagoudra3, Ishwar B Bagoji4, G A Hadimani4
1
Lecturer, Department of Dentistry, BLDE University’s Shri BM Patil Medical College, & Research Centre,
Vijayapura, Karnataka, India, 2Professor, Department of Oral Medicine and Radiology Vydehi Dental College
Bangalore, Karnataka, India, 3Medico Social Worker BLDE University’s Ukkali hospital branch Shri BM Patil
Medical College, & Research Centre, Vijayapura, Karnataka, India, 4Asst Professor, Department of Anatomy,
BLDE University’s Shri BM Patil Medical College, & Research Centre, Vijayapura, Karnataka, India

Abstract
Introduction: Early Childhood Caries (ECC) is a preventable chronic disease which is mainly affecting
infants and children worldwide. The early identification and detection of ECC can reduce pain, life
threatening conditions and helps in the growth and the overall development of the child.

Aim: To find out the prevalence of Early childhood caries (ECC) among the children attending the
Anganwadi’s of Ukkali Vijayapur district, and its relationship with parent’s education, occupation, socio
economic status of the family with feeding habits and early oral hygiene mentions.

Materials and Method: Community based cross sectional study among the selected Anganwadi’s children
of 1-5 years of age at Ukkali district Vijayapura.

Result: A total 142 subjects, 34 children were found to be having ECC, 57(40.1%) males and 85 (59.9%)
females. A significant association was found in these study with the age of the children, breast feeding
duration and the oral hygiene proposes, out of 142 cases 34 cases were having ECC therefore the prevalence
of ECC was 23.9%.

Conclusion: Future health promotion and education programs in Anganwadi’s should include oral health
issues and the risk factors for ECC, and its consequences should be addressed.

Key word: Children, Early childhood caries, Prevalence, Primary teeth

Introduction socioeconomic families. 1. Early childhood caries (ECC)

is a chronic, disease with its complex and multifactorial
Dental caries is one of the most common chronic etiology 2. ECC is commonly seen in any tooth surface
diseases of early childhood Dental caries in primary of primary teeth between the age group of children 1 to
dentition is often neglected since they exfoliate, and its 5years 3. Dental problems in early childhood age have
treatment is considered as economic burden among lower shown to be predictive of future dental problems, with
the growth and development of child also interfering
with nutrition, concentration, and school participation4.
Corresponding Author:
Dr. Ishwar B Bagoji, India, Is a developing country and the incidence
Asst Professor, Department of Anatomy, BLDE of dental caries is increasing due to the changing
University’s Shri BM Patil Medical College & lifestyle and dietary patterns.5 The Government of India
Research Centre Bijapur, Karnataka, India. initiated a National Scheme known as the Integrated
Phone: 9964669355, E-mail: [email protected] Child Development Services (ICDS) which aims at the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 433

delivery of a package of basic health services through cards were issued for the treatment and instructions are
various functionaries. Anganwadi worker (AWW) is given to the children to accompany with their parent for
the most periphery functionary of the ICDS scheme. the dental treatment.
She delivers services to mainly children below the
age of 6 years, including mainly nonformal, preschool Total children in eleven anganwadi centre of rural
education, health, and nutrition maintenance. Most of health Ukkali were about 1264. Male 668 and female
the preschool children belonging to low socioeconomic were 596. All the children of preschool who were
status attend Anganwadi schools 6. The prevalence of accompanied with their parents and present on the
ECC in the developing countries is reported to be as high day of examination are included in the study. Children
as 70%7. Some of the published studies showed an ECC suffering from systemic disease and absent on the day of
prevalence of 19-54% in the Indian population8. An early examination were excluded from the study.
identification of dental caries provides an opportunity
to identify the children who are at a greater risk for the
Results
disease so that appropriate preventive interventions can Out of the 142 subjects examined, 40.1% (57) were
be initiated to protect the unaffected teeth and protect males and 59.9% (85) were females. On the whole 23.9%
the permanent dentition10. To the best of our knowledge, (34) had ECC while 76.1% (108) children had no caries.
no other studies have been conducted to assess the
prevalence of dental caries among Anganwadi children Birth orders of total 142 children were distributed
in Ukkali village of Bijapur district. The present study is in five groups. The total 36 children in 1st order having
an effort to determine the prevalence rate and evaluate its ECC were, 10 (27.8%), 53 children in the 2nd order
associated risk factors of ECC among the Anganwadi’s having ECC were, 13(24.55%), 37 children in the 3rd
children within 5 years of rural health centre Ukkali. order having ECC were 5(13.5%), 13 children in the
4th order having ECC were 6(46.2%) and children with
Method 5th order were total are 3 none of them were effected
with ECC. No difference was found between the
The study group consisted of 142 preschool children birth order of the child and ECC. Mothers of total 97
of 1 to 5 years of age group from various Anganwadi children were illiterate, children effected with ECC were
centers, rural health Ukkali. Institutional Ethical 25(25.8%), mother with primary education total are 31,
Committee Clearance (IEC) was obtained, and the children effected with ECC were 6(19.4%), mother with
consent for examining the children was procured to the secondary education total are 11, 2(18.2%) were effected
Anganwadi’s worker and the parents of the children. with ECC, and 3 of them are higher education with
Clinical examination was done using a sterile mouth ECC are 1(33.3%). No difference was found between
mirror, and probe. The decayed teeth were recorded and mother’s educations. No difference was found between
patients who required treatment for the decayed tooth the social class of the family and ECC.

Table1: Association of ECC and Demographic variables of the Subjects

Variables ECC Absent ECC Present

p value
N Percent N Percent
1-2 45 100.0 0 0.0
Age (yrs) 3-4 52 65.0 28 35.0 0.000*
>4 11 64.7 6 35.3
Male 42 73.7 15 26.3
Gender 0.588
Female 66 77.6 19 22.4
1 26 72.2 10 27.8
2 40 75.5 13 24.5
Birth Order 3 32 86.5 5 13.5 0.137
4 7 53.8 6 46.2
5 3 100.0 0 0.0
 434 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Cont... Table1: Association of ECC and Demographic variables of the Subjects

Illiterate 72 74.2 25 25.8

Mothers Primary 25 80.6 6 19.4
0.830
Education Secondary 9 81.8 2 18.2
Higher 2 66.7 1 33.3
I 2 66.7 1 33.3
Social II 55 72.4 21 27.6
0.495
Class III 47 79.7 12 20.3
IV 4 100.0 0 0.0
*significant with p<0.05

Table 2 shows that all study subjects were having Bottle Feeding: Total 18 children gives a history of
the history of breast feeding. Around 9 children were bottle feeding with 6(33.3%) shows ECC present. No
breastfed for less than 6 months. No children were significant difference with history of bottle feeding and
having ECC. Out of 105 children were breastfed for one frequency of bottle feeding with ECC. No significant
year, 31(29.5%) showed ECC present. 28 children are difference seen with the content of bottle feeding, bottle
breastfed more than a one year around 3(10.7%), were feeding at night and frequency of meals per day with
having ECC positive. A significant association was ECC.
found between the history of breast feeding and ECC.
P- 0.026.
Table2: Association of ECC and Breast feeding variables of the Subjects

Variables ECC Absent ECC Present

p value
N Percent N Percent
<6 9 100.0 0 0.0
Breast feeding(months) 6-12 74 70.5 31 29.5 0.026*
>12 25 89.3 3 10.7
No 96 77.4 28 22.6
Bottle feeding 0.318
Yes 12 66.7 6 33.3
6-12 4 57.1 3 42.9
Duration of Bottle feeding (months) 12-18 5 62.5 3 37.5 0.397
>24 3 100.0 0 0.0
Twice 5 71.4 2 28.6
Frequency /day of Bottle feeding 0.732
Thrice 7 63.6 4 36.4
Yes 3 100.0 0 0.0
Sugar in Bottle feeding 0.18
No 9 60.0 6 40.0
No 7 70.0 3 30.0
Bottle feeding at night 0.737
Yes 5 62.5 3 37.5
No Meals 10 100.0 0 0.0
Once 8 66.7 4 33.3
Frequency of Meals/day 0.278
Twice 56 75.7 18 24.3
Thrice 34 73.9 12 26.1
*significant with p<0.05
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 435

Table 3 showed that 42 children not started cleaning having ECC. 31 children used to clean their teeth with
only 4 of these children showed ECC present. About 35 finger and paste, out of these 9(29.0%) were having
children started cleaning from 4 months and 8 of these ECC. 15 children used to clean their teeth with finger
children showed ECC positive. Around 44 children and powder (Lal Manjan, salt with coal powder) out of
started cleaning these 5(33.3%) were having ECC. 42 children not is to
clean their teeth , around 4(9.5%) of these showed ECC
Method of Cleaning: 54 children used to clean their present. No significant p value seen between method of
teeth with brush and paste, out of these 16 (29%) were cleaning and ECC.

Table3: Association of ECC and Teeth cleaning variables of the Subjects

ECC Absent ECC Present

Variables
p value
N Percent N Percent

Not Started 38 90.5 4 9.5

1-4 months 27 77.1 8 22.9

Cleaning Started Months/years 5-6 months 28 63.6 16 36.4 0.005*

9 -10 months 15 78.9 4 21.1

1-2 yrs 0 0.0 2 100.0

Brush/paste 38 70.9 16 29.1
Finger/paste 22 71.0 9 29.0
Method of Cleaning 0.074
Finger/powder 10 66.7 5 33.3
Do not Clean 38 90.5 4 9.5
*significant with p<0.05

Discussion urban Bangalore within Karnataka state was 27.5%10. In

the present study ECC prevalence is low compared to all
The present study was undertaken to assess the
above studies.
existing knowledge of early childhood oral health related
factors among eleven Anganwadi centre of rural health In this present study no significant association was
Ukkali, so that effective pediatric oral health measures found between the age of the children and ECC, this
can be provided, there by safe guarding the growth and finding does not coincide with finding of Wendt L K in
development of young children. Sweden showed that the prevalence increases with high
age group13.
A total of 142 children of less than 5 years of age
groups are selected and screened to determine the The present study the prevalence of ECC was
prevalence of ECC from the 11 Anganwadi’s at Ukkali. found to be more among girls (22.4%) compared to
The prevalence of ECC in the present study was, out boys (26.3%). ECC among male and female shows
of 142 cases 34 cases were having ECC therefore the no significant association. The present study doesn’t
prevalence of ECC is 23.9%. coincide with study done Olmez S14.

The mean dmft found in Karnataka (Bangalore), Children with birth order 1 and 2 showed higher
Andhra Pradesh and Kerala were 0.6, 1.63, and prevalence of ECC than children with subsequent birth
2.1 respectively 11. Another study was conducted orders. However no significant association was found in
to compare the prevalence and pattern of caries in the birth order and ECC.
4-5½-year-old children of urban Bangalore and non-
urban Chickaballapur within Karnataka state, India. The No significant association was found between the
results showed caries prevalence of 66.3% with a mean social class and mother’s education with ECC. Some
deft of 2.9 in Bangalore city whereas in Chickaballapur, study showed that higher ECC prevalence found with
the prevalence was 58.4%12. The prevalence of ECC in the lower family income15.
 436 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Significant prevalence of ECC with breast feeding children in Kosovo. European Journal of Dentistry
is seen in the present study. Correlates with study done Vol. 5, pp. 32-39
Roberts GJ16, showed that prolonged and excessive 4. Vargas CM, Ronzio CR. Disparities in early
breast feeding also has been suspected as a causative childhood caries. BMC Oral Health 2006; 6:S3.
factor in ECC.
5. Prakasha Shrutha S, Vinit GB, Giri KY, Alam S.
In present study bottle feeding duration, frequency, Feeding practices and early childhood caries: A
with or without sugar and frequency of meals shows no crosssectional study of preschool children in Kanpur
significant correlation with ECC. Some study showed district, India. ISRN Dent 2013;2013:275193.
that increased frequency of bottle feeding increases the 6. Park K. Textbook of Preventive and Social
prevalence of ECC17, 18. Medicine. 23rd ed. Jabalpur: M/s Banarsidas
Bhanot; 2015. p. 5902.
Maximum of children in the present study started
7. Desilva-Sanigorski AM, Calache H, Gussy M,
cleaning their teeth after the age group of 3 years.
Dashper S, Gibson J, Waters E. The VicGeneration
The children in the age group of 3, 4, 5 years showed
study-a birth cohort to examine the environmental,
a significant prevalence of ECC with cleaning of the
behavioural and biological predictors of early
teeth. As in accordance with other studies, caries
childhood caries: background, aims and methods.
prevalence was seen to increase significantly with age.
BMC Public Health 2010; 10:97.
As children grow older, change in their dietary habits
and oral hygiene practices pose a greater cariogenic 8. Saravanan S, Madivanan I, Subashini B, Felix JW.
challenge19, 20. The method of cleaning teeth did not Prevalence pattern of dental caries in the primary
show any significant relation with ECC. Tooth brushing, dentition among school children. Indian J Dent Res
early onset of tooth brushing, parental supervision of 2005; 16:140-6.
tooth brushing and daily use of fluoride dentifrices were 9. Tyagi R. The prevalence of nursing caries in
shown to significantly reduce prevalence of ECC 21, 22. Davangere preschool children and its relationship
with feeding practices and socioeconomic status
tDental health services should be made available in of the family. J Indian Soc Pedod Prev Dent 2008;
the peripheral areas to meet the needs of young children. 26:153-7.
Future health promotion and education programs in
10. Johnson NW. Dental Caries: Markers of high
Anganwadi’s should include oral health issues and
and low risk groups and individuals. Cambridge
the risk factors for ECC, and its consequences should
University Press; Cambridge: 1991.
be addressed. Public funded oral health program
should be started and targeted at children from lower 11. Virjee K, Aradhya SMR. Caries pattern in urban
socioeconomic status and non-urban children 4- 5½ year old. J Indian
Dent Assoc. 1987; 59:113–116.
Ethical Clearance Oral consent from parents and 12. Singhal DK, Acharya S, Thakur AS. Dental
children has been taken caries experience among preschool children of
Source of Funding- Self     Udupitaluk. J Oral Health Community Dent 2015;
9:59.
Conflict of Interest - Nil 13. Prashant Prakash, Priya Subramaniam, B.H.
Durgesh, and Sapna Konde. Prevalence of early
References childhood caries and associated risk factors in
1. Douglass JM, Douglass AB, Silk HJ. A practical preschool children of urban Bangalore, India: A
guide to infant oral health. Am Fam Physician. cross-sectional study. Eur J Dent. 2012 Apr; 6(2):
2004; 70:2113–20. 141–152.
2. Davies GN. Early childhood caries--a synopsis. 14. Wendt LK, Hallonsten AL, Koch G. Dental caries
Community Dent Oral Epidemiol. 1998; 26:106– in one and two year old children living in Sweden.
16. Swed Dent J 1991: 15: 1-6.
3. Begzati, A., Meqa, K., Siegenthaler, D., Berisha, M. 15. Olmez S, Uzemis M, Erden G. Association between
& Mautsch, W. (2011). Dental health evaluation of early childhood caries and clinical microbiological,
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 437

oral hygiene and dietary variables in rural Tarkish 20. Tewari S, Tewari S. Caries experience in 3-7 years
children. Turk J Pediatr 2003; 45; 231-6. old children in Haryana (India). J Indian Soc Pedod
16. Peressini S, Leake JL, Mayhall JT, Trudeau R. Prev Dent 2001; 19:52-6.
Prevalence of early childhood caries among first 21. Mahejabeen R, Sudha P, Kulkarni SS, Anegundi R.
nations children, District of Manitoulin, Ontario. Dental caries prevalence among preschool children
Int J Paediatr Dent 2004; 14; 101-10. of Hubli: Dharwad city. J Indian Soc Pedod Prev
17. Roberts GJ: Is breast feeding a possible cause of Dent 2006;24:1922.
Dental caries? J Dent 10; 346- 52, 1982. 22. Narang R, Saha S, Jagannath GV, Kumari M, Mohd
18. Hallett KB, O’Rourke PK. Social and behavioural S, Saha S. The maternal socioeconomic status and
determinants of early childhood caries. Aust Dent J the caries experience among 26 years old preschool
2003;48:2733. children of Lucknow city, India. J Clin Diagn Res
2013;7:15113.
19. Ghanim NA, Adenubi JO, Wyne AA, Khan NB.
Caries prediction model in preschool children in
Riyadh, Saudi Arabia. Int J Pediatr Dent 1998;
8:11522.
 438 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Professional and Psychological Help Seeking Behavior among

College Students

Shreevidya P
Ph. D Scholar, School of Social Work, Roshni Nilaya, Affiliated to Mangaluru University

Abstract
Mental and behavioral problems are the leading causes of health problems in young people both in high and
low resource countries, accounting for one third of all years lost productivity due to this disability. It implies
that, healthy students can productively contribute to the development of a country.19 As India is the world’s
most youthful nation college students seeking professional and psychological help for their mental health
issues and becoming mentally healthy is essential for their successful college life. This study is conducted
to understand the Professional Psychological Help Seeking Behavior of college students for their Mental
health issues and to know the gender differences. Convenient sampling was used with 60 respondents from
a reputed college of Mangaluru, Karnataka. Attitude towards professional psychological help seeking scale
(Fischer, 1995) and Socio demographic profile were used for data collection. The study revealed poor
attitude among college students for professional help seeking for mental health and recommends for an
increased education and awareness to reduce the perceived stigma for help seeking. More defined policies
and programmes have the potential to improve students’ access to a full range of mental health services
which in turn contribute to overall development.

Keywords; Professional Help-seeking, Mental Health, College Students

Introduction India is the world’s most youthful nation, with two-

thirds of population under the age of thirty-five. It is the
Students in India
strength and skills of these youngsters that will usher
According to World Health Organization (WHO), in New India. 20 Therefore, college students seeking
Mental and behavioral problems are the leading causes professional and psychological help for their mental
of health problems in young people in both high and health issues and becoming mentally healthy is essential
low resource countries, accounting for one third of all for their overall development which in turn contributes
years lost productivity due to this disability. It implies for healthy nation.
that, healthy students can productively contribute to
Mental Health Issues among College students
the development of a country. As stated by Division
for Social Policy and Development Disability of WHO defines Mental Health as “a state of well-
United Nations, Mental health issues are among the being in which the individual realizes his or her own
ten leading causes of disability in both developed and abilities, can cope with the normal stresses of life, can
developing countries. Poor mental health is both a work productively and fruitfully, and is able to make a
cause and a consequence of poverty, compromised contribution to his or her community”. It also emphases
education, gender inequality, ill-health, violence and that “mental health is not just the absence of mental
other global challenges. It impedes the individual’s disorder”.
capacity to work productively, realize their potential
and make a contribution to their community. There is Mental health issues are a set of clinically
growing recognition within the international community recognizable symptoms present in an individual for a
that invisible disabilities, such as mental health is one period of time and the individual experiences distress
of the most neglected yet essential development issues due to these symptoms as they interfere with his or her
in achieving internationally agreed development goals. personal functioning like academic work, relationships
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 439

and social interactions. Mental health professionals the United Nations General Assembly recognized
associated with college mental health services also opine the need to target mental health in development,
that late adolescent and college going persons are highly reinforcing previous international commitments toward
vulnerable to the limitations in personal growth, imposed mainstreaming disability issues in development. The
by emotional disturbances of varying severity. 21 WHO has developed the Mental Health Gap Action
Programme, along with technical tools to support non-
Transition from college students to adulthood, specialist mental-health service capacity in low- and
especially among college students can be an extremely middle-income countries. This international momentum
stressful period owing to many challenges those can to acknowledge and address the global burden of mental-
ultimately affect their mental health. Stress can be health problems is critical to dealing with this issue at a
negative or positive to an individual, depending on the global level.
factors such as strength and persistence of the stress,
social support. 22 Review of Literature
The Mental-health symptoms during the transition Kumar Rajesh, Prinja Shankar and Lakshmi
period have a significant impact on the development P.V.M.24 conducted a study to assess the perceived health
of students and their social and economic integration, problems and help seeking behavior and utilization
including employability. Mental-health issues have a pattern of adolescent health clinics. A pre-tested, semi-
significant impact across a wide range of developmental structured questionnaire was administered to 360 school
outcomes, limiting opportunities for social integration. going college students who were selected by stratified
One area that can be impacted by mental-health random sampling from two sectors of Chandigarh where
conditions during adolescence and young adulthood is services were being provided by a school-based and
the development of safe and healthy relationships with dispensary-based adolescent health clinic. The study
peers, parents, teachers and romantic partners. In fact, revealed that majority (81%) of the college students
adolescence is the developmental period that is critical having some health problem during last three months
for identity formation and taking on roles, especially prior to the survey; predominant (60%) problems were
with peers. 23 psychological and behavioral in nature. To resolve these
problems boys consulted mainly friends/peers (48%)
According to the Report on Mental Health and while girls consulted their mothers (63%). Compared to
Development 2008 Mental and behavioural issues are the dispensary-based adolescent health clinic, utilisation
the leading causes of health problems in young people was significantly higher in a school- based clinic where
in both high- and low-resource countries accounting proportion of psychological or behavioral problems
for one third of all years lost productivity due to this reported was also significantly higher.
disability.
Daniel Eisenberg 25 conducted a study using random
Attention to global mental health moves beyond sample of 5,555 college students from a diverse set of 13
treatment-oriented programmes in health-care settings universities, with an objective to see the association of
to include broader approaches inspired by public-health help-seeking behavior with both perceived public stigma
and social-inclusion considerations. Recently, mental- and people’s own stigmatizing attitudes or personal
health issues have attracted global attention. The 2007 stigma. There were three main findings: (a) Perceived
Lancet Series on Global Mental Health led to the launch public stigma was considerably higher than personal
of a coordinated Movement for Global Mental Health, stigma; (b) personal stigma was higher among college
comprising over 95 institutions and 1,800 individuals students with any of the following characteristics: male,
worldwide. younger, Asian, international, more religious, or from a
In 2010, the World Health Organization (WHO) poor family; and (c) personal stigma was significantly
produced a Report on Mental Health and Development and negatively associated with measures of help
(2010a), highlighting people with mental illnesses as a seeking whereas perceived stigma was not significantly
vulnerable group subject to stigma and social isolation, associated with help seeking.
human-rights violations and exclusion from policies Eisenberg, Golberstein and Gollust 26 conducted a
and decision-making that affected them. Later that year, study with the objective of quantify mental health service
in its resolution on global health and foreign policy,
 440 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

use and estimate how various factors are associated can ultimately affect their mental health.4 Hence,
with help-seeking and access in a university student seeking professional and psychological help for mental
population. A Web-based survey was administered to health is essential for the college students. This study
a random sample of 2785 college students attending a is conducted in Mangalore, Karnataka which is known
large, public university with a demo- graphic profile for its educational excellence and attracts student from
similar to the national student population. The study across the nation.
revealed that, 30% of respondents perceived a need for
professional help for their mental or emotional health Research Design: Cross-sectional Research design
in the previous year. As expected, college students with was applied.
current mental health issues, as indicated by positive Population: The target population was first-year
screens in the PHQ (Patient Health Questionnaire) degree college students of two reputed colleges in
depression or anxiety instruments, were significantly Mangaluru, Karnataka, India.
more likely to perceive a need for services and to receive
services. Sample Size and Technique: The sample size was
60, Convenient Sampling method was applied for the
Reviewed studies show that the help-seeking study.
behaviour of students has focused mainly on the friends,
parents or try to cope alone, and subsequently turn to Sources of data: The study used Primary data and
adult. Stigma is a considerable barrier to mental health reviewed secondary literature.
service delivery among students. In addition to that,
embarrassment and the lack of basic knowledge about Description of the Tools
mental health impact on the Help seeking behaviour of 1. Socio Demographic Sheet developed by the
students. The issue of stigma is further challenged by the researcher includes age, gender, religion, hobbies, type
lack of quality mental-health services. of college, mode of stay, financial background, parents’
occupation and qualification of parents, and such other
Methodology information that taps their college life.
Title: Help-seeking Behavior of College students
2. Attitude towards Seeking Professional
for Mental Health Issues
Psychological Help Scale (Fischer et.al., 1995): The
Aim of the Study: To assess the Help-seeking scale contains 10 items, reverse score items 2,4,8,9 and
Behavior of College students for Mental Health Issues. 10, and then add up the ratings to get a sum. Higher
scores indicate more positive attitudes towards seeking
Objectives: 1. To understand the Professional professional help. Calculate a mean for males, for
Psychological Help seeking behavior of college students females, and for each of the groups to examine group
for their Mental health issues differences. The scale is on public domain.
2. To know the gender differences in Professional Data Analysis: The data is analyzed through
Psychological Help Seeking Behavior among college descriptive statistics. Frequency, Mean and Standard
students. Deviation are used and SPSS 17.0 Version is applied.
Importance of the study: Mental health issues
Results and Discussion
among college students are detrimental to the
development of an individual and also to the country. Table 1- Demographic Variables
Mental and behavioral problems are the leading causes
of health problems in young people in both high and low Variables Frequency %
resource countries, accounting for one third of all years
lost productivity due to this disability i Thus, healthy Male 30 (50%)
students productively contribute to the development of a
Female 30 (50%)
country. Transition from college students to adulthood,
especially among college students can be an extremely Total 60 (100%)
stressful period owing to the many challenges those
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 441

Cont ... Table 1- Demographic Variables (±5.17) with mean percentage 49.53% which also shows
low level of help seeking attitude among female college
18 Years 39 (65%) students. Thus the study shows poor level of help seeking
behaviour among both male and female college students.
19 Years 21 (35%)
This will hamper the overall development of the student
Total 60 (100%) population by affecting their mental health and lead to
mental health issues.
High Income 8 (13.3%)
The study shows that the Professional and
Middle Income 48 (80%) Psychological Help Seeking Behaviour among both the
male and female college students are in low level. The
Low Income 4 (6.7%) mean score of ATPPHS among male college students
is much lower than the mean score of female college
Total 60 (100%)
students who in turn also seek poor level of help for their
mental health issues. This will lead to unprofessional
Table No.1 shows that there were equal number of
help seeking resulting in intensifying mental health
male (50%) and female (50%) college students. There
issues among college students which is highlighted in
were 65% college students in the age of 18 years, 35%
study by Chandrashekar iii that 15 to 20% of the college
were of 19 years age group. Regarding the financial
students having recognizable mental disorders. Only a
background of the participants, 8% of college students
few colleges provide counseling services through trained
were from high income background, 48% were middle
manpower in our state. College students with mental
income background and 4% were from low income
morbidity do not seek Psychiatric treatment because
background.
psychiatric services are not available in an affordable
Table 2- Help Seeking behaviour among College and approachable manner, stigma attached to mental
students disorders and lack of awareness. Thus majority of the
college students, who need help, remain unattended and
ATPPHS (Attitude towards Mean Score uncared. Similarly, NAMI conducted a national survey
Standard
professional psychological Mean of college students to learn about their mental health in
Deviation
help seeking) Percentage colleges in U.S.A. and highlighted that, stigma remains
the number one barrier to college students seeking help
Help Seeking Behaviour among 14.06 and survey respondents shared valuable ways in which
±6.20
college students (46.86%)
schools can work more effectively to combat stigma.
11.46 Thus, there is a need to create awareness on mental
Male ±5.38
(38.2%) health among college students. The professional help
seeking also need to be encouraged through the active
14.86
Female ±5.17 involvement of teachers and college management who
(49.53%)
can help the college students for professional intervention
by introducing Campus Mental Health Services which
Table No. 2 shows the mean score of Attitude will help to combat stigma and promote mental health
towards professional psychological help seeking among college students. The same has been highlighted
behaviour among college students. The maximum by Eisenberg, Hunt and Speer 10 who emphasized
score of the scale was 30 whereas the overall mean about help-seeking behavior for mental health issues in
score obtained in this study is 14.06 (±6.20) with college population and offers a perspective on next steps
mean percentage 46.86%. It shows a low level of help for improving knowledge and practice in this area. He
seeking behaviour among college students. With regard also stressed that, traditional barriers such as stigma can
to gender, the mean score of male college students was only partially explain the high prevalence of untreated
11.46(±5.38) with mean percentage 38.2%. This shows disorders and suggested for campus-based intervention
low level of help seeking attitude among male college strategies such as anti-stigma campaigns, screening
students. Whereas, the mean score of help seeking programs and gatekeeper trainings. Such programs
(ATPPHS) among female college students was 14.86 will create awareness among students; helps to adopt
 442 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

healthy coping styles and also to seek professional and 4. Herbert S H: Resilience based Intervention
psychological help for their mental health issues. for College students. PhD Thesis. NIMHANS
Bangalore, Department of Clinical Psychology;
Conclusion 2013.
In total, healthy students can productively contribute 5. Bradshaw C. Mental health matters social inclusion
to the development of a country. Mental health is not of students with mental health conditions.(Serial
popular area in India where the concept of campus on the internet) 2014(cited 2018 Jan 22); Available
mental health and policies to promote mental health from: www.un.org/esa/socdev/documents/
in schools and colleges is minimal. The help seeking students/students-mental-health.pdf
behaviour of college students for their mental health 6. Kumar R, Prinja S, Lakshmi P: Health Care Seeking
issues need to be encouraged by the government and Behavior of College students: Comparative Study
policy makers in such a way that promotes their mental of Two Service Delivery Models. ((Serial on the
health and intergenerational equity which will contribute internet) 2008 (cited 2016 Jan 10); Available from:
to their overall development. http://medind.nic.in/icb/t08/i9/icbt08i9p895.pdf

Ethical Clearance: This study is a part of my Ph.D 7. Eisenberg D. Stigma and Help Seeking for Mental
Study and Ethical Clearance is taken from Institutional Health Among College students. (Serial on the
Ethics Committee, School of Social Work, Roshni internet) 2009 (cited 2016 Jan 10); Available
Nilaya, Affiliated to Mangaluru University, Mangaluru. from: URL: https://journals.sagepub.com/doi/
abs/10.1177/1077558709335173
Source of Funding: Self 8. Eisenberg D et. al. Help-Seeking and Access
to Mental Health Care in a University Student
Conflict of Interest: Nil
Population. (Serial on the internet) 2007 (cited
References 2016 Jan 10); Available from: URL: https://
pdfs.semanticscholar.org/ 515b/5cc53ff418e22
1. Barker G. College students, social support 6ccb64ad8 d8238508bb5075.pdf
and help-seeking behaviour, An international
9. Gruttadaro Darcy, Crudo Dana: College students
literature review and programme consultation with
Speak: A Survey Report on Mental Health
recommendations for action. (Serial on the internet)
Conducted by NAMI (National Alliance Mental
2007(cited 2018 Feb1); Available from: https://
Illness). (Serial on the internet) 2012(cited 2016
apps.who.int/iris/ bitstream/ handle/10665/43778/
Mar 29); Available from: https://www.nami.
9789241595711_eng.pdf;jsessionid=385BC16D2
org/ getattachment/About-NAMI/Publications-
E489B894678933 D2217D2EF? sequence=1
Reports/Survey-Reports/College- Collegestudents-
2. Modi N: Exam Warriors. Penguin Random House Speak_A-Survey- Report-on-Mental-Health-
India Pvt. Ltd. ISBN; 9780143441502. India; 2018 NAMI-2012.pdf
3. Chandrashekar C R: Manual for College Teachers 10. Eisenberg, Hunt & Speer: Help seeking for
on College students Counseling. Department of mental health on college campuses. (Serial on
Collegiate Education: Government of Karnataka. the internet) 2012 (cited 2016 Mar 29); Available
Bangalore 29; 2008. from: http://www-personal.umich.edu/~ daneis/
symposium/2012/readings/ Eisenberg2012.pdf
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 443

Evaluation of Prehypertension among School going

Adolescents in Chennai

Srihari R1, Dilara K2, Latha R3, Manikandan S4

1Demonstrator, 2Professor,Department of Physiology, 3Professor, Department of Paediatrics, Sri Ramachandra
Medical College & RI, Chennai, 4Associate Professor, Department of Physiology, Tagore Medical College &
Hospital, Chennai

Abstract
Aim:- Adolescence is an important phase of life and increased stress has made them prone for early
development of Metabolic disorders. Worldwide prevalence of Prehypertension is increasing and early
identification of which will help to manage the development of early hypertension and its associated
complications. Hence, current study aims to evaluate the prevalence of prehypertension among school going
adolescents in Chennai.

Methods:- The study was conducted among school going adolescents (n-264) in Chennai between the age
group 15-19yrs. Anthropometric measurements were taken and stress and sleep hygiene were assessed using
validated questionnaires. Blood pressure was recorded using Hawkley random zero sphygmomanometer.

Results:- The overall prevalence of Prehypertension was found to be 22.3%. Prehypertension was found to
be more in females (23.1%) than males (21.6%).

Conclusion:- There is an increased prevalence of prehypertension among school going adolescents in

Chennai. Adolescents should be taught about the importance and benefits of healthy lifestyle for a healthy
future.

Keywords:- Adolescents, Prehypertension, Sleep, Stress, Cardiac issues

Introduction more prone for psycho-somatic disorders 1.

Adolescence is a critical and crucial phase of Prehypertension is a recently coined term and
human life and plays an important role in determining in 2003, the Seventh Report of the Joint National
an individual’s future. As per WHO, Adolescence is the Committee on prevention, detection, evaluation and
‘period between 10-19years of life’1. Adolescence is treatment of high blood pressure (JNC7) has defined
recognized as both enjoyable and stressful period, and prehypertension as ‘the Systolic blood pressure (SBP)
the stress phase of adolescence is reported as the most between 120-139mmHg or the diastolic blood pressure
stressful period in the entire lifespan of an individual. (DBP) between 80-89mmHg’2. Prolonged persistence
In current era, along with the pre-existing psycho- of Prehypertension makes an individual more prone
physiological stress, academics, family and peer pressure for early development of sustained hypertension3,4.
has increased the stress level and have made adolescents Hypertension is a global health issue and has been
identified as major risk for most of the cardiovascular
diseases. In 2010, Hypertension has been reported as
Corresponding Author:-
major cause for morbidity and mortality worldwide 5.
Dilara Kamaldeen
Professor of Physiology, Sri Ramachandra Medical In recent years, prevalence of prehypertension
College & RI, Chennai, Tamilnadu, India is increasing among adolescents and remains
E-Mail: [email protected] undiagnosed6,7. Prehypertension being a risk factor for
Mob.: 9840067879 hypertension if left undiagnosed makes adolescents to
 444 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

develop early hypertension thus making them prone for the participants and were assisted to complete them.
early cardiovascular diseases and premature death 8,9. Anthropometric measurements like Height, weight,
Hence, early identification of prehypertension among Neck circumference (NC), Waist-hip ratio (WHR) were
adolescents becomes need of the hour. taken and BMI was also calculated.

Material and Method Arterial Blood pressure was measured using a

Hawksley random zero sphygmomanometer with
Study participants:- appropriate size cuffs. The participants were asked to
A cross sectional study and was commenced after relax in supine lying for 10minutes and Blood Pressure
obtaining permission from the institutional ethics (BP) was recorded in sitting position. Three readings
committee. Study participants were recruited from a were taken with regular intervals and BP was noted5.
private school in Urban Chennai, and the school was BP of all the participants were recorded by trained
selected using computerized randomization software healthcare professionals
from the school list of urban corporation. Participants
Statistical analysis
were healthy school going adolescents and between the
age group (15-19yrs) (n-264). Students with pre-existing The Data were tabulated in MS Excel sheet and
primary and secondary hypertension were excluded and SPSS Version 21.0 was used to analyze the data.
participants those who got parent’s consent and also Descriptive statistics was calculated for background
gave assent were included in the study. variables. Association between categorical variables
was tested by chi-square test and p<0.0.5 was taken as
Study tools:- statistically significant.
General and demographic details about the
participants were collected using a questionnaire.
Findings
Anthropometric measurements like Height, weight, Total number of participants considered for the
Neck circumference (NC), Waist and Hip Ratio were study were 271 and those who willingly participated
measured. Blood pressure was assessed using Hawksley and completed the study were 264, consisting of
random zero sphygmomanometer. 134 males and 130 females (n-264). Mean age of the
study participants was 15.75+0.65. Among the total
Stress was assessed using Perceived Stress Scale participants 50.8% were males and 49.2% were females.
(PSS). PSS is a 10 item self reported questionnaire Majority of the study participants were from board exam
where the participants answer to ten different questions/ appearing class (39%).
situations. Based on a structured scoring pattern the
participants will be categorized in to mild, moderate 22.3% of the study participants were found to have
and severe stress10. Sleep hygiene was assessed using prehypertension out of which 35.5% of them belong to
Epworth Sleepiness Scale for Children and Adolescents the board appearing class. (Figure 1)
(ESS-CHAD). ESS-CHAD has eight different situations
for which the participants should answer his chances of Genderwise, 21.6% of males and 23.1% of the
dozing in a scale of 0-3. Total score < 10 signifies good females were found to have prehypertension though the
sleep hygiene and total score >10 signifies presence of p value was statistically insignificant.
Excessive Daytime Sleepiness, a sign of compromised Majority of the participants were found to be
Sleep hygiene11. moderately stressed. 19% of participants with mild
Study Procedure:- stress, 26.8% of participants with moderate stress and
17.2% of participants with severe stress were found
The school authorities were explained about the to have prehypertension and p value was found to be
purpose and benefits of the study and written permission statistically insignificant.
was obtained. Informed consent form was distributed
two days before the data collection day to get consent 32.2% of the participants with compromised sleep
from parents and assent was also obtained from the hygiene were found to have prehypertension and p value
participants. General questionnaire, Perceived Stress was found to be statistically significant showing that
Scale, Epworth Sleepiness Scale were explained to reduced sleep hygiene increases chances of developing
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 445

blood pressure. in East Nigeria showed prevalence of Prehypertension

among adolescents to be 17.3% with females having
more prevalence than males12. Another study conducted
in Houston showed that atleast 30% of adolescents had
one elevated BP during recording13. A study conducted
in Kerala reported prehypertension among adolescents
to be 24.5%14 and another study conducted in southern
part of Tamilnadu showed prevalence of prehypertension
among school going adolescents to be 14.1% 5. These
reports reveal the fact that prevalence of prehypertension
is more among adolescents which could be due to their
psycho-physiological, psycho-social factors and other
lifestyle modifications. Genderwise, prehypertension
was found to be more in females (21.6%) than males
(23.1%). Ingeneral females are more prone for stress
and related psychological issues due to hormonal
Fig 1. Prevalence of Prehypertension among adolescents and other psycho-social factors, which along with
Table 1. Genderwise prevalence of academic pressure would have made females to develop
Prehypertesnion among adolescents prehypertension than male adolescents 13.

Stress is common among school going adolescents

Gender Prehypertension p value
and has negative impact on health. Distress is a
phenomenon which triggers negative pathways in the
Males 29 (21.6%)
host and increases the level of stress hormones. Stress
0.780*
hormones such as cortisol, catecholamines increases heart
Females 30 (23.1%)
rate, damages blood vessels and causes prehypertension,
*p<o.o5 is statistically significant which if undiagnosed slowly progresses to chronic
Hypertension15. In our study we found that adolescents
Table 2. Stress and Prehypertension with stress develop prehypertension though the p value
was statistically insignificant
PSS Score Prehypertension p value
The results have shown that adolescents
Mild stress 15 (19%) with compromised sleep hygiene (ESS>10) have
prehypertension. Sleep is required for good physical
Moderate stress 34 (26.8%) 0.244* and mental health. In adolescents sleep becomes an
indispensable component required for learning, memory
Severe stress 10 (17.2%)
consolidation and healthy growth. Sleep deprivation
*p<o.o5 is statistically significant triggers stress hormones and sympathetic nervous
system. Frequent stimulation of sympathetic nervous
Table 3. Sleep and Prehypertension
system increases free radicals and damages blood
vessels predisposing to prehypertension and early
ESS Score Prehypertension p value
cardiac diseases 15,16,17,18,19.
ESS <10 40 (19.5%)
0.03* Persistent prevalence of prehypertension makes
ESS > 10 19 (32.2%)
adolescents more prone for development of early
*p<o.o5 is statistically significant hypertension. According to WHO, Hypertension
is major risk factor for increased mortality. Young
Discussion individuals with hypertension were more prone to
The current study shows the prevalence of develop hypertensive cardiovascular complications
Prehypertension among school going adolescents to than older individuals 20, which leads to decreased
be to be 22.3%. A study conducted among adolescents quality of life and premature death. Prehypertension
 446 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

among adolescents has been found to be associated with a semi-urban areas in Erode district, Tamilnadu. Int
cardiac, renal alterations and target organ damage 21,22. J Sci Study. 2017;4(12):155-159.
Adolescents with prehypertension were found to have 6. Muntner P, Henle J, Cutler JA, Wildman RP,
Left Ventricular Hypertrophy (LVH). Even adolescents Whelton PK. Trends in blood pressure among
with mild elevated blood pressure were found to children and adolescents. JAMA. 2004;291:2107-
have target organ damage and early occurrence of 13.
metabolic syndrome 23. Than normotensive adolescents
7. Falkner B. Children and adolescents with obesity
prehypertensive adolescents were reported to have
associated high blood pressure. J Am Soc
increased arterial stiffness and decreased diastolic
Hypertens. 2008;2:267-74.
function 24.
8. Webber LS, Cresanta JL, Voors AW, Berenson
Conclusion GS. Tracking of cardiovascular disease risk factor
variables in school age children. J Chronic Dis.
The current study shows that prevalence of 1983;36:647-60.
prehypertension is high among school going adolescents
9. Lauer RM, Clarke WR. Childhood risk factors for
in Chennai. Persistent prevalence of prehypertension
high adult blood pressure. The Muscatine study.
makes them more prone for development of early
Paed. 1989;84:633-41.
hypertension and cardiac diseases which inturn reduces
their quality of life. Hence, adolescents should be 10. Cohen S, Kamarck T, Mermelstein R. A global
taught about stress management, importance of physical measure of perceived stress. J Health Soc
exercises and healthy diet to lead a healthy life 16,17. Behav.1983; 24:386-96
11. Johns MW. A new method for measuring daytime
Conflict of Interest:- No conflict of interest sleepiness: the Epworth Sleepiness Scale. Sleep.
Source of Funding:- Self funding 1991;14:540-5.
12. Fortune AU, Anthony NI, Ada RC, Josephat
Ethical Clearance:- Institutional ethics committee MC. Hypertension and prehypertension among
(IEC) clearance obtained. adolescents in secondary schools in Enugu, South
East Nigeria. Ital J Paed. 2013;39(70):1-6.
References
13. Alisa AA, Joshua AS, Ronald JP, Karen MR.
1. World Health Organization. Adolescence: The Prevalence of persistent Prehypertension in
Critical Phase: The Challenges and the Potential. Adolescents. The J Paed. 2012;160(5):761.
New Delhi: Regional Office of the South East Asia, 14. Geethadevi MA, Bindhu V, Sobha A. Prevalence
1997: 1 and determinants of prehypertension and
2. Chobanian AV, Bakris GL, Black HR, Cushman hypertension among adolescents: a school based
WC, Green LA, Izzo JR. Seventh report of the in a rural area of kerala, India. Int J Res Med Sci.
joint national committee on prevention, detection, 2015;3(1):58-64.
evaluation and treatment of high blood pressure. 15. Srihari R, Dilara K, Latha R, Manikandan S. Effect
Hypertension. 2003;42:1206-52. of stress on sleep hygiene among school going
3. Lane DA, Gill P. Ethinicity and tracking adolescents in Chennai. J Fam Med Prim Care.
blood pressure in children. J Hum Hypertens. 2019;8:2917-20.
2004;18:223-8. 16. Srihari R, Dilara K, Latha R, Manikandan S.
4. Juhola J, Magnussen CG, Viikari JS, Kahonen M, Assessment of sleep hygiene among school going
Hutri-Kahonen N, Jula A. Tracking of serum lipid adolescents in Chennai. Ind J Pub Heal Res Dev.
levels, blood pressure and body mass index from 2019;10(8):301-05.
childhood to adulthood: The cardovascualr risk in 17. Srihari R, Mathangi DC, Sriteja Y, Remya K,
young finns study. J Paediatr. 2011;159:584-90. Mathangi and Shyamala R. Second digit and fourth
5. Anuradha G, Muraleetharan G, Abinaya R, digit ratio – an adjunct tool to predict obstructive
Tamilkodi M, Sachithanantham S. Prevalence sleep apnea. Indian J Physiol Pharmacol.
of Prehypertension and Hypertension and its 2014;58(3):292-295.
determinants among Adolescent school children of
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 447

18. Srihari R, Manikandan S, Semblingam P, young Israeli adults. Hypertension. 2006;48:254-

Vimalarani S. Prevalence of Excessive Daytime 259.
Sleepiness among medical students in Chennai. 22. Tsai P, Semma S. Prevalence and determinants
World J of Pharm Sciences. 2014;3(4):1819- of prehypertensive status in the Taiwei general
1826 population. J Hypertension. 2005;23:1355-60.
19. Srihari R, Mathangi DC, Shyamala R. 23. Choi KM, Cistulli S. Prevalence of prehypertension
OSA:An Awaking disorder!. IOSR J Pharmacy and hypertension in a Korean population:
2014;4(4):4-7. Korean National health and Nutrition survey. J
20. Lee MH, Kang DR, Kim HC, Ahn SV, Khaw Hypertension. 2006;24:1515-21.
KT, Suh I. A 24.year follow up study of blood 24. Lee JY, John E, Fan J. Comparison of risk factors
pressure tracking from childhood to adulthood between prehypertension and hypertension in
in korea: The Kangwha study. Yonsei Med J. Korean male industrial workers. J Pub Heal Nurs.
2014;55:360-6. 2006;23:314-23.
21. Grotto I. prevalence of prehypertension and
associated cardiovascular risk profiles among
 448 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Study of Death among Children Below Five Years of Age and

its Relation to Parentseducation and Place of Residence Using
Verbal Autopsy as a Tool in Deharadun

Sushil Dalal1, Kiran Pande2, Vishal Modgil3

1
Associate Professor dept of Community Medicine MMU Mullana Amballa, 2Assistant Professor Dept of OBG
MMU Mullana Ambala, 3Final Year PG Student

Abstract
Around the world more than 10 million children under the age of five die every year and the world poorest
countries continue to bear the burden of these deaths 1. Prevalence of under-five mortality vary from 4 to
more than 28 deaths per 1000 live births The study was conducted to find out relation in-between child
mortality of under-five years of age and parents education along with place of residence using verbal autopsy
in Dehradun.

Methodology:The survey was done on all the house of the deceased children residing in our field practice
areas by visiting their houses.

Results:Most of the parents were found illiterate among 83 deaths reported during study period.

Conclusion:Many of the under five children deaths can be prevented if parents are literate, which can help
in reducing mortality rate among under five children.

Keywords:poorest countries, parent’s education, deceased children.

Back ground   Material and MethodsThe study was undertaken

for one year in the field practice areas of department
Information on factors leading to death is extremely
of community medicine HIHT Dehradun after taking
important for policy-making, planning, monitoring and
approval of institutional ethical committee. The total
evaluation of health programs, as well as necessary
population registered under Rural Heath Training
for field research, comparisons, and awareness. This
Centre(Rajeev Nagar)& Urban Health Training Centre
is particularly more so important for childhood deaths,
was 12,588 and12,930 respectively out of which under
which is constituting a major portion of all deaths, and
five children were 1297 at RHTC and 1325 at UHTC.
of which many intervention programs are currently
attempting to reduce mortality among under five deaths1.. All deaths except still births registered with Rural
Education has been one of the key concepts used as a and Urban Health Training Centre were included in the
variable in explaining health. The influence of parental study. When a child died, the mother or the respondent
education on infant and child health and mortality has was questioned in detail about the parents education and
proved to be universally significant. In the literature on place of residence of children prior to death. A drafted
child health, parental education has received particular questionnaire (Englishversion) developed by WHO,
attention, as indeed have all other social, demographic was modified suitably, as well as certain variables
and health characteristics of the parents2. were added to itto find out any correlation in-between
under five children death and parents education along
Corresponding author: with place of residence 3. The information so collected,
Dr Sushildalal was first coded and then entered in the computer. The
Associate professor dept of community medicine MMU analysis was done by using SPSS software. Appropriate
mullanaAmballa, [email protected] statistical methods (proportion and chi – square test)
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 449

were applied as per requirement.

Result
Total number of deceased children in both the areas were 83, out of which 39(46.9 %) were in rural area and
44 (53.1 %) in urban area. Out of 39 deaths in rural area, 29 (74.4 %) died before the age of one year while 10 (25.6
%) died in age group of 365 days - < 5 year. Similarly in urban areas 44 deaths took place. Out of these 25 (56.8 %)
died below age of 1 year and 19 (43.2 %) died in age group of 365 days- < 5 year. Table 2 and table 3 shows that
proportionately more children’s had died of illiterate parents then of literate parents irrespective of urban and rural
areas.

Table 1 distribution of deceased children by age, sex and place of residence (n=83)

Total deaths
Rural (%) Urban (%) Chi squar value Degree of freedom P value
(%)

Age of deceased
children

0-28 days 17 (43.6) 15(34.1) 32(38.6)

29-<365 days 12(30.8) 10(22.7) 22(26.5)
365 days-< 5Yrs 10(25.6) 19(43.2) 29(34.9) 3.219 2 >0.05

Sex of deceased
children

Male 18(46.2) 26(59.1) 44(53.0)

1.389 1 >0.05
Female 21(53.8) 18(40.9) 39(47.0)

Table 2 : Distribution of deceased children by education of father and place of residence ; n = 83.

Place of Residence
Total
Rural Urban
Education of Father No. of deaths No. of deaths No. of deaths
(0–5 yrs) (0– 5yrs) (0–5 yrs)

Illiterate 21 (52.8 %) 22 (50.0 %) 43 (51.8 %)

Just illiterate 4 (10.3 %) 10 (22.7 %) 14 (18.9 %)

8 (8.5 %) 3 (6.8 %) 11 (13.3 %)

Primary

Junior high school 3 (7.7 %) 3 (6.8 %) 6 (7.2 %)

High school 3 (7.7 %) 6 (13.6 %) 9 (10.8 %)

0 (0.0 %) 0 (0.0 %) 0 (0.0 %)

Intermediate

Graduate & above 0 (0.0 %) 0 (0.0 %) 0 (0.0 %)

Total 39 (100.0%) 44 (100%) 83 (100.0%)

 450 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 3 : Distribution of deceased children by education of mother and place of residence ; n = 83.

Place of Residence
Total
Rural Urban
Education of Mother
No. of deaths No. of deaths No. of deaths
(0–5 yrs) (0– 5yrs) (0–5 yrs)

Illiterate 29 (74.4 %) 32 (72.7 %) 61 (73.5 %)

Just illiterate 0 (0.0 %) 3 (6.8 %) 3 (3.6 %)

Primary 5 (12.8 %) 1 (2.3 %) 6 (7.2 %)

Junior high school 2 (5.1 %) 4 (9.1 %) 6 (7.2 %)

High school 2 (5.1 %) 2 (4.5 %) 4 (4.8 %)

Intermediate 1 (2.6 %) 2 (4.5 %) 3 (3.6 %)

Graduate & above 0 (0.0 %) 0 (0.0 %) 0 (0.0 %)

Total 39 (100.0%) 44 (100%) 83 (100.0%)

Discussion post-natal period, with maternal education providing

more protection than paternal education. Maternal
In the present study higher percentage of mortality
and paternal education were independent predictors of
was observed amongst children, belonging to fathers
mortality beyond the neo natal periodwhich suggests the
who were illiterate (53.8 % - rural and 50.0 % - urban).
importance of educated men in this paternalistic society
Children belonging to illiterate mothers also showed
in addition to the role played by the mothers in protecting
higher percentage of mortality in both rural and urban
the infant from mortality risks. In another study done by
areas i.e. 74.4 % and 72.7 % respectively. It is generally
Syamala( 2004 )6observed that the association between
observed that the literacy status of mothers in urban and
mother’s education and survival rate of children during
rural areas has a greater impact on the health status of
infancy is strong and direct. This pattern of association
children particularly in relation to mortality, than that
is observed in each group of the mother.
of fathers.According to NFHS – 3 Uttarakhand 4 under
5 mortality was 97.2 % whose parents had no education, In another study done by Khalique et al ( 1993 )
while it was 54.1 % among those whose education 7
concluded in his study conducted in 9 villages of Rural
was less than 10 years and 28.1 % where parents had Health Training Centre, Jawan, Aligarh, India observed
education , of 10 years or more. Findings by other authors that higher percentage of mortality was presents amongst
also showed that mortality rates in illiterate parents were children belonging to fathers who were illiterate or just
higher as compared to the literates.The literacy rate in literate ( 59.38 % Rural and 56.25 % Urban ) . Children
the study area particularly in the urban slums is very low belonging to illiterate or just literate mothers also
which could be again due to migratory population from showed high percentage of mortality in both rural and
other states. If we compare the literacy level with that of urban areas i.e. 73.44 % and 62.50 % respectively. It
Uttarakhand NFHS – 3 (Uttarakhand)4 we find that 86 was observed that the literacy status of mothers in urban
% of males and 65 % females are literate in Uttarakhand and rural had a greater impact on the health status of
while reverse is the case of our study population. children particularly in relation to mortality, than that
of fathers in terms of percentage. It was also observed
In a study done by Katz et al ( 2003 )5 observed
that mortality was low in children whose fathers had
that maternal and paternal education was important as
intermediate or degree qualification (6.25 % rural and
predictors of mortality only for infant who died in the
12.50 %). Children of mothers with similar educational
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 451

qualification also showed low mortality (3.12 rural (usually incomplete primary schooling) than those
and 12.50 urban).It was also observed in NHFS-3 without schooling.(Orubuloye and Caldwell 1975)14
Uttarakhand (2006)4 that children, whose mothers have whereas Caldwell in 1980 reached to the conclusion that
no education are thrice as likely to die before their first the main proselytizer for modern science is the school,
birthday as children whose mothers have completed at even in its earliest grades when no science is taught
least 10 years of school. Our study also indicates more formally (Caldwell 1980) 15.
or less similar results in accordance of previous studies.
Education of mother that were significant in their
In a study done in Turkey byToros and Kuluamong magnitude and each likely to result in the greater
1982 birth cohorts found that father’s education to stand survival of the children of more educated mothers. The
out as one of the most important factors associated first of these is that educated mothers were more likely
with infant survival. They report that babies whose to take children to the health centre for both preventive
fathers do not have primary school education are and curative medicine. Their mothers-in-law allowed
1.6 times more likely to die within the first year of it and expected it, for most parents now try to arrange
life than babies whose fathers have at least finished their sons’ marriages to educated young women and
primary school. Babies whose mothers have no primary one of their strongest motives is that such women are
school education, however,are 1.15 times more likely more likely to ensure the survival of their grandchildren
to die in their first year8.Where as in a cross-national (Caldwell,1983b) 16. It was observed that
study by Mensch, Lentzner and Preston (1985), it was
shown that mother’s education was a more powerful Belief in the necessity of access to modern health
explanatory variable than father’s education in rural services intensifies with each year at school. It is this
areas9.In another study done by Hobcraft, McDonald import of both modern medicine and modern education
and Rutstein (1984) showed in their cross-national study with its commitment to modern medicine, and indeed all
that in Latin American countries, mother’s education modern science, which determines how thoroughly both
had more explanatory power, while in some Asian and curative and preventive services are used; it explains the
Islamic countries, father’s education and occupation large differentials in child survival by maternal duration
and mother’s work status emerged as rival predictor of education found in the contemporary Third World to
variables .10GŸrsoy-Tezcan also found in their study in a greater degree than has ever been the case in the West
1992 that the husbands’ formal education surpassed the (Caldwell1986).17
women’s formal education as well as all other criteria in
explaining child mortality11. Where as In 1989 Preston’s
Conclusion
Is literacy a missing link between female schooling and literacy of parents plays a crucial role in decreasing
reduced child mortality in developing countries? An under five mortality in one way or the other ways
affirmative answer might be based on Preston’s (1989) especially in poorer countries. Our emphasis must be
model of mortality reduction, which gives a central place on parent’s literacy rate while we make policiesand
to literacy in the spread of improved health knowledge programs for under five children.
to mothers of young children12.
Conflict of Interest – none
Another study done by Jain in 1985found the effect
of female education is complementary to that of health Source of Funding- self
services. In fact, under certain circumstances the effects
of the two factors may even be synergistic, because both Ethical Clearance – taken from ethical committee
facilitate changes in health seeking behaviour. These
References
points were illustrated in an earlier study by comparing
education-specific infant mortality rates among rural 1. Bang AT, Bang RA, Diagnosis of causes of
women of two states in India, Kerala and Uttar Pradesh childhood deaths in developing countries by verbal
(Jain 1985b)13. In an interesting study done by Caldwell autopsy: suggested criteria W.H.O. bulletin 1992;
in Nigeria 1975 found that maternal behaviour is 70(4): 499-507.
probably important, he observed an area in Nigeria far 2. Forum: Parental education and child mortality
from medical services much better survival rates were AkileGyrsoy Department of International
found among the children of mothers with schooling Relations, Marmara University, Istanbul, Turkey.
 452 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Health Transition Review 1994; 4 : 183 – 229. Studies 1984; 38(2): 193-223.
3. Development of verbal autopsy standards. 11. GŸrsoy-Tezcan A. Infant mortality: a Turkish
Available from URL:http://www.who.int/whosis/ puzzle? Health Transition Review 2, 1992; 2: 131-
mort/verbal autopsy standards 1.pdf. 149.
4. National family health survey (NFHS – 12. Preston S H,. Resources, knowledge and child
3),Uttarakhand. International Institute for mortality: a comparison of the US in the late
Population sciences Deonar, Mumbai – 400 088, nineteenth century and developing countries
2005 – 2006. today, in Selected Readings in the Cultural, Social
5. Katz J, West Jr. KP, Khatry SK. Risk factors for and Behavioural Determinants of Health, ed.
early infant mortality in Sarlahi district, Nepal. Bull J.C. Caldwell and G. Santow. Canberra: Health
World Health Organ 2003; 81(10): 717 – 25. Transition Centre, Australian National University
1989;66-78.
6. Syamala TS, Relationship between socio
demographic factors and child survival : Evidences 13. Jain, Anrudh K, Relative roles of female education
from Goa, India. J. Hum. Ecol 2004; 16(2): 141- and medical services for decreasing infantmortality
145. in rural India. in Good Health at Low Cost, ed. S.B.
Halstead, J.A. Walshand K. Warren. New York:
7. Khalique N, Sinha SN, Yunus M, Mallik A. Early
The Rockefeller Foundation 1985b; 187-189.
childhood mortality – A rural study. J Royal Soc
Prom Health 1993; 113: 247 – 249. 14. Orubuloye I.O. and John C. Caldwell. The impact
of public health services on mortality: a study of
8. Toros A, Kulu I, Selected factors affecting infant
mortality differentials in a rural area in Nigeria.
mortality. In Infant Mortality in Turkey: Basic
Population Studies 1975; 29(2): 259-272.
Factors, Ankara: Hacettepe Institute of Population
Studies 1988. 15. Caldwell, John C. Mass education as a determinant
of the timing of fertility decline. Populationand
9. Mensch B, Lentzner H and Preston S, Socio-
Development Review 1980; 6(2): 225-255.
Economic Differences in Child Mortality in
Developing Countries, New York: United Nations 16. Caldwell, John C, Reddy PH and Pat Caldwell.
1985. The causes of marriage change in South India.
Population Studies 1983b; 37(3): 343-361.
10. Hobcraft JN, McDonald JW and. Rutstein SO,.
Socio-economic factors in infant and child 17. Caldwell, John C. Routes to low mortality in poor
mortality: a cross-national comparison- Population countries. Population and Development Review
1986; 12(2): 171-220.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 453

Marriage Trajectories among Patient with Metal Health

Problem

Chittaranjan Subudhi1, Ramakrishna Biswal2, Padmanaban Srinivasan3

1AssistantProfessor, Department of Social Work, Central University of Tamil Nadu, India, 2Assistant Professor,
Department of Humanities and Social Sciences, National Institute of Technology Rourkela, India,
3Associate Professor, Department of Education, Central University of Tamil Nadu, India

Abstract
Objective: To explore effect of mental illness on marriage and marital life among the tribal Patient with
Mental Illness (PMI).

Method: To achieve the objective of the study, qualitative method with multiple case study has been adopted.

Population and Sampling Technique: Population is a tribal Person with Mental Illness (PMI) and Purposive
Sampling Technique is used.

Findings: The analysis has been categories into two broad areas, that is, effects of mental illness among
married patient and unmarried patient with mental illness. Results indicate that, there is an adverse effect of
mental illness on marriage and marital life among the patient with mental illness.

Conclusion: Marriage and mental health problems are closely related and multi-faced one. The evidence
shows that, there is an adverse effect of mental illness on marriage and marital life among the tribal patient
with mental illness.

Keywords: Marriage, Mental Illness, Marriage Trajectories, Marital Life, Tribal

Introduction in achieving the personality maturation through psycho-

social status.
Everybody will have aspirations in their life.
Marriage is one among them. In general, Marriage is a If any one of the spouse becomes mentally ill, there
union between a man and a woman for the rest of the life. comes the problem in the union. If the problem is more,
They are united not only physically, but psychologically, then the gap between them will be more. Sometimes it
and socially too. The united souls now form a family. may result in break of the union also. There is an adverse
Marriage is considered as a sacred religious obligation effect of mental illness on the marriage and marital life
between heterosexuals that admits individual into a among the patient with mental health problems3-5. Even
family life1. It gives more balanced to individual’s there is positive association between mental illness
lives through establishing an enduring and continuing and subsequent divorce also4. Different legislatures on
bond between husband and wife. It helps in solving and marriage also have certain constraints on the marriage
reducing emotional, psychological, economical and other of person having mental health problems. In Hindu
problems2. So marriage is not only gratifying the sexual Marriage and Special Marriage Acts, marriage became
needs of the individuals but also helps the individuals voidable in the presence of severe mental illness6.
Because the impact of illness will decrease the social
Corresponding Author: abilities from successful marital life. Marital discord is
Chittaranjan Subudhi, one of the consequences among people having chronic
Assistant Professor, Department of Social Work, mental health problems7. Behere, Rao and Verma (2011)
Central University of Tamil Nadu, India, have mentioned that, mental illness and problems in
Email: [email protected] marriage are closely associated. Even patient with
 454 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

mental illness is considered as a burden to the spouse8. sampling’ with inclusion and exclusion criteria.
Inclusion Criteria: Following are included: Gender
When compared to men, if the woman in a family is of the sample is both male and female; the age group
educated, then the family will blossom. The same is in is from 18 and above who is diagnosed with any form
the case of illness. When compared to men, if the women of mental disorder as per International Classification of
in a family fell in ill, then the family will be affected Disease (ICD) 10; Currently admission in the hospital
more. Among the spouses, if the women are affected, (In-door patients). Exclusion Criteria: Following are
then the trouble is more. The condition for married excluded: Outdoor patients (OPD); Refused to give the
women having mental illness is very worst as they are information; Mental retarded persons.
sent back to their natal homes, divorced, or in the form
of abandoned9-10. In Indian society, the expectation of a The key subject of the study is tribal person with
married woman is different from natal house to in-laws mental illness. Since the subject is affected with mental
house10. In Indian marriage system, the severity notion illness, their cognitive ability may be reduced and the
of suffering is more when women married a mentally ill information provided by the patient may be incomplete.
man than men married a mentally ill women10. Studies In order to get the in-depth information, it is required to
show that, constant neurotic behaviour of the patient collect the information from the family members or care
creates a marital tension to the spouse and increase the givers also.
alienation among them11-12.
Data Collection procedure: Data sources for the
Mental illness also reduces the probability of study include the interviews with the tribal patient with
getting married. Pre-existing mental illness reduce the mental illness. Data collection for this study consisted
chance of marriage along with in delaying the marriage of face to face structured interviews with fifty patients
process also4, 9. Low marital rates have been reported and their family members / care givers. The researcher
among the patient with mental health problems from conducted interviews between June 2015 and May 2016.
the several studies9. In case of schizophrenia, patients The mean duration of personal interview is 56.74 minutes
are more likely to be staying alone or unmarried7.This with range of 22 minutes to 150 minutes. A specially
piece of research tries and find how mental is related to designed interview schedule was used to collect the
prosperity of marriage and the married life. information. The interview process has conducted with
one case in several times as per the availability of the
Objective of the Study: The present research respondent, the family members / care givers, time and
explores the impact of mental illness on marriage and their mood.
marital life among the tribal patient with mental illness.
Ethical Consideration and confidentiality:
Materials and Method The proposed study has been approved by the Ethical
Study Design: The study is based on qualitative Committee Review Board (ECRB) of Ispat General
design with multiple case study method. Qualitative Hospital (IGH), Rourkela, India. All the information
methods are more suitable for understanding the including personal identifications shared by the
phenomenon of mental illness, as it focuses on the respondents have been kept confidential; only the average
experience of the subjects. information has been used for the research purpose.

Study Area: The purposed study has been carried Data Analysis and Interpretation
out in the institutional setup. The researcher has selected Socio-demographic details of the responded:
the Department of Psychiatry, Ispat General Hospital The representation of male and female proportion is 28
(IGH), Rourkela, Odisha. IGH is a multi-speciality (56%) and 22 (44%) respectively. The age of the patients
hospital located in the sector 19 of Rourkela city. The with mental illness ranged from 18-72 with the mean
hospital was setup and administered Rourkela steel age of the sampling 36.34. Majority of the sample (56%)
plant. belongs to the age group of 21-40. 64% respondents
Study Population and Sampling: The present with mental illness are married while 36% respondents
study has fifty cases of tribal people with mental illness. are unmarried. The unmarried age ranges from 18 to 40.
The sampling procedure had followed the ‘purposive
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 455

Impact of Illness on marriage and marital life of leaving alcohol and it has its subsequent negative effects
the patient with mental illness to the family and the children. In that case wife is staying
separately for the better future of the children with a
The impact of mental illness on marriage and peaceful and dignified life.
marital life among the patient with mental illness has
been categories into two broad areas i.e. effects of Impact of Illness on Marriage among Unmarried
mental illness after marriage and before marriage. As Patient: Data representing on impact of illness on
a result, the respondents are divided into two broad marriage among unmarried patient shows that, 8%
categories: married (64%) and unmarried (36%). The not attended marriage age, another 8% responded not
married category again divided into three types, namely: to marry, yet another 8% reported that they wait till
normal, disturbances, and divorce or separated. Likewise recovery of the illness, and worry about the marriage
unmarried category has divided into four types: not attend represents for 16% sampled population.
the marriage age, not to marry, wait till the recovery of
the illness, and worry about the marriage. Not to marry: Three important reasons found
by the researchers for ‘not to marry’. The family members
Impact of illness on Marital Life: Data representing of the PMI don’t want to spoil another (partner) life.
on impact of illness on marital life shows that, out of Sometimes, it is believed by the patient and the family
64% married PMI, 42% represents a normal marital members that, the patient may suffer after marriage, if
life without any marital discord, 12% respondents have the partner may not able to cope with the patient. In
family discord and rest 8 % are divorced or staying some cases, though family members are interested for
separate. marriage but the patient don’t want to go for marriage
because s/he doesn’t want loose the freedom of another
Normal: In most of the married patient those have human being.
reached their adult hood or/and late adult hood stage,
they don’t have marital discord. They are trying to cope Worry about the marriage: For most of the male
up with the situation and manage the illness along with cases where age is not reaching the marriage age or
their family members also. And in the rest of the case, nearly about to marriage age, the family members are
where the partner is cooperative they are also maintain ready to wait till recovery of the illness. But in the
the balanced marital life and try to control the illness. case of female attending the marriage age, it is creating
In case of married female, where the husband and other headache to the family members.
in-laws members are cooperative, in that case family
life going smooth and normal. Family support is the Discussion
main reason to maintain normal life for the patient with Evidence from the data shows, there is high impact
mental illness. of mental illness on marriage and marital life among the
Disturbances: The researchers found below PMI. This finding is supported by the findings of the
mentioned reasons for the marital discord among existing study13.The present research also shows that, in
PMI. In case where the partner is not supporting or adulthood and in late adult hood, the marital life is normal.
not understanding the situation about the patient, the Research conducted by Miller et al.14 shows that, mental
disturbances have started. The interference of the in- disorders are positively associated with the marital
laws members or not getting support from them is disputes but for later age populations it is negatively
also creating marital discord among the female patient associated. Another research which supports the same is
and husband. If the male person is consumes alcohol by Oltmanns and Balsis (2011) which states that Well-
during the medication is the main reason for the family being in long-term marriages seems to be influenced by
disturbances. The researchers also found some other factors that are somewhat different from those factors
reasons like lack of proper sexual relationship, dubious that have been identified in younger couples15. Mental
attitude towards the partner, create the disturbances. illness is a risk factor for both marriage and marital life.
These are the causes are the symptoms or side effects of Nambi (2005)9 has mentioned that, alcohol addict is one
the illness or psychiatric medicines. of the prominent cause of family disturbance among
the substance user’s patients. So, high rate of divorces
Divorce/separated: The main reason for the and family disturbances are virtually inevitable among
divorce or separated is, where the patient (male) is not families with alcohol addicts due to high incidence of
 456 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

domestic violence16. 2011; 124(6), 474-486.

5. Thara, R., & Srinivasan, T. N. Outcome of marriage
16% of the samples are worried about their change
in schizophrenia. Social psychiatry and psychiatric
of getting married. This report is supported by the two
epidemiology. 1997; 32(7), 416-420.
findings. a. Pre-existing mental illness having worsen
condition for marriage and reduce the chance of marriage 6. Sharma, I., Reddy, K. R., & Kamath, R. M.
(Behere et al., 2011; Nambi, 2005).b. Premarital mental Marriage, mental illness and law. Indian journal of
health problems are associated with lower likelihood of psychiatry. 2015; 57(Suppl 2), S339.
ever marrying (Breslau et al., 2011). 7. Rao, T. S. S., Nambi, S., & Chandrashekhar, H.
Marriage, mental health and Indian legislation.
Limitations: The study has focused only limited Indian journal of psychiatry. 2009 51, 113-128.
sample size due to time constraint.
8. Behere, P. B., Rao, S. T., & Verma, K. (2011).
Conclusion Effect of marriage on pre-existing psychoses.
Indian journal of psychiatry. 2011; 53(4), 287.
The authors conclude that, marriage and mental
9. Nambi, S. Marriage, mental health and the Indian
health problems are closely related and multi-faced one.
legislation. Indian journal of psychiatry. 2005;
The evidence shows that, there is an adverse effect of
47(1), 3.
mental illness on marriage and marital life among the
tribal patient with mental illness. Mental health problems 10. Srivastava, A. Marriage as a perceived panacea
are working as conflagration in marriage and marital life to mental illness in India: Reality check. Indian
in the Indian marriage system. So, further extensive and journal of psychiatry. 2013; 55(Suppl 2), S239.
large sample empirical studies are to be undertaken to 11. Ovenstone, I. M. The development of neurosis in
understand the severity of the problem. the wives of neurotic men: Part II: Marital role
functions and marital tension. The British journal
Conflict of Interest: No of psychiatry. 1973a; 122(571), 711-717.
Source of Funding: The first author is enrolled in 12. Ovenstone, I. M. The Development of Neurosis in
PhD programme at the National Institute of Technology the Wives of Neurotic Men Part I. Symptomatology
Rourkela, Odisha, India and Personality. The British journal of psychiatry.
1973b; 122(566), 35-45.
Ethical Clearance: Yes, Ethical Committee 13. Barrett, A. E. Marital trajectories and mental
Review Board (ECRB) of Ispat General Hospital (IGH), health. Journal of health and social behavior. 2000;
Rourkela, Odisha 451-464.

References 14. Miller, R. B., Nunes, N. A., Bean, R. A., Day, R.

D., Falceto, O. G., Hollist, C. S., & Fernandes, C.
1. Abraham, M. F. Contemporary Sociology: An L. Marital problems and marital satisfaction among
introduction to concepts and theories. Oxford Brazilian couples. The American Journal of Family
University Press; 2015 Therapy, 2014; 42(2), 153-166.
2. Dasgupta, S. and Saha, P. An introduction to 15. Oltmanns, T. F., & Balsis, S. Personality disorders
sociology. Pearson Publication; 2012 in later life: Questions about the measurement,
3. Agarwal, A. K. Pattern of marital disharmonies. course, and impact of disorders. Annual review of
Indian journal of psychiatry. 1971; 13:185-193. clinical psychology. 2011; 7, 321-349.
4. Breslau, J., Miller, E., Jin, R., Sampson, N. A., 16. Batra, L., & Gautam, S. Psychiatric morbidity and
Alonso, J., Andrade, L. H., ...& Fukao, A. A personality profile in divorce seeking couples.
multinational study of mental disorders, marriage, Indian journal of psychiatry, 1995; 37(4), 179.
and divorce. Acta Psychiatrica Scandinavica.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 457

Prevalence of Goiter and its Association with Consumption

of Iodized Salt among School Children, in a Rural Area,
Tamilnadu

D.Jayashri1, B.Charumathi1, Timsi Jain2, Gomathy Parasuraman3, Ruma Dutta3

1
Post Graduate, 2Professor and Head, 3Associate Professor, Department of Community Medicine,
Saveetha Medical College Hospital, Thandalam, Kanchipuram District

Abstract
Background: Iodine Deficiency Disorders is a significant public health problem all over the world.Iodine
is essential element for thyroid function, necessary for normal growth, development and functioning of
brain and body. Objectives: To estimate the prevalence of goiter among school children and to assess
the prevalence of useof iodized salt. Material and Methods: A Cross sectional study conducted among
Children between 6-12 years of agein Mappedu area.A pre-tested questionnaire, Rapid test kit to find iodine
content of salt and clinical examination to assess goitre was done for the study subjects.The sample size
calculated was120.Dataanalysis:Proportions and chi-square was used for analysis. Results: 65% were
using iodized salt and remaining 35% were using non-iodised salt.The prevalence of goiter was found to be
17(14.2%). Conclusion: One-third of children and their family were not consuming adequately iodized salt.
The consumption of iodized salt is still less in the community and Iodine Deficiency Disorders continue to
be a public health problem.

Key words: IDD, Goiter, Iodized Salt, Rapid test kit.

Introduction In Tamil Nadu, the IDD control cell was established

with Central Government assistance and is functioning
Iodine Deficiency Disorders is known to be a
since 1st July 1994.Goiter surveys and resurveys of all
significant public health problem all over the world.
the districts are being carried out periodically since 1991.
Iodine is essential element for thyroid function, necessary
According to National Family Health Survey (NFHS)-4
for normal growth, development and functioning of brain
in Tamil Nadu proportions of households using iodized
and body.Iodine deficiency is known to cause endemic
salt is 82.8%.TotalGoitre rate is reported as 13.5% in
goitre..1
Tamil Nadu.6
Salt iodization programs is being implemented in
Although the importance of iodized salt and its usage
many countries of the world for more than five decades
has increased in the community,Iodine deficiency poses
,currently only two-thirds of the global population (71%)
a threat to health, wellbeing and economic productivity
is estimated to be covered by iodized salt, while the rest
of the community.Progress toward the elimination of
(31%) of the world population have insufficient iodine
Iodine Deficiency Disorder can only be demonstrated if
intakes, with the most affected WHO regions being
it is measured.
South-East Asia and Europe.2
Monitoring iodine levels of salt and iodine status of
Iodine deficiency disorders are estimated to result in
population are the two important components of Iodine
loss of 2.5 million disability adjusted life years (DALYs)
Deficiency Disorder program monitoring, hence the
(0.2% of total globally).3 In India it is estimated that more
study has been conducted.
than 71 million individuals suffer from Iodine Deficiency
Disorder, while another 200 million people stay in iodine Objectives
deficient areas.4The Iodine Deficiency Disorder control
goal in India was to reduce the prevalence of IDD below 1.To estimate the prevalence of goiter among school
10% in the entire country by 2012.5 children in rural area.
 458 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

2.To assess the prevalence of use of iodized salt by starch solution was used to test the presence of iodine
among them . in salt.

Methodology Clinical Examination:

A cross sectional study was conducted in Primary Enlargement of thyroid gland was assessed and
School,Mappedu between May 2018 – July 2018. presence of goiter was graded as per WHO guidelines. 6,11
Children between 6-12 years of age were selected by
using Simple Random Sampling method. The sample • Grade 0: Thyroid gland was neither palpable
size of 120 was calculated by using 76.2% of households nor visible/ no goiter.
residing in rural area were using iodized salt.7Using a • Grade 1: A mass in the neck that is consistent
pre-tested questionnaire,details regarding edible salt with an enlarged thyroid that is palpable but not visible
used within the family was obtained. Children were when the neck is in normal position. The mass moves
asked to bring 1-2 teaspoon of salt which is used for upwards with deglutition/goitre palpable not visible.
cooking purpose at their home in a sealed plastic bag
and Iodine content in salt wasestimated using Rapid Test • Grade2: A swelling in the neck that is visible
Kit. when the neck is in normal position and consistent with
enlarged thyroid when the neck is palpated/goiter visible
Children were clinically examined for the presence and palpable.
of enlargement of thyroid gland.Children who were
not present in the school at the time of data collection Operational Definition For Iodised Salt:
and those who are not willing to participate were
Iodised salt is defined as one which contains iodine
excluded from the study. Data was entered in MS Excel.
content of ≥ 15ppm at the household level as determined
Proportions and chi-square were used for data analysis.
by Rapid Test Kit.12,13,14
Salt Sample Collection & Testing:
Results
One teaspoon of salt was obtained from each
household for testing purposes.Rapid test kit was used 120 children participated in the study, they belonged
to estimate the iodine content of salt. 8,9,10 to 6-12 years age group mean age was found to be 9.14
years. Majority of them (50.8%) were using powdered
• One to two drops of the test solution was put on form of salt. 80% of the study population were storing
the salt sample,if the colourchanged from white to blue/ salt away from the fire.More than 90% of respondents
purple, indicated the presence of iodine to threshold of have kept the salt in closed container.Majority of the
15ppm. households have bought packed type of salt 88.3% while
11.7% were found to purchase unpacked type of salt.
• For alkaline salt samples or salt with high (Table-1)
moisture content, one drop of recheck solution followed

Table 1: Background Characteristics of Study Subjects(N=120)

BACKGROUND CHARACTERISTICS OF THE STUDY SUBJECTS (n = 120)

S.NO CHARACTERISTICS (N) (%)

1 AGE
6 years 18 15.0
7 years 15 12.5
8 years 14 11.7
9 years 16 13.3
10 years 18 15.0
11 years 20 16.7
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 459

Cont... Table 1: Background Characteristics of Study Subjects(N=120)

12 years 19 15.8
2 FORM OF SALT
Powdered 61 50.8
Crystalline 59 49.2
3 PLACE OF KEEPING THE SALT
Kept near fire 24 20.0
Kept away from fire 96 80.0
4 TYPE OF SALT BOUGHT
Packed 106 88.3
Unpacked 14 11.7
5 STORAGE OF SALT
Open container 8 6.7
Closed container 112 93.3

All the 120 children brought the salt samples from In the present study 61 salt samples were in
their houses. On testing the salt samples with Rapid powdered form and remaining 59 were crystalline.
Iodine testing kit 65% of the samples colour was changed 70.5% of powdered salt was found to be iodised while
to blue which indicate the presence of iodine≥15ppm. 59.3% of the crystalline salt was iodised.This difference
(Table-2). was not found to be statistically significant.(Table-4)
Table 2- Distribution of Iodized Salt among Table 4- Association Between Iodine Contentof
Study Participants. Salt and Form of Salt.
Iodine Content of
N (%)
Salt Non- TOTAL
Form of salt Iodized(%)
Non-Iodized 42 35.0 Iodized (%)

Iodized 78 65.0
Powdered 43(70.5) 18(29.5) 61
Total 120 100.0

Among the salt samples which the participants told Crystalline 35(59.3) 24(40.7) 59
they buy packed salt 70.8% were found to be iodised.
While only 21.5% of unpacked salt was iodised. This
difference was found to be statistically significant. Total 78(100) 42(100) 120
(Table-3)
Chi square: 1.644,P value :0.199. *P<0.05 is considered
Table 3-Association between Iodine Contentof as significant
Salt and Types of Salt.
Clinical examination was done among school
Non- Total children, the presence of enlargement of thyroid was
Type of salt Iodized (%)
Iodized (%) checked and grading was done as per WHO guidelines.
Goitre was diagnosed in 17 children. The prevalence
Packed 75(70.8) 31(29.2) 106
of goiter was found to be 17(14.2%). Among those 17
Unpacked 3(21.5) 11(78.5) 14 children, 15(12.5%) of the children were found to have
grade 1 and 2 children (1.7%) were found to have Grade
Total 78(100) 42(100) 120 2 Goiter.(Table-5).
*Chi square:13.225,P value: 0.000 *P<0.05 is
considered as significant.
 460 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Table 5- Distribution of goitreamong the In the present study all except 1 child who were
participants diagnosed to have clinical Goiter were not consuming
iodised salt. Odd’s Ratio was found to be 47, this shows
Grading of Goiter N (%) all those who were not consuming iodised salt were at
47 times greater risk of getting Goiter. Goiter is just
G0 103 85.8 one of the clinical manifestation of Iodine Deficiency
Disorders,IDDs can also manifest as mental retardation,
G1 15 12.5 still birth, abortion, deafness, mutism, squint and
neuromotor defects.16
G2 2 1.7
More number of packed and powdered salt samples
Among 17 children who were clinically diagnosed to were found to be iodized in comparison to unpacked
have goiter, 16 (94.2%) were not consuming iodised salt and crystalline salt. Indian government has issued the
while only 25.2% children without any signs of clinical notification on banning the sale of non-iodised salt for
goiter were not consuming iodised salt. The difference direct human consumption in the country in May 2006
was found to statistically highly significant.(Table-6) under the Prevention of Food Adulteration Act 1954.17
In the present study one third of the families are found
Table 6- Association between iodized salt and to consuming non-iodised salt. Therefore Government
goiter among study participants. should take necessary actions to check the sale of
unpacked salt and non-iodised crystalline salt in the
Goitre Goitre
Iodine Total market.
Present Absent
Content
(%) (%)
Conclusion
Non-
16(94.2%) 26(25.2%) 42 One-third of children and their family were not
Iodized
consuming adequately iodized salt. National Iodine
Iodized 1(5.8%) 77(74.8%) 78
Deficiency DisordersControl Programmewas startedfifty
Total 17(100%) 103(100%) 120 years back, but the consumption of iodized salt is still less
and Iodine Deficiency Disorders continue to be a public
*Chi square:30.42,P value : 0.000 *P<0.05 is considered
health problem. Hence health education regarding Iodine
as significant OR= 47.
deficiency disorders and adequate utilization of iodized
salt is the need of the hour. Strict actionsshould be taken
Discussion
on the sale of non-iodised salt to have significant impact
This study was carried out to assess the utilization on the health and well-being of the country.
of iodized salt in the rural community and prevalence
of Clinical goiter.In the present study only 65% of the Limitation: The Urinary iodine excretion level was
participants were consuming iodized salt which was less not estimated in this study.
than reported by NFHS 4 in rural Tamil Nadu 76.2%.7
Conflict of Interest: Nil
In our study 49.2% of the participants were using
Source of Funding: Nil
crystalline form of salt and 11.7% were getting unpacked
salt. Ethical Clearance: Ethical approval was obtained
from the Institutional Review Board (IRB) and
The prevalence of goiter was found to be 14.2% in
Institutional Ethics committee. Written informed consent
our study which was found to be similar to the results
was obtained from the parents of the study participants
of national level survey data conducted by ICMR
and information sheet regarding the study was given to
where the goiter prevalence was 14.1% (5-14 years age
all the participants.
group).15Chandrakant et al reported 13.5% of school
children showed enlargement of thyroid gland.6 Zargar References
et al reported a higher prevalence of goiter30.2 % in
children less than 6 years old and 50.6 % in children 1. J. Larry Jameson, Leslie J. De Groot. IDD. In: J.
greater than 12 years old in Kashmir.15 Larry Jameson, Leslie J. De Groot, eds. De Groot
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 461

and Jameson Endocrinology. 4 ed. Philadelphia: jsessionid=19A02512D332B971398645CCC4

Saunders; 2008: 1529. FEFB5D?sequence=1, Accessed on 26 March
2. UNICEF. The State of the World’s Children. 2019.
Adolescence: An Age of Opportunity. New York: 10. Government of India. Policy guidelines on
United Nations Children’s Fund; 2011. Available National Iodine Deficiency Disorders Control
from URL:https://www.unicef.org/adolescence/ Programme, IDD and Nutrition cell, DGHS,
files/SOWC_2011_Main_Report_EN_02092011. MOH and FW,GOVT.OF India:2006. Available
pdf. Accessed on 26March 2019. from URL:http://pbhealth.gov.in/Revised%20
3. World health Organization. The world health Policy%20 Guidelines% 20Govt.%20 of%20
report: Reducing risks,promoting healthy life. India. pdf. Accessed on 26 March 2019.
Geneva:World health organization,2002 Available 11. Sunderlal, Adarsh, Pankaj.Applied
from URL: https://www.who.int/whr/2002/en/. NutritonProgrammes and Interventions.
Accessed on 26 March 2019. Textbook of Community Medicine and
4. Revised policy guidelines on National Iodine Preventive and Social Medicine,5thedition:CBS
deficiency disorders control programme: IDD Publications;2017,p.189-247.
and nutrition cell; Ministry of Health and 12. K Park.Nutrition and Health.
Family welfare,Oct-2006.Available from URL: Park’sTextbook of Preventive and
http://pbhealth.gov.in/Revised%20Policy%20 Social Medicine,24thEdition:Banarsidas
Guidelines%20Govt.%20of%20India.pdf. Bhanot;2017,p.646-704.
Accessed on 02 March 2019. 13. United Nations Children’s Fund. Sustainable
5. National Rural Health Mission IDD & Nutrition Elimination of Iodine Deficiency, Progress since
Cell. Revised Policy Guidelines On National the 1990 World Summit for Children; May,
Iodine Deficiency Disorders Control Programme. 2008. Available from: URL:http://www.unicef.
New Delhi: Directorate General of Health org/iran/Sustainable_Elimination_of_iodine_
Services Ministry of Health & Family Welfare, Deficiency_053008%281%29.pdf. Accessed on 26
Government of India; 2006. Available from: http:// March 2019.
www.whoindia.org/LinkFiles/Nutrition_Revised_ 14. Chandrakant S, Pandav, P Krishnamurthy, R
Policy_Guidelines_On_NIDDCP.pdf, Accessed on Sankar, KapilYadav,C.Palanivel. A Review of
02 March 2019. Tracking Progress towards Elimination of Iodine
6. Chandrakant S, Pandav, P Krishnamurthy, R Deficiency Disorders in Tamilnadu, India. Indian
Sankar, KapilYadav,C.Palanivel. A Review of Journal of Public Health 2010;54(3):120-125.
Tracking Progress towards Elimination of Iodine 15. Zargar AH, Shah JA, Laway BA, Mir MM.
Deficiency Disorders in Tamilnadu, India. Indian Prevalence of Goiter among school children in
Journal of Public Health. 2010;54(3):120-125 Kashmir valley.Indian Pediatrics 1997;64(2):225-
7. NationalFamilyHealthsurvey-4(2015- 30.
2016),TamilnaduFactsheet. Available from 16. Suryakantha.Nutrition and Health.Textbook of
URL:www.rchiips.org/nfhs/factsheet_nfhs-4. Community Medicine with Recent Advances,3rd
shtml, Accessed on 10March 2019 Edition: Jaypee Brothers;2018,p.153-212.
8. Rupali Roy, Manish Chaturvedi, DeepikaAgrawal, 17. Revised Policy Guidelines On National Iodine
HaroonAli,”Household use of iodized salt in rural Deficiency Disorders Control Programme, revised
area”,Journal of Family Medicine and Primary edition –October 2006.Available from URL:http://
Care,2016;5(1):77–81 pbhealth.gov.in/ Revised%20Policy%20
9. WHO/NHD. Assessment of iodine deficiency Guidelines%20 Govt.%20of%20 India.pdf.
disorders and moitoring their elimination:Aguide Accessed on 26 March 2019.
for programmemanagers.3rded.2007, Available
from URL:https:// apps.who.int/iris/bitstream/
handle/10665/43781/9789241595827_eng.pdf;
 462 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Health Care Facilities in Child Care Institutions in Delhi

Hrishika1, Rakesh Rai2

1PhD Scholar, 2Assistant Professor, Amity Institute of Social Sciences, Amity University, Noida, Uttar-Pradesh,
India

Abstract
UNCRC which is known as United Nation’s Convention on the Rights of the Child has clearly distinct that
an individual who has not accomplished 18 years of age is known as a child. The recent figures in the area of
child rights shows that total child population in India is 472 million which makes thirty nine percent (39%)
of India’s entirety population [1]. Orphaned and destitute children in India are found to be 20 million [2].
Children who found in difficult circumstances are categorized in two categories that is Children who needs
care and protection and who are conflict with law [3] and these children placed in custody of institutions where
they stay for long period or short period which depends on the recognized need of the child. Children living
in institutions or children homes necessitate basic care, health and educational services. These integration
and rehabilitation functions must address needs of children and helps in removing challenges from their
path of development. As endorsed in Juvenile Justice (Care and Protection) Act 2015 these institutions must
follow standardized norms and provide services to cater the obligatory requisite to all children. The services
include food, protected shelter, apt attire, remedial aid and other required service. The aim of this research
study is to understand significance of the facilities provided to children with special reference to health care
facilities in Child Care Institutions in Delhi.

Keywords: Child Care Institutions (CCIs), Children in Need of Care and Protection (CNCP), Condition of
Health, Health- facilities, Medical-care, Medical-services

Introduction all kinds of needs which comprise emotional support,

physical care, psychological desires and economic needs
In India population of the children (including 0-18
of the child. A family is usually the most important and
years) is estimated 472 million. According to National
protective environment of the children (Richard Carter,
Institute of Urban Affairs (2016) in India 39% of the total
2005). Both bodies UNCRC and the Juvenile Justice
population contains children. Even after end numbers
(Care and Protection of Children) Act 2000 [3] mentioned
of laws and policies have been implemented after the
that it is the prime duty of biological families of the
independence era the visible extreme poor condition of
children to help children grow in protected environment.
children can be seen through recent surveys and research
Further it states that in deficiency of familial support it is
studies. Children have equal rights but issues related to
the accountability of State to obligatory protects children
protection of children have always indeterminate and
who are underprivileged and destitute of family love and
unaddressed matters of nation. The studies have shown
support [9]. All Children who by the law are identified
that a huge number of children suffer abuse, neglect,
in need of protection are located in institutions. The
unequal access to resources, poverty, discrimination,
duration of the stay of children in these institutions can
and homelessness despite of existence of laws and
be up to days, months or years depending on the nature
policies [6]. A number of researches have been taken up
of each child case [4]. India’s population of orphaned and
over a period of time to describe the deprived condition
destitute children is anticipated to be 20 million which
of children living in difficult circumstances in India.
reflects the needs of these institutions [3]. State plays a
It is factual and so evident that children are dependent
vital role in providing safe shelter to these children so
on adults primarily on their parents for their needs,
that they must grow with their full potential. Special
growth and development. It is believed that family holds
provisions are made in Juvenile Justice (Care and
the primary responsibility of the child. Family caters
Protection) Act 2015 (abbreviated as J.J Act) which
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 463

promotes accurate rehabilitation and adaptation of to all children. These children homes are endorsed
children in society [5]. to register under the act. It is mandatory to pursue
the uniform rules and regulations defined in the act
Understanding Children in Need of Care and [8]. To regulate CCIs a provision of cancelation of the
Protection CNCP cases: registration and punishment is given if the home violates
A child is known as a person below 18 years of his/ rules, regulations and standard norms prescribed under
her age as mentioned in Convention on the Rights of the act. Children residing in homes are in need of
the Child (abbreviated as CRC) but it is also noted that rehabilitation and require integration in the society [11].
age of a child defined in diverse legislations pertinent These institutions are being established to provide secure
to them in different circumstances [7]. A child who is place of stay children, to address whole rehabilitation,
in any circumstances like abused, working, orphaned, to uphold physical and mental health and on the whole
at families at risk, abandoned, differently abled, victims growth and development of all children.
of sexual exploitation, on streets, beggars, affected Facilities provided in Child Care Institutions:
by disasters, physically and mentally abused, drug
falls under the purview of CNCP cases as mentioned i. Basic and essential care facility:
in JJ Act. Cases of CNCP are hear by the proficient
government organization namely Child Welfare Basic and essential care facilities provided in
Committee (abbreviated as CWC). CWC is a work Child Care Institutions are meant to endow with basic
surface of members wherein a chairperson and four necessities to children including safe accommodation,
members designate to exercise their rights in cases of age and gender suitable garments, sufficient as well as
CNCP. These members are proficient in their fields healthy food, supervision and attention from the adults
[10].
and every case of CNCP produces before the bench.
The best interest of the child is main objective of the ii. Health care facility:
committee and keeping the needs of every case of the
child it takes decision to return them to their original Providing proper medical assistance and taking
parents or custodian or to available suitable members care of children health is the most vital function of
of family. CWC issues certificate to child who is with Child Care Institutions. The heath care services given
permission is available for adoption in the cases where to children includes: facilitate immunization as per their
child cannot be placed in original family. There are also age, monitoring of physical growth and maintenance of
cases where child cannot be placed in family or family the records, routine check ups and arranging visits of the
like environment thus child stays in children homes doctors, taking children to doctors as and when needed,
depending upon his/ her age and needs identified in the giving children medicinces on time, taking care of their
respective cases. diet and ensuring proper medical care.

Significance of Child Care Institutions (CCIs): iii. Educational facility:

The foundation of Child Care Institutions was laid Children living in CCIs are attending formal
down to address the challenges of children who live in education. Every child has right to be admitted to school.
extreme complicated circumstances and are in need of Children who require extra attention bridge and tuition
long term place of safety. It is widely measured as one classes are arranged for them to ensure that no child
of the best sources to rehabilitate children. Under the would lack behind in education because of their past
provisions of the JJ Act the term “child care institution” events.
is defined as any home for children whether run by the
government or non government authority or place of iv. Counseling facility for psychological needs:
safety or specialized adoption agency and a fit facility Child Care Institutions provide regular counseling
intended to provide care and protection to children. The sessions to all children which is done by a qualified
basic and fundamental function of all types of children psychologist to address and cater psychological and
homes is to address the developmental needs of the mental well being of every child in institutional care.
children. It means that CCIs are designated to grant
physical, emotional, mental and educational facilities
 464 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

v. Recreational facility: diseases due to the inappropriate and harmful events

occurred in their previous life prior coming to homes
Child Care Institutions arrange and organize age [12]
. Children are found to be frequently ill and have
suitable recreational activities such as dance, yoga, complains of frequent fever, stomach pain, headache,
music, picnics, outings, sightseeing, monuments visits, etc, due to lower immunity system and malnourishment.
educational visits, participation in cultural events, festival
celebrations, national and international days celebration, Heath care facilities in Child Care Institutions:
birthdays celebration this further enlightening child’s Each child care institutions have medical staff including
concentration and aptitude as well as provide children a full time nurse and a visiting physician. When children
opportunity to explore and experience new world. are admitted in child care institutions the medical staffs
takes care of all the health related needs of the children
Objectives and essential amenities are being provided. Children
• To understand the significance and facilities homes have both visiting as well as regular doctors and
provided to children in Child Care Institutions in Delhi. other staff to examine standard health check of children.
The health care team or staff members are responsible to
• To study the health care facilities provided to provide following services to all the children:
children residing in Child Care Institutions in Delhi.
• Facilitating immunization as per the age of the
Methodology child,

The study was undertaken to understand health care • Monitoring of physical growth including
services provided to children who are staying in Child weight, height, head and chest circumference,
Care Institutions in Delhi. Integrated research approach
using both quantitative and qualitative method is been • Maintenance of the health records and
adopted to gain better understanding of contemporary individual files,
status of children in institutional care. A interview • Routine check ups,
schedule (semi structured) was used as tools and
techniques of data collection. Data analysis was done • Arranging visits of the doctors in case of refer
using thematic analysis also using Statistical Package to special doctors,
for Social Science (SPSS) software.
• Taking children to hospitals as and when
The study was conducted in children homes in Delhi needed,
and included both types of children homes- NGO as well
• Giving children medicines on time,
as government. The children who are in long term care
were interviewed. • Taking care of the eatery habit and diet of each
child,
The sample was collected from 4 children homes
out of which 2 were NGO homes and 2 homes were of • Ensuring delivery of medical services to all the
government in nature. The sample sizes of 20 children- children.
10 male and 10 female from both children homes were
approached. The children were from the age group of Quantittive Analysis:
10 - 18 years. A total number of 5 stakeholders working
Relationship between health of the children and
under heath care unit of the children homes were also
nature of children homes:
interviewed to know the process of health care services.
As this study covered both type of children homes
Findings government and NGO hence to find out the relationship
Thematic Analysis: between health of the children and nature of the children
homes test namely Two sampled t test was applied.
Health of the children: It was found that at the time
of the admission of children in institutions children are
diagnosed with infirmity similar to skin diseases, fits,
lower immunity, low weight, malnourishment and other
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 465

Don’t Know Good Not Good Grand Total

Row Labels
Count %age Count %age Count %age Count %age

Govt. Home 3 30.00% 4 40.00% 3 30.00% 10 50.00%

NGO Home 1 8.33% 8 83.33% 1 8.33% 10 50.00%

Grand Total 4 18.18% 12 63.64% 4 18.18% 20 100.00%

Name of the test - Two Sample t-test

t = 0.22086

df = 4

p-value = 0.418

95 percent confidence interval: (-5.768231,Inf)

The above mentioned data indicates no connection between health condition of children and the nature of
children home. It further indicates that children in NGO home are evenly healthy as in children living in government
homes. And the same health facilities are offered to children in both the homes.

Conclusion facilities to health, a place of safety, and educational as

well as emotional support to all children residing in these
The establishment of Child Care Institutions was children homes. This study was conducted to understand
initiated to save children from any type of complex and health care facilities provided to children living in
destructive situation and is considered as one of the institutions covering both types of children home that is
finest mean to cater to the needs of children who are not NGO and Government. Outcomes of the study indicate
in parental care due to some reasons and have need of both the children homes that are government and NGO
safe- place, support and care which can be for long or provides facilities to children and adhere rules and
short period of time depending on the needs identified guidelines as endorsed in JJ Act. It was found in the study
by the competent authorities. It is known as fit facility that children who are admitted in Child Care Institutions
for children. Child Care Institutions are approved and gone through horrendous encounters occurred in their
obliged to fulfill all requirements from giving basic early period of life because of which they are more prone
 466 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

with sickness like fits, skin illnesses, worse resistance, [2.] Report on2nd biennial conference on Improving
low weight, malnourishment and others. Children when standard of care for alternative child and Youth
admitted to child care institutions their wellbeing needs care: Systems, Policies and Practises. 2016.
are taken consideration by staff members and all essential [3.] The Juvenile Justice (Care and Protection of
and fundamental things is been given to them. There children) Amendment Act 2000
are ordinary and low maintenance specialists and staff
[4.] United Nation’s Declaration of the Rights of the
medical caretakers who screen customary registration of
Child. Geneva. 1989.
the children. At the point when they fall ill they are taken
to the medical clinics and hospitals by their caregivers. [5.] Nilima, M. Children Protection and Juvenile Justice
The information proposes that children in government System for Children in Need of Care and Protection.
home are similarly healthy as children living in NGO 2018.
run homes. And the same health facilities are offered to [6.]Savita, B. Children in India and their Rights. National
children in both the homes. Human Rights Commission. 2006.
[7.] Bajpai, A. Child Rights in India: Law, Policy and
Ethical Clearance: As part of the primary data,
Practice”. India. 2012.
the data was collected under the PhD programme of
Amity University by the PhD scholar from children [8.] Verma, A. K. Neglected child- Changing Perspective.
living in child care institutions and stakeholders. The 1993.
consent of the primary respondents was taken at the time [9.] Development, M. o. (n.d.). India: Building a
of interviews and their identities remain confidential. Protective Environment for Children. India:
Hence, data does not contain any identifiers and no Government of India.
ethical issues were involved in this research study. [10.] Bhalla, T. M. Case Study on Compliance of
Therefore, no ethical clearance was taken. Juvenile Justice (Care and Protection of Children)
Rules 2007 by Juvenile Institutions in Kolkata”.
Source of Funding: The data was collected under
2014.
the PhD programme hence this research study is self
financed by the PhD scholar. [11.] UNICEF, T. U. Children in Institutions: The
Beginning of the end?. 2003.
Confict of Interest: Nil [12.] Gupta, K. M. Mental Health Challenges and Best
Practices in Children Homes in India. 2005.
References
[1.] Status of Children in Urban India, Baseline Study.
2016.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 467

E-waste: The Serious Health Hazard

Trailokya Deka
Assistant Professor, Deptt. of Economics, B. P. Chaliha College, Nagarbera, Kamrup (Assam)

Abstract
Science and technology have led to production of many electronics and electric tools and equipments
starting from 18th century. Especially twenty first century is characterized by change in traditional habits
and customs and adoption of modern technologies in all around the works and activities of the world.
Electronic gadgets are meant to make our life happy and smooth functioning. These electronic gadgets
have penetrated every aspects of our life. Frequent change of television sets; computers and mobile phones
become the general habit of majority individuals in the world. We like to keep ourselves updated with the
current scientific advancements. In all such a situation we never think about appropriate recycling of old
electronic equipments. We frequently throw out the old electric items and usually become interested to
purchase updated new items. Electronic wastes (e-waste) are increasing all around the life and works of
human being. Each unit of e-waste may create every types of hazardous situation especially the health
related. Electrical equipments contain toxic substances and their disposal and recycling becomes a question
of health nightmare. Paper discussed definition, types and all about the health hazards of e-waste. Paper also
explained little about the recycling of e-wastes in India.

Keywords: E-waste, Hazards, Human Health, Recycling, Technology, etc.

Introduction varies region to region but urban areas suffers more than
the rural areas.
Advances in science and technology have led to
production of many electronics and electric tools and Defining E-waste:
equipments starting from 18th century. More specifically
21st century is characterized by change of traditional Electronic waste or e-waste refers to all forms of
habits and customs and adoption of modern technology electronics and electrical equipments and it’s different
along with luxurious tools or equipments. All electronic small and big parts that have been redundant by it’s
gadgets are meant to make our lives happy and smooth owner as waste without the intent of re-use1. E-waste
functioning. These electric gadgets have penetrated encompasses various forms of electrical and electronic
every aspect of our lives. Frequent change of television equipments that may be old, might have reached the end
sets; computers and mobile phones become the general of life and most importantly cease to be of any value
habit of every individual. Some times to make ourselves to the present owner. E-waste is also synonymously
updated with the current scientific advancements we called WEEE, the short form of Waste Electrical and
also become bound to change our electronic items. In all Electronic Equipment and has been identified as one of
such situation we never think about reuse or appropriate the fastest growing waste streams in the world. E-waste
recycling of old electronic items. We frequently throw may or may not create visible mountains like municipal
out the old electric items and purchase regularly the waste but definitely a very complex, non biodegradable
updated new items. In that way electronic wastes and toxic form of modern waste. With scientific and
(e-wastes) are increasing day by day in every walk of technological advancements total quantity of e-waste
works and human life. Each unit of e-waste may create and at the same time problems generated by e-waste has
every types of hazardous situation especially the health been increasing day by day.
related. Electronics and electrical equipments contain
Types of E-waste:
toxic substances and their disposal and recycling become
a question of health nightmare. Though the problem Electronics and electrical goods are broadly
 468 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

classified into major heads- ‘White goods’ comprise of Asia, China generates the highest e-waste quantity both
household appliances like refrigerator, washing machine, in Asia and the world (7.2 Mt.). Japan generated 2.1 Mt,
dishwashers, air conditioner etc., ‘Brown goods’ that and India 2 Mt. The top four Asian economies that have
include television, cameras etc. and ‘Grey goods’ the highest e-waste generation in relative quantities are-
include computers, scanners, printer, mobile phones Cyprus (19.1 KG per inhabitant), Hong Kong, China (19
etc2. Including all the above mentioned categories, total KG per inhabitant), Brunei and Singapore (around 18
E-waste emphatically covers the following important KG per inhabitant) (Balde, CP et al, 2017). Amount of
tools and equipments- E-waste is expected to grow to 52.2 Mt. in 2021 with an
annual growth rate of 3% to 4%.
• Temperature Exchange Equipments: It
include different types of cooling and freezing items like Quantity of current (2016) E-waste generation for
refrigerators, freezers, air conditions, heat pumps etc. a few countries of the world is given in the following
table. As it is shown in the table, quantity of E-waste
• Screens and Monitors: It include different generation ranges between 0.8 to 28.5 KG per inhabitant.
types of televisions, monitors, laptops, notebooks and
tablets. Table: Country wise domestic E-waste generated
in 2016
• Large Equipments: It includes washing
machines, dryers, dish washing machines, electric
E-waste generated (in KG per
stoves, large printing machines, copying equipments etc. Sl. No. Country
inhabitant)

• Small Equipments: It includes vacuum

1 Australia 23.6
cleaners, microwaves, ventilations, toasters, electric
kettles, radio, calculators, video camera, electric toys, 2 Bangladesh 0.9
small medical devices, etc. 3 Bhutan 2.5
• IT and Telecommunication Equipments: 4 China 5.2
It includes all types of mobile phones, GPS, routers,
5 France 21.3
telephones and personal computers.
6 Germany 22.8
• Different Lamps: It include high intensity
discharge lamps, LED lamps, fluorescent lamps etc. 7 India 1.5

All the above mentioned electric and electronic items 8 Italy 18.9
or equipments have different life period and respective 9 Japan 16.9
economic values. After the end of lifetime owners
generally throw out the equipments and respectively add 10 Malaysia 8.8
to total quantity of E-waste. 11 Myanmar 1.0

E-waste Statistics: 12 Nepal 0.8

Global quantity of E-waste generation in 2016 was 13 Norway 28.5

around 44.7 Mt. or 6.1 KG per inhabitant. The global 14 Pakistan 1.6
quantity of e-waste in 2016 is mainly comprised of
small equipment (16.8 Mt.), large equipment (9.1 Mt.), 15 Singapore 17.9
temperature exchange equipment (7.6 Mt.), and screens 16 Sri Lanka 4.5
(6.6 Mt.) respectively. Lamps and small IT represent a
smaller share of the global quantity of e-waste generated 17 Thailand 7.4
in 2016, 0.7 Mt. and 3.9 Mt. respectively. According to 18 USA 19.4
one estimate, about 20 to 50 million tonnes of E-waste are
being generated annually worldwide. Significantly, most 19 Vietnam 1.5
of the E-waste in 2016 was generated in Asian continent Source: The Global E-waste Monitor, 2017, Balde, C.P.
which is around 18.2 Mt. or 4.2 KG per inhabitant. In et.al.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 469

If we see the level of E-waste generated in developed Besides, wastes from medical operations are
and developing countries of the world then the difference directly dumped on nearby soil and water bodies. These
is quite large. The richest country in the world in 2016 activities are carried out without wearing any protective
generated an average of 19.6 KG per inhabitant whereas measures like masks, gloves etc. In many urban regions
the poorest generated only 0.6 KG per inhabitant. people are using cable wastes as fuel to cook food. In
fact, people are being exposed to toxins 24 hours a day
In India, total 65 cities generated more than 60 as they live, cook and sleep in the same place where
percent of the total E-waste in the country. Among the waste is being recycled. Thus, in absence of suitable
top ten cities that generate E-waste in India, Mumbai process and protective measures, recycling E-waste
ranks first, followed by Delhi, Bangalore, Chennai, results toxic emissions to the air, water, soil and poses a
Kolkata, Ahmadabad, Hyderabad, Pune, Surat and serious environmental and health hazard.
Nagpur respectively. Department of IT wants to provide
internet connectivity in all villages in India and wants Some of the available academic literature also
to increase the internet penetration to 90 subscribers per explained the same serious types of issues developed
1000 people by 2019. Further, the replacement rate of from e-waste. As it is explained by Yu, Welford and Hills
PCs in new age service sectors like BPOs, IT advertising (2006), overall human health risks from e-waste include
etc. are on the rise. India by 2020, targeted to achieve breathing difficulties, respiratory irritation, coughing,
a PC penetration of 80 per 1000 from the existing 14 choking, pneumonitis, tremors, neuropsychiatric
per 1000 people. At present India have approximately problems, convulsions, coma and even death. According
15 million computers, target being 85 million computers to Raghupathy, K., Chaturvedi, Arora, Henzler (2010),
by 2020. Unfortunately, if all these goals are attained e-waste workers are also exposed to other hazards
that will directly lead to manifold increase in E-waste leading to physical injuries and chronic ailments such
in India (https://rajyasabha.nic.in...E-Waste in India; as asthma, skin diseases, eye irritations and stomach
2011). disease. Similarly Yang, Jin, Xu & Lu (2011) explained
that particulate matter collected from e-waste recycling
E-waste Health Hazards: areas can lead to inflammatory response, oxidative stress
E-waste now makes up around 05 percent of all and DNA damage. Thus the health related hazardous
municipals’ solid wastes worldwide, more or less the issues of e-waste are serious to discuss in every works of
same amount as general plastic waste, but much more human life. It is urgently needed to tackle the problem
hazardous. With the fast and rapid technological change generated from the waste electronics and electric tools
and lesser lifespan of all electric and electronic products, and equipments.
the problem of E-waste seems to be further compounded E-waste Recycle:
in future days to come. E-waste has different potential
environment and health impacts if not recycled or cycled Currently, out of total e-waste recycled in the
inappropriately. country mere 05 percent is recycled by the handful of
formal recyclers and the rest is recycled by the informal
Electronic products are the multifaceted mixture recyclers. The E-waste recycled by the formal recyclers
of several hundreds of tiny components. Most of is done following environmentally sound practices which
the components in electronic devices contain Lead, ensure that the damage to environment is minimized.
Mercury, PVCs, Brominated Flame Retardants (BFRs), Formal recyclers also adopt processes so that the work
Chromium, Beryllium and, Phthalates. Many of these tiny force is not exposed to toxic and hazardous substances
components and substances contain deadly chemicals. released while recycling the waste. Most of the processes
These chemicals are the sprain on human health and the used by the informal recyclers are manual, using simple
environment. Long term exposure to these substances tools like hammer, screw driver, scissor etc. and by the
can damage the nervous system, kidney and bones, use of rudimentary techniques like burning of wires in
and the reproductive and endocrine systems of human open and using acid baths for the extraction of precious
health. Some of the problems are even Carcinogenic. metals.
Heavy amounts of BFRs are used to manufacture several
millions of mobile phones in the world. BFRs have been The situation in India is alarming because of
linked to neurotoxicity3. adoption of unethical practices. India has also become
 470 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

the dumping ground of all kinds of waste from the E-waste Monitor. United Nations University
developed countries. E-waste finds it’s way into India (UNU), International Telecommunication Union
in the name of second hand use or scrap metals. E-waste (ITU) and International Solid Waste Association
is being recycled in all most all the metros in India. (ISWA), Bonn, Geneva. 2017.
Problem of E-waste recycling gets further complicated 2. Sitaramaiah Y, Kusuma Kumari M. Impact of
due to the adoption of unethical practices by corporate electronic waste leading to environmental pollution.
and IT companies. According to one estimate, only a few JCHPS special issue. 2014; ISSN 0974 2115.
quantity of available e-waste in India is being recycled
3. Rajya Sabha Secretariat. E-waste in India. New
through the authorized recycling facility. This shows
Delhi: Rajya Sabha. 2011. Available from: https://
that some corporate are selling the waste to informal
rajyasabha.nic.in › rsnew › publication_electronic
recyclers to make some quick money without realizing
› E-Waste_in_india.
that they are putting people and the environment at great
risk. 4. Chaudhary, N. Electronic wastes in India: A study
of panel issues. ILI Law Review. The Indian Law
Conclusion Institute, New Delhi. 2018; winter issue, Vol.II.
5. Yu J, Welford R, Hills P. Industry responses to
Handling of E-waste is dangerous due to chemicals
EU WEEE and ROHS Directives: Perspectives
present in the products and the way to tackle the problem
from China. Corporate Social Responsibility and
is to design clean products that free from chemicals
Environmental Management. 2006; Vol.13 (5).
with longer life span. They should be easy and safe to
recycle and not expose workers and the environment 6. Raghupathy L, Krger C, Chaturvedi A, et al.
to hazardous chemicals. Manufacturers of electronic E-waste recycling in India: Bridging the gap
products must stop using hazardous chemicals and between the informal and formal sector. 2010.
substitute them with safer alternatives. Available from: http://www.iswa.org/fileadmin/
galleries/General%.
Unfortunately, the trend of going green and clean 7. Yang F, Jin S, Xu Y, et al. Comparisons of IL-8,
manufacturing products free from chemicals is slowly ROS and p53 responses in human lung epithelial
catching up in the world as well as the country India. cells exposed to two extracts of PM2.5 collected
In April 2008, Ministry of Environment and Forest, from an e-waste recycling area. Environmental
Government of India has issued ‘Guide lines for Research Letters, China. 2011; Vol.6 (2).
environmentally sound management of E-waste’. It
8. Alan Watson, Kevin Brigden, Melissa Shinn, et
focuses on the need to facilitate the recovery or reuse
al. Toxic Transformers: a review of the hazards of
of useful electric materials. It incorporates reduction of
brominated and chlorinated substances in electrical
e-waste quantity in every walk of life. If appropriately
and electronic equipment. Technical Note.
implemented, government initiative will reduce the
Greenpeace Research Laboratories, England. 2010.
wastes destined for final disposal and subsequently
ensure environmentally sound management of all 9. Devin N. Perkins, Marie-Noel Brune Drisse,
materials in India. Tapiwa Nxele, et al. E-Waste: A Global Hazard.
Icahn School of Medicine, Mount Sinai, New York.
Declaration: 2014.

Preparation of this article is not based on any 10. Keshav Parajuly, Ruediger Kuehr, Abhishek Kumar
external source of funding. It is an original work and Awasthi, et al. Future E-waste scenarios: The
Sustainable Cycles (SCYCLE) Programme. Report.
has not been sent to any other journal for publication.
United Nations University (UNU), Germany. 2019.
Conflict of interest is nil. Moreover, we have a tradition
to submit a copy of paper to Institutional Research 11. Lundgren, Karin. The global impact of e-waste:
Committee. Fully checked and author is individually addressing the challenge. International Labour
responsible for its content. Office Publications. Geneva. 2012.
12. Anusree PS, Balasubramanian P. Awareness
References and disposal practices of e-waste with reference
1. Balde, CP, Forti V, Stegmann P, et al. The Global to household users in Kochi City. International
Journal of Recent Technology and Engineering.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 471

2019; ISSN 2277-3878, Vol.8. 14. https://www.ncbi.nlm.nih.gov › pmc › articles ›

13. Pinto, V. NE-waste hazard: The impending PMC6236536
challenge. Indian Journal of Occupational and 15. www.greenpeace.to › publications › Toxic-
Environmental Medicine. 2008; Vol.12 (2). Transformers-2010
 472 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A Survey of Oral Medicine Curriculum and Practice in India

Priyanka.S.R1, M.Arvind2
1Post Graduate Student, 2Professor & Head, Department of Oral Medicine and Radiology, Saveetha Dental
College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, India

Abstract
Background: Oral Medicine specialists provide clinical care to patients with a wide variety of chronic
diseases affecting the oral and maxillofacial region, oral manifestations of systemic diseases and behavioral
disorders and provide general dental care to patients with medically compromised states. It is important to
conduct studies that address the strengths and shortcomings of our specialty and the current system of its
education and practice in order to yield highly skilled professionals and truly serve the oral health care needs
of the public.

Aim & Method: This study aims to describe the current status of Oral Medicine curriculum and practice
in India. A survey was designed to assess the current status of oral medicine education and clinical practice.
The survey was sent to Oral Medicine Specialists across India to assess their opinion and analyze the benefits
and shortcomings of the present system.

Results: 52 respondents completed the survey from various states across India. More than 87% of
respondents considered management of oral mucosal diseases, salivary dysfunction, oral manifestations
of dermatological diseases, HIV, oral manifestations of systemic disease and facial pain as part of Oral
Medicine. Only 27% of respondents reported participating in multidisciplinary clinics for treatment of
patients, and 85% of respondents agreed to the need for presence of multidisciplinary clinics. 85% of
respondents agreed to the suggestion of developing a curriculum for training in Special Care Dentistry for
Oral Medicine postgraduates in India.

Conclusion: Limitations to this survey study include a small sample size. Future efforts at defining the
scope of oral medicine practice in India and improvements in training and education can help model future
graduates and inspire undergraduates to choose Oral Medicine as a career.

Keywords: Oral Medicine, Survey, Clinical Practice, Oral Medicine curriculum

Introduction of Oral Medicine defines it as the discipline of dentistry

concerned with the oral health care of medically
Oral Medicine is a specialty largely credited to
compromised patients and the diagnosis and nonsurgical
Dr.Lester Burket, considered as the Father of Oral
treatment/management of medically related disorders or
Medicine [1]. It has been a recognized specialty in many
conditions affecting the oral and maxillofacial region [2].
but not all countries and has been a way to integrate
Medicine and Dentistry, via oral health and its effects on Oral Medicine experts typically provide non-
systemic health and vice versa. The American Academy surgical treatment to various oral mucosal diseases,
soft and hard tissue lesions, salivary gland disorders,
Corresponding Author: viral, bacterial and fungal infections of the oral cavity,
Dr.Priyanka.S.R temporomandibular joint disorders, orofacial pain
Post Graduate Student syndromes, chemosensory disorders, oral complications
Department of Oral Medicine and Radiology of cancer chemo/radiotherapy and also care for patients
Saveetha Dental College, 162, Poonamallee High Road, with oral manifestations of systemic illnesses[1]. Oral
Velappanchavadi, Chennai – 600077 Medicine as a specialty is driven by the type of training
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 473

offered, and the scope of clinical practice. Very few from previous studies, with a closed response
articles have been published that have investigated the pattern. Standardized emails linked to online survey
standard of training in postgraduates and the scope of questionnaires (using Google Forms) were used. The
clinical practice globally [3, 4]. In two global survey email invitation to participate in the survey was sent
studies, results have been quite parallel, most of the to Oral Medicine specialists across India. A total of 52
respondents recognizing postgraduate Oral Medicine respondents fully completed the survey. Data obtained
training as a distinct field, and that the scope of practice were analyzed using simple descriptive statistics.
and training competence in diagnosing and managing oral
conditions that have been previously listed [3, 4]. Stoopler Results:
et al have reported that India had the largest number of The average age of Oral Medicine practitioners in
oral medicine specialists compared to other countries, India among the respondents was 33.8 years, with an
maybe because the Oral Medicine specialist initially average experience of 7.8 years. The distribution of
screens patients in dental hospitals [4]. The objectives respondents based on location has been illustrated in
of this survey is to describe the status of Oral Medicine Figure 1. The average number of colleagues practicing
training and clinical practice among experts in India, to with the respondents in a hospital setting was 7.6.
discuss the benefits of the current system, to address any Respondents reported a mean of working 27 h per week
possible shortcomings and to make recommendations to including clinical practice, teaching and administrative
remodel future training and practice. duties with a maximum of 40 hours per week

Materials and Method

The survey was designed using existing information

Figure 1 Percentage of respondents by state.

Figure 2 Distribution of professional responsibilities among practitioners

Less than 25% of the time was spent on research of participants hold a PhD. 5.7% of participants had a
among practitioners. fellowship or equivalent by a board examination and
certification. Majority of respondents reported that no
94.3% of participants had a formal training for three funding was obtained and training was predominantly
years followed by an examination for certification. 24% self-funded.
 474 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

Most commonly, practitioners reported to be a part A prospective survey conducted by the Diplomates
of Oral Medicine department in Hospital/ Dental College of the American Board of Oral Medicine showed an
settings with maximum time spent on teaching duties. increase in patients with medically compromising states,
The most common settings for Oral Medicine practice with more than 80% of cases requiring a comprehensive
were dental hospitals and dental schools, followed by evaluation of the medical condition and dental treatment
private practice. Practice in medical schools was the for patients with severe systemic disease. Majority
least common. of referrals were from general dentists and medical
practitioners [6]. This highlights the changing scenario
When asked about the definition of Oral Medicine, in oral medicine treatment needs among the public.
more than 87% respondents considered management A survey conducted among medical practitioners in
of oral mucosal diseases, salivary dysfunction, oral Chennai about the awareness of Oral Medicine as a
manifestations of dermatological diseases, HIV, oral specialty in dentistry. Only 71% of respondents were
manifestations of systemic disease and facial pain as aware of the specialty of Oral Medicine and the scope
part of their duties. Fewer respondents considered of the specialty. 29% were not aware of it and many oral
management of patients with physical and mental manifestations and orofacial disorders were not always
disabilities and general dentistry for medically complex referred to the right dental practitioner [7]. The aging
patients in the definition of Oral Medicine. Oral medicine population will lead to an increase in oral complications
plays an important role in detection, treatment and in medically compromised patients and practitioners
monitoring of oral potentially malignant disorders, oral will spend most of the times caring for the elderly and
manifestations of systemic diseases and oral treatment severely ill patients. So, the integration of medicine and
of medically compromised states. The latter two are dentistry becomes even more important and training
important as they are the link between medicine and oral medicine graduates in managing oral health needs
dentistry that can be a useful service for both the patient of medically compromised, physically challenged
and the medical practitioner. Oral manifestations can and behaviorally compromised patients is imperative
sometimes be the starting point of diagnosis of a systemic [8]. Figure 3 shows the types of oral and maxillofacial
illness or may be a sign of progression of the disease diseases that constitute the definition of oral medicine
state which highlights the importance of collaboration according to the survey respondents.
between doctors and oral medicine practitioners [5].

Figure 3 Definition of Oral Medicine

95% of survey respondents agreed that there is a patient, especially, patients undergoing cancer therapy,
need for better communication and integration between patients in intensive care units and patients in long term
dental and medical practitioners. Collaboration between care facilities where dental care can be provided by a
the dental and medical profession can highly benefit the trained professional rather than non-dental personnel as
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 475

poor oral health can contribute to increased morbidity these patients and the rate of occurrence demonstrates
and decreases quality of life [9]. This reinforces the need the importance of general medicine knowledge and
for educating the oral medicine graduates to serve as a training in handling such patients [12-14]. Inclusion of
partner to physicians thereby enhancing the level of care Special Care Dentistry in the Oral Medicine curriculum
provided to patients [9]. does pose challenges in obtaining national consensus.
Studies to identify types of patients, services available
Only 27% of respondents reported participating in and core skills required to qualify dentists are required
multidisciplinary clinics for treatment of patients, and for the introduction of Special Care Dentistry in the
85% of respondents agreed to the need for presence of curriculum [15].
multidisciplinary clinics. The use of multidisciplinary
clinics is especially important when treating oncology 90% of respondents were open to the introduction
patients, patients with severe systemic illnesses. of the internet and Smartphone applications in
communication among clinicians and between patients
24% of respondents reported less than 25% of and clinicians. Although studies have confirmed safety
patients are seen on follow up, 45% of respondents had and benefits of Smartphone use in healthcare, adequate
more than 50% of patients with follow up visits. training and awareness of possibilities and limitations is
imperative. This can be an adjunct in doctor-doctor and
doctor-patient communication and help in referral and
documentation [16, 17].

Discussion
This preliminary study was an attempt to investigate
the current status Oral Medicine education and clinical
Figure 4 Use of Multidisciplinary clinics practice across India. Our objective was to assess the
practitioner and practice characteristics, investigate
Figure 5 represents the types of oral and maxillofacial
the types of patients treated, and the opinion of oral
diseases and conditions seen in oral medicine practices
medicine specialists in on recommending changes
in India as reported by the respondents. Previous
and improvement in training and curriculum. Our
studies from other countries have reported the scope of
findings suggest that oral medicine specialists in India
practice, sources of referral, lesion occurrence and types
treat a wide variety of patients including oral mucosal
of patients reporting to Oral Medicine Practices [10, 11].
lesions, mucocutaneous diseases, salivary gland
Reports such as these are required to be done periodically
disorders, temporomandibular joint disorders, and oral
and methodically to better understand the scope of oral
manifestations of systemic diseases. Fewer respondents
medicine practice in India and to improve the curricula
reported participation in multidisciplinary clinics, the
of postgraduate students for them to be better equipped
presence of a Special Care Dentistry curriculum in
with knowledge and skills needed to handle patients [10].
the Oral Medicine postgraduate training. But almost
all respondents considered provision of dental care
for medically compromised patients, physically and
mentally disabled patients to be a part of Oral Medicine
Practice [4]. The diversity in practice characteristics can
be attributed to regional variations in opinions among
specialists, different systems of training and clinical
practice.

There is increasing evidence that oral health has

Figure 5 Percentage of patients with different orofacial a significant effect on overall systemic health and that
diseases.
there are inadequacies in the interrelationships between
85% of respondents agreed to the suggestion of dental and non-dental health care providers. It is time
developing a curriculum for training in Special Care for dental education to establish integration of dental
Dentistry for Oral Medicine postgraduates in India. and medical training and practice in order to increase
Various studies have reported the medical problems in
 476 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

oral health knowledge among medical professionals 2. American Academy of Oral Medicine. Oral
and to increase the knowledge of oral-systemic health medicine definition. At: www.aaom.com/about-
interface and a working knowledge of General Medicine aaom/.
among dental professionals. Oral Medicine Specialists 3. Rogers H, Sollecito TP, Felix DH, Yepes JF,
may be considered the best choice for this integration Williams M, D’Ambrosio JA, Hodgson TA,
because of its close connection with general health and Prescott‐Clements L, Wray D, Kerr AR. An
systemic disease [18, 19]. Oral Medicine graduates should international survey in postgraduate training in Oral
be competent enough to understand the interactions Medicine. Oral diseases. 2011 Apr 1;17(s1):95-8.
between, oral health, nutrition, general health, drug
4. Stoopler ET, Shirlaw P, Arvind M, Lo Russo L,
interactions, oral effects of systemic diseases, and also
Bez C, De Rossi S, Garfunkel AA, Gibson J, Liu
be familiar with provision of dental care to severely
H, Liu Q, Thongprasom K. An international survey
ill and physically/mentally challenged patients in a
of oral medicine practice: Proceedings from the 5th
hospital setup. Training in Special Care Dentistry can
World Workshop in Oral Medicine. Oral diseases.
provide the specialists the ability to handle challenges
2011 Apr 1;17(s1):99-104.
associated with treating physically/medically/mentally
compromised patients including the management 5. Zakrzewska JM, Downer C, Lopes V. The oral
of medical emergencies, management of anxiety, medicine clinic—what is its role?. Journal of the
management of frail/elderly patients, patients with severe Royal Society of Medicine. 1994 Jul 1;87(7):390-2.
systemic disease, patients in long term care facilities, 6. Miller CS, Hall EH, Falace DA, Jacobson JJ,
treatment under general anaesthesia and sedation, and Lederman DA, Segelman AE. Need and demand
provision of dental treatment in different setups like for oral medicine services in 1996. Oral Surg Oral
hospitals, intensive care units, nursing homes, special Med Oral Pathol Oral Radiol Endod 1997;84:630-
schools and general practice [15, 20]. 4.
7. Subramanian VS. Awareness of Oral Medicine
Older trends of procedure driven/mechanical
Specialty among Medical practitioners in and
dentistry are gradually being replaced by a more
around the locality of Chennai: A Survey.
preventive/regenerative approach. Oral medicine is the
Research Journal of Pharmacy and Technology.
best choice to handle the noninvasive and preventive
2016;9(8):1073-6.
aspects of future oral healthcare and for the integration into
the medical field [21, 22]. Future studies are recommended 8. Miller CS, Epstein JB, Hall EH, Sirois D. Changing
to obtain a more detailed report of the status of oral oral care needs in the United States: the continuing
medicine in India. Efforts at defining the scope of oral need for oral medicine. Oral Surgery, Oral
medicine practice in India and improvements in training Medicine, Oral Pathology, Oral Radiology, and
and education can help modeling future graduates and Endodontology. 2001 Jan 31;91(1):34-44.
inspire more students to choose oral medicine as a career. 9. Migliorati CA, Madrid C. The interface between
oral and systemic health: the need for more
Conflict of Interests: The authors declare no collaboration. Clinical Microbiology and Infection.
conflict of interests. 2007 Oct 1;13(s4):11-6.
Source of Funding: Self-Funding 10. Suarez P. Oral conditions of 1,049 patients referred
to a university‐based oral medicine and orofacial
Ethical Clearance: Not Required pain center. Special Care in Dentistry. 2007 Sep
1;27(5):191-5.
References 11. Farah CS, Simanovic B, Savage NW. Scope of
1. Sollecito TP, Rogers H, Prescott-Clements L, practice, referral patterns and lesion occurrence of
Felix DH, Kerr AR, Wray D, Shirlaw P, Brennan an oral medicine service in Australia. Oral diseases.
MT, Greenberg MS, Stoopler ET. Oral medicine: 2008 May 1;14(4):367-75.
defining an emerging specialty in the United States. 12. Al-Bayaty HF, Murti PR, Naidu RS, Matthews
Journal of dental education. 2013 Apr 1;77(4):392- R, Simeon D. Medical problems among dental
4. patients at the school of dentistry, the university of
the West Indies. Journal of dental education. 2009
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 477

Dec 1;73(12):1408-14. dental journal. 2010 Oct 23;209(8):399-404.

13. Sardella A, Demarosi F, Lodi G, Canegallo L, 18. Tanaka K, Honda T, Kitamura K. Dentistry in
Rimondini L, Carrassi A. Accuracy of referrals to Japan should become a specialty of medicine with
a specialist oral medicine unit by general medical dentists educated as oral physicians. Journal of
and dental practitioners and the educational dental education. 2008 Sep 1;72(9):1077-83.
implications. Journal of dental education. 2007 Apr 19. Hein C, Schönwetter DJ, Iacopino AM. Inclusion of
1;71(4):487-91. oral-systemic health in predoctoral/undergraduate
14. G.Muthu Laakshmi. Awareness of Oral Cancer curricula of pharmacy, nursing, and medical schools
among a Hospital based Out-Patient Population around the world: a preliminary study. Journal of
– A Questionnaire based study. Journal of Dental Education. 2011 Sep 1;75(9):1187-99.
Pharmaceutical Sciences and Research. 2016, Vol 20. Sanz M, Treasure E, Dijk WV, Feldman C,
8(7), 687-691. Groeneveld H, Kellett M, Pazdera J, Rouse L,
15. Dougall A, Pani SC, Thompson S, Faulks D, Sae‐Lim V, Seth‐Smith A, Yen E. Profile of the
Romer M, Nunn J. Developing an undergraduate dentist in the oral healthcare team in countries with
curriculum in Special Care Dentistry–by consensus. developed economies. European Journal of Dental
European journal of dental education. 2013 Feb Education. 2008 Feb 1;12(s1):101-10.
1;17(1):46-56. 21. Spielman AI. The future of oral medicine.
16. Petruzzi M, De Benedittis M. WhatsApp: a 22. Kragelund C, Reibel J, Hadler‐Olsen ES, Hietanen
telemedicine platform for facilitating remote oral J, Johannessen AC, Kenrad B, Nylander K, Puranen
medicine consultation and improving clinical M, Rozell B, Salo T, Syrjänen S. Scandinavian
examinations. Oral surgery, oral medicine, Fellowship for Oral Pathology and Oral Medicine:
oral pathology and oral radiology. 2016 Mar statement on oral pathology and oral medicine in
31;121(3):248-54. the European Dental Curriculum. Journal of Oral
17. Bradley M, Black P, Noble S, Thompson R, Lamey Pathology & Medicine. 2010 Nov 1;39(10):800.
PJ. Application of teledentistry in oral medicine
in a community dental service, N. Ireland. British
 478 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

A Retrospective Study on Side of Nerve Involvement and

Distribution of Pain in Patients with Trigeminal Neuralgia

Priyanka.S.R1, M.Arvind2
1Post Graduate Student,2Professor & Head, Department of Oral Medicine and Radiology,
Saveetha Dental College and Hospital, Chennai, India

Abstract
Background: Trigeminal neuralgia is chronic, debilitating and painful condition involving the trigeminal
nerve and has a major impact on patients’ quality of life. It is characterized by brief attacks of excruciating
pain in the area of distribution of one or more branches of the trigeminal nerve. It has an annual incidence of
about 4.5 to 12.6 per 100,000 population and has a female predilection. According to studies, it commonly
occurs in the older age group and a hallmark of idiopathic trigeminal neuralgia is that it occurs twice as often
on the right side of the face. There are various hypotheses proposed to explain this side predilection.

Aim: To evaluate and analyze the side of occurrence, distribution of pain in patients diagnosed with
trigeminal neuralgia among patients visiting Saveetha Dental College.

Materials and Method: The retrospective clinical data of 42 patients who reported with a complaint of
orofacial pain and diagnosed with trigeminal neuralgia in the department of Oral Medicine and Radiology,
Saveetha Dental College from Jan 2016 to Dec 2017 were obtained. The data regarding age of onset, gender,
side of nerve involvement, and distribution of pain was retrieved and analyzed.

Results: Trigeminal neuralgia was mostly diagnosed in the 5th and 6thdecades of life with a mean age of
55.3 years. Male patients were affected more than female patients but the difference was not comparable. It
affected the right side more frequently and the maxillary branch was the most commonly involved.

Conclusion: This study investigated the clinical characteristics of 42 patients diagnosed with trigeminal
neuralgia. Further multicentre studies need to be done to investigate the clinical characteristics and imaging
studies need to be done along with anatomical studies to investigate causes for nerve entrapment as an
etiological agent for trigeminal neuralgia.

Keywords: Trigeminal neuralgia, site predilection, trigeminal nerve, orofacial pain, neuropathic pain

Introduction branches merged as one within the cranial cavity. The

name “trigeminal nerve” meaning “three twins” was
The trigeminal nerve is the principal nerve that derived from the name “nerf trijumeau” given by a
provides general sensory supply to the face, scalp Danish anatomist Jacques-Benigne Winslow [1]. The
and mouth. First described by Galen in 200 A.D as 2 mesencephalic nucleus, main sensory nucleus, spinal
pairs of separate nerves due to its large peripheral nucleus and the motor nucleus give rise to sensory and
branches, Fallopius (1500’s) later said that the three motor fibres. The nerve from the pons has a relay in
the Meckel’s cave wherein the Gasserian ganglion lies.
Three divisions of the trigeminal nerve arise from the
Corresponding Author:
gasserian ganglion and exit the cranial cavity through the
Dr.Priyanka.S.R
superior orbital fissure, foramen Rotundum and Ovale.
Department of Oral Medicine and Radiology
The 3 divisions are the ophthalmic (V1) and Maxillary
Saveetha Dental College, 162, Poonamallee High Road,
(V2) and the Mandibular division (V3). The nerve may
Chennai – 600077
be involved in a number of pathologies. A thorough
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 479

understanding of its anatomy is of vital importance in MRI to rule out recognizable causes and to visualize
diagnosis and treatment of disease [2]. possible compressing vessels on the nerve root [9].

Trigeminal neuralgia (TN) is a rare condition One clinical hallmark of classical TN is that the right
causing excruciating, intermittent, short lasting, usually side is more commonly affected than the left but there
unilateral facial pain, also called as tic doloreux meaning are no reasons for the blood vessels causing vascular
“painful spasm”. The prevalence tends to be higher in compression to be more tortuous in the right side. One
females than in males and most commonly reported hypothesis which said that higher incidence on the right
above the age of 40 with a peak at 50-60 years. The right side is caused by improper brushing on this side by right
side has been reported to occur more frequently than the handed people leading to a higher incidence of caries
left [3, 4]. Sharp, stabbing or shooting, electric shock-like was discarded because the frequency of left sided TN
pain occurs in the area of distribution of one or more in left handed people is not different from right handed
branches of the nerve. Pain is provoked by light touch to individuals [12]. Anatomical and radiological studies
areas of the face termed as trigger zones. Trigger factors have reported that foramina rotundum and ovale are
include washing the face, brushing teeth, shaving, and asymmetrical and that the left side is wider and larger
others [5].TN can be classified as Classical TN (idiopathic than the right [13] [14]. Vascular compression produces
or primary TN) and Symptomatic TN (secondary TN). demyelination, an inflammatory reaction and an increase
Patients with multiple sclerosis are also susceptible and in perivascular lymphocytes, lipid laden macrophages
frequently have bilateral facial pain [6]. While classical and collagen content of the neuronal extracellular matrix
TN occurs without an apparent cause, symptomatic distal to the site of compression [15] [16]. Neto et al [17]
TN can usually be attributed to a recognizable disorder say that these changes can cause entrapment of the nerve
or pathology in intrinsic or extrinsic locations such on the right side more commonly than the left because
as trauma, infections such as herpes zoster, multiple of the difference in size of the foramina which could
sclerosis, space occupying lesions including cysts and explain the higher incidence of TN on the right side.
tumours[7, 8]. For example, cases of TN related to multiple sclerosis
is also more common in the right side, and in bilateral
Several mechanisms attempt to explain the neuralgia, the right side had more severe symptoms
pathogenesis of classical TN. The leading theory is the than the left [18]. No differences in size of foramina
demyelination of sensory nerve fibres due to compression have been established in women and men [17]. Although
by blood vessels at the nerve root. The offending vessel earlier reports show a strong female predilection, recent
is the superior cerebellar artery or the anterior inferior reports suggest that only 60 % of the TN patients are
cerebellar artery. Histological studies have revealed focal female. No known racial or ethnic risk been reported [19].
demyelination in the vicinity of the vascular compression. The objective of this study is to investigate the clinical
The demyelinated axons allow spontaneous generation characteristics of patients diagnosed with TN.
of ectopic nerve impulses and ephaptic transmission to
adjacent fibres[9]. The “Ignition hypothesis” (Devor et Materials and Method
al) is the most accepted hypothesis stating that TN arises
from abnormalities of the afferent neurons in the root This descriptive study was carried out in the
or ganglion. Injury from neurovascular conflict causes department of Oral Medicine and Radiology. Clinical
axons hyperexcitability, resulting in paroxysmal painful data was retrieved retrospectively from the electronic
sensory discharge. Neighbouring neurons are recruited, clinical record database of patients diagnosed with TN
leading to a rapid buildup of electrical activity (ephaptic from January 2016 to December 2017. 42 patients who
cross talk) and pain amplification as the demyelinated were diagnosed with TN based on clinical features and
neurons lie in close contact. Devor described the stop response to treatment with carbamazapine were included.
mechanism as due to post-discharge hyperpolarisation All patients were examined using orthopantomography
which makes the nerve refractory to further excitation. to rule out any pathology or other odontogenic causes.
This is seen as asymptomatic periods between attacks Clinical data regarding age, gender, side and distribution
of pain [10]. The disease is characterized by recurrences of pain over areas supplied by the trigeminal nerve were
and remissions with 50% of patients reporting periods of collected and analyzed for applying descriptive statistics.
spontaneous remission lasting weeks, months or years
[11]. Patients with new onset TN typically undergo an
 480 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

RESULTS:
The age of patients varied from 31 to 85 years with a mean age of 55.3 years at presentation. Table 1 shows the
distribution of patients based on age of onset.

Table 1 Age distribution among patients

Age in years Male (n=23) Female (n=19) Total (n=42) Percentage (%)

31-40 1 3 4 9.5%

41-50 4 3 7 16.6%

51-60 5 8 13 30.9%

61-70 12 4 16 38%

71-80 0 1 1 2.3%

>80 1 0 1 2.3%

Out of 42, 23 (54.7%) patients were male and 19 (45.2%) were female. Most of male patients were in their 6th
decade of life and most of the female patients were in their 5th decade of life. Most common age group for occurrence
of TN was 51-60 years (30.9%). Table 2 shows the side involved in male and female patients. 61.9% of patients
had right sided TN and 33.3% had left sided neuralgia. The difference in side involved is more apparent in female
patients – 14 (73.6%) patients had right sided neuralgia and only 3 (15.7%) patients had left sided neuralgia. No cases
of bilateral TN were found.

Table 2 Side of involvement among male and female patients

Side of Involvement Male (n=23) Female (n=19) Total (n=42) Percentage (%)

Right 12 14 26 61.9%

Left 11 3 14 33.3%

Table 3 shows the involvement of various divisions of the trigeminal nerve in the sample. The right maxillary
division was the most commonly involved nerve seen in 26.1% of patients. This was followed by equal involvement
of left maxillary and right mandibular division of the trigeminal nerve seen in 19% of cases each. A combination
of right maxillary and right mandibular division of the trigeminal nerve was involved in 11.9% of patients. The
involvement of the ophthalmic division was the least common. Only 1 patient was diagnosed with TN of the left
ophthalmic division. 1 patient had involvement of right ophthalmic and maxillary nerves. In female patients, the
most common area involved is the area distributed by the right mandibular division and in male patients, the most
commonly involved nerve was the right maxillary nerve.

Table 3 Pain distribution among divisions of trigeminal nerve

Division of Trigeminal nerve

Male (n=23) Female (n=19) Total (n=42) Percentage (%)
involved

Right ophthalmic (V1) 0 0 0 0

Left ophthalmic (V1) 1 0 1 2.3%

Right maxillary (V2) 7 4 11 26.1%

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 481

Cont... Table 3 Pain distribution among divisions of trigeminal nerve

Left maxillary (V2) 5 3 8 19%

Right mandibular (V3) 3 5 8 19%

Left mandibular (V3) 3 1 4 9.5%

Combinations

Right maxillary and mandibular

1 4 5 11.9%
(V2,V3)
Left maxillary and mandibular
2 2 4 9.5%
(V2,V3)
Right ophthalmic and maxillary
1 0 1 2.3%
(V1,V2)

Total 23 19 42 100%

Discussion
such as glossopharyngeal neuralgia, hemifacial spasm,
Neuralgic pain imposes substantial amount
the right and left sides are equally affected and the
of burden to affected patients. Patients experience
foramina of these nerves are only slightly asymmetrical
excruciating pain that lasts seconds to minutes followed [13, 22]. Even TN occurring due to cysts and tumours in
by a painless refractory period in between attacks. Even
the posterior cranial fossa occur predominantly on the
during the refractory period, patients are overwhelmed
right side even though the cysts and tumours showed no
with fear that the pain could occur at any instant. This
side predilection [17].
causes significant impairment in function and daily
life [20]. Clinical criteria for diagnosis based on pain As substantial recurrence rates are reported after
characteristics are given by the International Headache decompression surgery, involvement of other factors
Society. Neurological examinations, MRI scanning, is more likely. Nerve entrapment in the foramina may
Sensory testing, electrophysiological studies may be be one such factor. So, more studies are required to test
used as specific investigations to rule out organic causes this hypothesis as it may improve treatment and patient
for symptomatic TN [8]. Early epidemiological studies selection for surgery. In this investigation, as reported in
have reported the right trigeminal nerve to be more previous studies [23-26], right side was more commonly
involved than the left. There is very little research to involved than the left side. But, in contrast, male patients
explain this phenomenon. Neto et al have stated the were affected more than female patients. This may be
following reasons to support their hypothesis that nerve attributed to the small sample size. Anatomical studies
entrapment following vascular compression of nerve could also reveal an asymmetry in foramina in the right
root is responsible for more incidence of right sided and left side in different populations. Imaging and
TN [17]. The difference in size of foramen ovale and anatomical studies should be done to detect and quantify
rotundum is one reason. But, while the difference in size any such discrepancies which could explain the side and
of foramen ovale is found in 75% of cases, difference in gender predilection in the Indian population.
size of foramen rotundum is seen only in 8% of cases
[13, 14]
. Another finding that supports this hypothesis is Conclusion
related to Bell’s palsy. In Bell’s palsy, the facial nerve
This study investigated the clinical characteristics
also shows oedema and both right and left sides are
of 42 patients diagnosed with TN. It was more common
involved with equal frequency. This could because there
in the right side and more common in male patients.
is very little asymmetry in the stylomastoid foramen
The major limitation to the present study is the small
and internal acoustic meatus for the right and left side
[13, 21].
sample size which could have caused discrepancies in
In other syndromes involving the cranial nerves
the results compared to previous studies and the results
 482 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1

cannot be generalized to a larger population. Further 12. Penman J. In: Vinken PJ, Bruyn GW, editors.
multicentre studies need to be done to investigate the Handbook ofclinical neurology: Trigeminal
clinical characteristics and imaging studies need to be neuralgia. New York: AmericanElsevier Publishing
done along with anatomical studies to investigate causes CO; 1964. p. 296–321.
for nerve entrapment as an etiological agent for TN. 13. Berge JK, Bergmann RA. Variations in size and in
symmetry of foramina of the human skull. ClinAnat
Conflict of Interests: The authors declare no
2001;14:406–13.
conflict of interests.
14. Shapiro R, Robinson F. The foramina of the middle
Source of Funding: Self-Funding fossa; a phylogenetic, anatomic and pathologic
study. Am J Radiol 1967;101:779–94.
Ethical Clearance: Not Required
15. Hilton DA, Love S, GradIdge T, Coakham HB.
References Pathological findings associated with trigeminal
neuralgia caused by vascular compression.
1. Renton T, Egbuniwe O. Pain Part 2a: trigeminal Neurosurg 1994;35:299–303.
anatomy related to pain. Dental update. 2015 Apr
16. Rappaport ZH, Govrin-Lippmann R, Devor M. An
2;42(3):238-44.
electronmicroscopic analysis of biopsy samples
2. Bathla G, Hegde AN. The trigeminal nerve: of the trigeminal root taken during microvascular
an illustrated review of its imaging anatomy decompressive surgery. StereotactFunctNeurosurg
and pathology. Clinical radiology. 2013 Feb 1997;68:182–6.
28;68(2):203-13.
17. Santo Neto H, Camilli JA, Marques MJ. Trigeminal
3. Koopman JS, Dieleman JP, Huygen FJ, de Mos M, neuralgia is caused by maxillary and mandibular
Martin CG, Sturkenboom MC. Incidence of facial nerve entrapment: greater incidence of right-sided
pain in the general population. Pain 2009; 147: facial symptoms is due to the foramen rotundum
122-7. and foramen ovale being narrower on the right side
4. Obermann M, Katsarava Z. Update on trigeminal of the cranium. Medical hypotheses. 2005 Dec
neuralgia. Expert Rev Neurother 2009;9(3):323–9. 31;65(6):1179-82.
5. Zakrzewska JM, McMillan R. Trigeminal neuralgia: 18. Siegfried J, Lindenberger J. Trigeminal neuralgia
the diagnosis and management of this excruciating in multiple sclerosis. Il Dolore 1979;1:183–6.
and poorly understood facial pain. Postgraduate 19. Bennetto L, Patel NK, Fuller G. Trigeminal
medical journal. 2011 Jun 1;87(1028):410-6. neuralgia and its management. BMJ 2007; 334:
6. Hupp WS, Firriolo FJ. Cranial neuralgias. Dental 201-5.
Clinics. 2013 Jul 1;57(3):481-95. 20. Tolle T Duke E, Sadosky A. Patient burden of
7. Zakrzewska JM, Patsalos PN. Long-term cohort trigeminal neuralgia: results from a cross-sectional
study comparing medical (oxcarbazepine) and survey of health state impairment and treatment
surgical management of intractable trigeminal patterns in European countries. Pain Pract
neuralgia. Pain 2002;95:259e66. 2006;6:153-60.
8. Vasappa CK, Kapur S, Krovvidi H. Trigeminal 21. Sanna M, Saleh E, Russo A, Taibah AK. In: Atlas
neuralgia. BJA Education. 2016 Apr 26;16(10):353- of temporal bone and lateral skull base surgery.
6. Stuttgart: Thieme Medical Publishers; 1995. p. 37–
9. Prasad S and Galetta S (2007) The trigeminal nerve. 50.
In: Goetz C (ed.) Textbook of Clinical Neurology, 22. Patel A, Kassam A, Horowitz M, Chang YF.
3rd edn, pp. 165–183. Philadelphia: Elsevier Microvascular decompression in the management
10. Devor M, Amir R, Rappaport ZH. Pathophysiology of glossopharyngeal neuralgia: analysis of 217
of trigeminal neuralgia: the ignition hypothesis. cases. Neurosurgery 2002;50:705–10.
The Clinical journal of pain. 2002 Jan 1;18(1):4-13. 23. Rai A, Kumar A, Chandra A, Naikmasur V,
11. Zakrzewska JM, Linskey ME. Trigeminal Abraham L. Clinical profile of patients with
neuralgia. Bmj. 2014 Feb 17;348(9):g474. trigeminal neuralgia visiting a dental hospital: A
prospective study. Indian Journal of Pain. 2017
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 1 483

May 1;31(2):94. Trigeminal neuralgia: a retrospective multicentre

24. Yadav S, Mittal HC, Sachdeva A, Verma A, study of 320 Asian patients. Oral surgery, oral
Dhupar V, Dhupar A. A retrospective study of medicine, oral pathology and oral radiology. 2017
72 cases diagnosed with idiopathic trigeminal Jan 31;123(1):51-7.
neuralgia in indian populace. Journal of clinical and 26. Shah SA, Murad N, Salaar A, Iqbal A. Trigeminal
experimental dentistry. 2015 Feb;7(1):e40. neuralgia: analysis of pain distribution and nerve
25. Sathasivam HP, Ismail S, Ahmad AR, Basri NN, involvement. Pakistan Oral Dent J. 2008;28(1):37-
Muhamad H, Tahir NF, Saw CL, Kipli NH, Lau SH. 41.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 395

Antibacterial Activity of Combination between Probiotic Milk

and Mango Honey Against Streptococcus Mutans

Inaaroh Waachidah Azzulfiyyah1, Isnaeni1, Noor Erma1

1Chemistry
Pharmacy, Faculty of Pharmacy, Universitas Airlangga,
Dharmawangsa Dalam Street No.4 ‑ 6, Airlangga, Surabaya (60286), Indonesia

Abstract
Background: Streptococcus mutans commonly found in oral cavity and can be a pathogenic bacteria that
leads to dental caries. Rinsing the oral cavity with antibiotic oral therapy is not suggested as the treatment of
dental caries, because it has side effects. It can cause resistance of Streptococcus mutans towards antibiotic.

Objective: To analyze the antibacterial activity of honey of mango, prebiotic milk, and the combination of
both against Streptococcus mutans bacteria

Method: The antibacterial activity test was performed by agar diffusion method with Müeller Hinton agar
medium to determine the minimal inhibitory concentration inhibition (MIC). A study had been conducted
on the antibacterial activity of the combination of honey of mango and probiotic milk of Lactobacillus
paracasei ATCC BAA52 on the growth of Streptococcus mutans. Fermented milk was made by inoculating
Lactobacillus paracasei ATCC BAA52 fermented milk, mango honey and their combination at optimum
ratio (propotition) into fresh milk at 45°C, then incubated for 24 hours at room temperature

Result: The result of probiotic milk characterization showed that the pH of probiotic milk decreased compared
to fresh milk from from pH 6.33 to 3.89. Furthermore, the MIC of each samples against Streptococcus
mutans were determined

Conclusion: Combination between mango honey (Mangifera indica) and probiotic mlik (Lactobacillus
paracasei ATCC BAA52 can give optimum anti bacteria activities against Streptococcus mutans

Keywords: Antibacterial activity, probiotik milk of Lactobacillus paracasei ATCC BAA52, Mango Honey,
Streptococcus mutans.

Introduction an acid environment, and capable to produce a sticky

polysaccharide, called dextran. S. mutans can adhere to
Streptococcus mutans is a facultative anaerobic
the dental enamel and promote other acidoduric bacteria
bacterium, gram positive cocci bacterium. It is
towards dental enamel, which leads to dental caries (1).
commonly found in human oral cavity and being the
most pathogenic bacteria which causes dental caries (1). Rinsing the oral cavity with liquid containing
The characteristics of S. mutans are acidogenic, which antibiotic is one of solution to prevent dental caries.
produces acid, acidoduric, which is capable surviving in Unfortunately, it can not prevent dental caries
compeletely because it has side effect that leads to that
Correspondence Author: antibiotic resistance(2). To avoid the antibiotic resistance,
Isnaeni scientists nowadays develop extracts and biological
Chemistry Pharmacy, Faculty of Pharmacy, Universitas active compounds isolated from nature that used for
Airlangga, Dharmawangsa Dalam Street No.4 ‑ 6, herbal medicine (3).
Airlangga, Surabaya (60286), Indonesia
Exploring the probiotics usage is one of the ways
e‑mail: [email protected]
to resolve that problem. Probiotic contains hydrogen
Phone Number: +6281999201024
396 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
peroxide (H2O2), organic acids, and peptide compounds Probiotic milk Lactobacillus paracasei and honey
namely bacteriocin which are active as antibacterial(4). of mango Mangifera indica have a different ingredient,
Probiotic milk Lactobacillus paracasei has ability to which is active as antibacterial. This study will observe
inhibit the growth of pathogenic bacteria S. mutans in its the antibacterial activity of combination of probiotic
host(5). Consuming probiotics regularly can inhibit the milk Lactobacillus paracasei and honey of mango
growth S. mutans without causing side effects. Mangifera indica in various ratio, then it will be found
the combination of both ingredients in certain ratio which
In addition to probiotics, currently it has been has maximum antibacterial activity(10). The purpose of
developed the treatment using natural ingredients that this study is to observe the best ratio of mango honey
have activity as antimictobial, on of which using honey. and probiotic milk to impede the growth of mutans.
Honey is a sweet liquid that derived from plant nectar,
which processed by bees and stored in honeycomb Materials and Method
cells(4). The high consentration of sugar in honey, which Materials: The samples includes, Lactobacillus
is 38.5% fuctose, can cause hipertonic condition that paracasei ATTCC BAA52 honey mangoes and
promotes bacterial cell plasmolysis. It results inhibiting Streptococcus mutans. The media was de Man Ragosa
bacterial growth and promoting bacterial cell death(6). Sharpe Agar (MRS) (Himedia Lab), Müeller Hinton
The carbohydrates in honey are in the form of reducing Agar (OXOID), NaCl (Pa Merch), clindamycin
sugars, which are glucose and fructose, with minimum antibiotic (p.g.) as positive control group, and sterile
content is 65% (7). destilled water from the Microbiology Laboratory.
Both probiotic milk and honey have antibacterial Equipment: The equipment that used in this study
activity with different mechanism(8). Probiotic milk were analytic scales (Sartorius BL10S), incubator
Lactobacillus paracasei contains hydrogen peroxide (Menmert), Öse (Sengkelit), ring (Silinder), vernier
(H2O2), organic acids, and peptide compounds namely caliper (Jason), vortex (Maxi Mix II Type 37600),
bacteriocin which are active as antibacterial(9). Honey micro pipette (Socorex), autoclaf (Huxley HL‑340),
also has ability to inhibit the growth of phatogenic spectrophotometer (Parkin Elmer Lambda EZ201),
bacteria, such as E. coli, Listeria monocytogenes, and ependorf, shaker, colony counter, centrifuge (EBA 20),
S. aureus, which is influenced by the concentration of Oswald viscocity‑meter, Cup and Bob viscocity meter,
reducing sugars and high concentration of sucroses in pH meter (Schott glass mainz tipe CG 842), laminar
honey (6). air flow cabinet, petri dish and the other laboratory
glassware.

Results
Table 1: The minimum inhibitory concentration of probiotic Lactobacillus paracasei against Streptococcus
mutans in various concetrations (% v/v)

Probiotic Milk The diameter of inhibitory zone against Streptococcus mutans (mm)
Mean + SD
Concentration (% v/v) Replication 1 Replication 2 Replication 3
100 15,35 16,40 15,75 15,38 + 0,53
90 14,10 14,95 15,05 14,70 + 0,52
80 11,75 12,05 11,55 11,78 + 0,25
70 11,60 11,85 11,05 11,50 + 0,41
60 11,05 11,75 10,80 11,20 + 0,49
55 11,00 10,50 10,45 10,65 + 0,30
Control (+) 26,75 26,70 27,20 26,88 + 0,28

The results showed the minimum inhibitory concentration of probiotic milk Lactobacillus paracasei
concentration of probiotic milk Lactobacillus paracasei was less than 55%, so it could not inhibit the growth of
against Streptococcus mutans is 10.65 + 0.30 mm Streptococcus mutans.
at concentration 55%. It can be interpreted if the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 397
Table 2: The minimum inhibitory concentration of honey of mango in various concentration (% v/v)

Concentration of honey The diameter of inhibitory zone against Streptococcus mutans (mm)
Mean + SD
of mango (% v/v) Replication 1 Replication 2 Replication 3
50 14,80 16,55 17,35 16,23 + 1,30
25 13,50 13,20 12,00 12,90 + 0,79
12,5 ‑ ‑ ‑ ‑
6,2 ‑ ‑ ‑ ‑
3,1 ‑ ‑ ‑ ‑
1,6 ‑ ‑ ‑ ‑
Control (+) 26,75 26,70 27,20 26,88 + 0,28

The result shows that the minimum inhibitory mutans. It can be interpreted if the concentration of
concentration of honey of mango was 10,40 + 0,96 mm at honey of mango solution that was less than 17.5%, could
concentration 17.5% against the growth of Streptococcus not inhibit the growth of Streptococcus mutans.

Table 3: The minimum inhibitory concentration of honey of mango in various concentration (% v/v)

Concentration of honey The diameter of inhibitory zone against Streptococcus mutans (mm)
Mean + SD
of mango (% v/v) Replication 1 Replication 2 Replication 3
22,5 11,95 11,80 12,40 12,13 + 0,24
20 11,50 11,20 10,05 10,91 + 0,77
17,5** 9,50 11,40 10,30 10,40 + 0,96
15 ‑ ‑ ‑ ‑
Control positive 26,75 26,70 27,20 26,88 + 0,28

The measurement diameter of inhibitory zone was conducted at ratio 1:9, 2:8, 3:7, 4:6, 5:5, 6:4, 7:3,
of combination honey of mango and probiotic milk 8:2, 9:1. The antibacterial activity was determined by
Lactobacillus paracasei against tested bacterial in various the clear zone around hole, that could be measured. To
concentration is displayed in Table 5 and Figure 4. The obtain the combination which had maximal antibacterial
test of antibacterial activity of the combination honey activity could be done by measuring the diameter of
of mango and probiotic milk Lactobacillus paracasei inhibitory zone using Varnier Caliper(9).

Table 4. The antibacterial activity of the combination honey of mango and probiotic milk Lactobacillus
paracasei against Streptococcus mutans at vairous ratio (% v/v)

Diameter of Inhibitory Zone (mm)

The ratio of (% v/v) honey of mango
Mean SD
solution 50% : probiotic milk Replication 1 Replication 2 Replication 3
1:9 15,75 14,50 15,40 15,22 0,64
2:8 14,10 16,35 14,20 14,88 1,27
3:7 15,15 15,65 15,30 15,37 0,25
4:6 12,50 12,90 13,50 12,97 0,50
5:5 14,80 14,10 16,10 15,00 1,01
6:4 14,30 16,15 14,40 14,95 1,04
7:3 16,05 15,95 16,35 16,12 0,21
8:2** 17,35** 16,90** 17,10** 17,12** 0,22**
9:1 15,30 16,85 17,50 16,55 1,13
Honey of mango solution 50% 14,80 16,55 17,35 16,23 1,30
Probiotic milk L. paracasei 100% 12,95 14,50 14,15 13,87 0,81
Control positive 18,15 18,10 18,10 18,12 0,03
398 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Discussion the optimum combination characterization was carried

out, which included organoleptic (color, taste odor), pH,
The result of this research shows the positivity.
viscosity and specific gravity (14). Based on the results
The combination of honey of mango and probiotic
of the selected combination characterization it has a pH
milk L. paracasei at the ratio 8:2 showed the optimum
of 3.89 + 0.00, the viscosity is 5.33 ± 0.390 cps and the
antibacterial activity against S. mutans, with diameter of
specific gravity is 1.096 ± 0.000 g/mL.
inhibitory zone as 17,12 + 0,22 mm. Based on statistical
analysis using one way ANOVA, the combination honey In the combination of honey of mango and probiotic
of mango and probiotic milk L. paracasei at the ratio of milk L. paracasei at the optimum ratio 8:2, there was
8: 2 did not show a significant difference in antibacterial a synergistic effect even though the concentration of
activity compared to the inhibition zone of 50% honey probiotic milk was less than honey of mango (14). It
of mango solution. Despite the diameter of inhibition caused by honey of mango containing more sources
zone of probiotic milk L. paracasei is greater than the which can be used as an energy for probiotic bacteria
diameter of inhibition zone of a honey of mango solution. L. paracasei. In a combination honey of mango and
However, when compared to the inhibitory zone of probiotic milk L.paracasei, honeyof mango can play
probiotic milk L. paracasei, there were significant a role in two things, namely as an energy source for
differences in antibacterial activity (11). probiotic milk bacteria L. paracasei or can inhibit the
growth of probiotic milk bacteria L. paracasei (15). This
The result shows that there was a decrease in the
study examnies the effect honey of mango on the growth
diameter of the inhibition zone along with the decreasing
of probiotic bacteria L. paracasei, proved that mango
concentration of honey of mango. It can be seen from the
honey did not inhibit the growth of probiotic bacteria L.
diameter of the inhibition zone produced by 50% and
paracasei.
25% honey of mango of 13.03 + 0.15 mm and 13.03
+ 0.57 respectively. While the concentration honey of The analysis of antibacterial activity in this study
mango below 25% did not produce antibacterial activity. using difusion method, because of its advantages. This
The test results showed that the MIC of mango honey method is quite simple, does not require long time and
solution to S. mutans was at a concentration of 17.5% preparation, and can also be used to see the senstivity of
with a inhibition zone diameter of 10.40 + 0.96 mm. antibacterial samples at certain concentratiom of various
types of tested bacteria (16). The standard solution used in
After that, the determination of MIC in probiotic
this study was clindamycin with a concentration of 0.01
milk L. paracasei was carried out at various
ppm which was previously optimized for the antibacterial
concentrations, namely at concentrations of 100%, 90%,
activity of clindamycin with various concentrations of
80%, 70%, 60%, 55%, 50%, 45%, 25%, 12.5%, 6.2%,
S. mutans (3). A concentration of 0.01 ppm was chosen
3.1% and 1.6%. In the result was found that the MIC of
because at concentrations above 0.01 ppm clindamycin
probiotic milk L. paracasei against S. mutans was at a
produced a diameter of the inhibition zone that was too
concentration of 55%, with a inhibition zone diameter of
large which could lead to difficulty of measuring the
10.65 + 0.30 mm. By knowing the MIC of probiotic milk
diameter of the sample inhibition zone. Clindamycin is
L. paracasei at a concentration of 55%, it proved that
chosen as a standard solution or positive control because
probiotic milk L. paracasei has a smaller antibacterial
it is an effective antibacterial used to cure tooth damage
activity compared to honey of mango which has MIC at
due to the growth of Streptococci bacteria (17).
a concentration of 17.5% (12).

The result showed the combination honey of mango Conclusion

and probiotic milk L. paracasei at the selected ratio was Based on the results of this study, it can be
25% with inhibition zone diameter 13.03 + 0.57 mm concluded that the Minimum Inhibitory Concentration
against S. mutans. When compared to MIC each sample (MIC) of probiotic milk Lactobacillus paracasei
of honey of mango and probiotic milk L. paracasei, it ATCC BAA52 on Streptococcus mutans was 55%,
can be said that the combination of honey of mango and with inhibition zone diameter of 10.65 + 0.30 mm.
probiotic milk L. paracasei at the selected ratio has a Minimum Inhibitory Concentration (MIC) of honey
minimum inhibitory concentration greater than honey of mango solution against Streptococcus mutans was
of mango (13). But it is lower than the concentration 17.5%, with inhibition zone diameter 10.40 + 0.96 mm.
minimum inhibition of probiotic milk L. paracasei. Then
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 399
Minimal Inhibition Concentration (MIC) combination monoesters suppressing cell growth of
of honey of mango (Mangifera indica) and probiotic Streptococcus mutans in the presence of sucrose.
milk Lactobacillus paracasei ATCC BAA52 at a ratio Curr Microbiol. Springer; 2000;41(3):210–3.
of 8: 2 to Streptococcus mutans by 25% with inhibition 8. HERMAWATI AH. AKTIVITAS KOMBINASI
zone diameter 13.03 + 0.57 mm. MADU MANGGA dan SUSU PROBIOTIK
SEBAGAI ANTIBAKTERI TERHADAP
Ethical Clearance: This research process did not
Staphylococcus aureus ATCC 6538 dan
involve any participant in the survey, but instead using
Escherichia coli ATCC 8739 PENELITIAN
agar diffusion method in laboratory in accordance with
EKSPERIMENTAL LABORATORIS. Universitas
the ethical research principle based on the regulation of
Airlangga; 2016.
research ethic committee. The present study was carried
out in accordance with the research principles. This 9. Mufida L, Setijanto RD, Palupi R, Bramantoro
study implemented the basic principle ethics of respect, T, Ramadhan C, Ramadhani A. Caries and dental
beneficence, non‑maleficenct, and justice. and oral hygiene profile of drug (narcotics and
dangerous drugs) users at drug rehabilitation
Conflict of Interest: There is no report about any centers. J Int Oral Heal. Medknow Publications;
conflict related with this author’s research. 2019;11(7):6.

Source of Funding: This study is funded by the 10. Yudaniayanti IS, Primarizky H, Nangoi L. The
author self only. effects of honey (Apis dorsata) supplements on
increased bone strength in ovariectomized rat as
References animal model of osteoporosis. In: AIP Conference
Proceedings. AIP Publishing; 2018. p. 20004.
1. Hamada S, Slade HD. Biology, immunology, and
11. Samot J, Badet C. Antibacterial activity of probiotic
cariogenicity of Streptococcus mutans. Microbiol
candidates for oral health. Anaerobe. Elsevier;
Mol Biol Rev. Am Soc Microbiol; 1980;44(2):331–
2013;19:34–8.
84.
12. Israili ZH. Antimicrobial properties of honey. Am J
2. Addy M. Oral hygiene products: potential for harm
Ther. LWW; 2014;21(4):304–23.
to oral and systemic health? Periodontol 2000.
Wiley Online Library; 2008;48(1):54–65. 13. PANGESTU L. DAYA HAMBAT PROBIOTIK
TERHADAP PERTUMBUHAN KOLONISASI
3. Yadav NR, Garla BK, Reddy VK, Tandon S, Prasad
Streptococcus mutans. Universitas Airlangga;
S. Antimicrobial Effect of Honey on Streptococcus
2017.
Mutans of Dental Plaque. J Oral Heal Community
Dent. 2014;8(2). 14. Steinberg D, Kaine G, Gedalia I. Antibacterial
effect of propolis and honey on oral bacteria. Am J
4. Bogdanov S, Jurendic T, Sieber R, Gallmann P.
Dent. 1996;9(6):236–9.
Honey for nutrition and health: a review. J Am Coll
Nutr. Taylor & Francis; 2008;27(6):677–89. 15. Li P, Gatlin III DM. Dietary brewers yeast and
the prebiotic GrobioticTM AE influence growth
5. Truusalu K, Naaber P, Kullisaar T, Tamm H,
performance, immune responses and resistance of
Mikelsaar R‑H, Zilmer K, et al. The influence of
hybrid striped bass (Morone chrysops× M. saxatilis)
antibacterial and antioxidative probiotic lactobacilli
to Streptococcus iniae infection. Aquaculture.
on gut mucosa in a mouse model of Salmonella
Elsevier; 2004;231(1‑4):445‑56.
infection. Microb Ecol Health Dis. Taylor &
Francis; 2004;16(4):180–7. 16. Liang C‑C, Park AY, Guan J‑L. In vitro scratch
assay: a convenient and inexpensive method for
6. Mundo MA, Padilla‑Zakour OI, Worobo RW.
analysis of cell migration in vitro. Nat Protoc.
Growth inhibition of foodborne pathogens and
Nature Publishing Group; 2007;2(2):329.
food spoilage organisms by select raw honeys. Int J
Food Microbiol. Elsevier; 2004;97(1):1–8. 17. Lee SS, Zhang WU, Li Y. The antimicrobial
potential of 14 natural herbal dentifrices: results
7. Watanabe T, Katayama S, Matsubara M, Honda
of an in vitro diffusion method study. J Am Dent
Y, Kuwahara M. Antibacterial carbohydrate
Assoc. Elsevier; 2004;135(8):1133–41.
400 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Prevalence of Premarital Sex among Adolescents in Kulende,

Sango in Ilorin South Local Governmrnt Area,
Kwara State, Nigeria

Oniyangi, Shuaib Olanrewaju1, Jamiu Abdul Qudus Tosin1,

Umar Ibrahim Babangida2, Ahmad Makama Getso2, Sindama Helen3
1Department of Health Promotion and Environmental Health Education,University of Ilorin. Ilorin,
2
Department of Physical and Health Education, Bayero University, Kano, 3University of Jos, Plateau, Nigeria

Abstract
Premarital sex is explained as a penetrative vaginal or anal sexual intercourse performed between couples
before formal marriage. It is characterized as being unanticipated, unpredictable, inconsistence with values
and personality, uncontrollable and becoming the common feature of adolescents. This study investigated (i)
peer pressure and (ii) poor parents‑adolescent communications as factors influencing premarital sex among
adolescents in Kulende, Sango, Ilorin South Local Government Area, Kwara State, Nigeria. A descriptive
research design of survey type was employed for this study. The population for the study comprised of all
Adolescents in Kulende, Sango, Ilorin South Local Government Area, Kwara State, Nigera. A multistage
sampling technique was used for the study. Simple random sampling technique was used to select four
two hundred (200) respondents for the study. Researcher’s designed structured questionnaire which was
validated by four experts from the Departments of Health Promotion and Environmental Health Education;
University of Ilorin. A correlation co‑efficient of .75r was obtained through test re‑test method using Pearson
Product Moment Correlationon respondents outside the study sample. Data collection was conducted by
the researchers and four trained research assistants. The two postulated null hypotheses were tested using
the inferential statistics of chi‑square @0.05 alpha level. The finding of this study revealed that i. Peer
Pressure influenced premarital sex among adolescents in Kulende, Sango, Ilorin South Local Government
Area, Kwara State, Nigeria with the calculated chi‑square (ᵪ2) value of 159.842 is greater than the table
chi‑square (ᵪ2) value of 16.92 at the freedom (df) 9 @ 0.05 alpha level and ii. Poor Parents‑adolescents
communications influenced premarital sex among adolescents in Kulende, Sango, Ilorin South Local
Government Area, Kwara State with the calculated chi‑square (ᵪ2) value of 165.853 is greater than the
table chi‑square (ᵪ2) value of 16.92 at the freedom (df) 9 @ 0.05 alpha level. Based on the findings of the
study it was concluded that peer pressure and poor parents‑adolescent communication influenced premarital
sex among adolescents in Kulende, Sango, Ilorin South Local Government Area, Kwara State, Nigeria.
Therefore,it was recommended that i. teachers and school guardians should sensitize their students on the
influence of peers in the engagement of adolescents in premarital sex and ii. parents and guardians should
take it as their responsibility to create an intimacy, a good relationship and communication skills with their
children as this will limit adolescent’s early exposure to premarital sex.

Keywords: Prevalence, Premarital, Sex and Adolescents.

Introduction is need to apply caution and restraint. Sexual activities

among adolescents have been reported to be increasing
Sex is one of the most profound emotionally
worldwide. Several studies in sub‑Saharan Africa have
charged, mysterious experiences that mortals have. Its
also documented high and increasing premarital sexual
necessity and importance in proper adult’s physical and
activities among adolescents9. Premarital sex is an act of
emotional functioning is incontrovertible. However, in
deviation, it is a departure from social norms that attract
order for it not to have negative consequences, there
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 401
social disapproval which is likely to elicit negative Peer group influence is another factor that
sanctions1. encourages premarital sex.They were of the opinion that
young people often face enormous pressure especially
Furthermore, Pre‑marital sex is explained as from peers to engage in sex. Most information for their
a penetrative vaginal or anal sexual intercourse knowledge comes from peers of the same sex who may
performed between couples before formal marriage. It themselves lack adequate information or are incorrectly
is characterized as being unanticipated,unpredictable, informed. Growing peer pressure of premarital sex
inconsistence with values and personality, uncontrollable plays major role in sexual decision making among
and becoming the common feature of adolescents. More youths12. Furthermore, Gender is an important factor in
than half of the world population constitutes young understanding attitudes towards sexual intercourse. It
people that are less than 25 years old, and majority of the is a factor which is consistent with findings from Asian
populations live in developing country. Starting from a countries, whereas, premarital sexual activity for boys is
recent time, premarital sexual action during adolescence considered a socially acceptable rite of passage8, while
and emerging adulthood leads to a wide range of girls tend to be labeled and stigmatized, and are often
adverse outcomes in sub Saharan Africa which include blamed for sexual encounters that result in pregnancy and
unintended pregnancies, illegal abortions, and sexually sexually transmitted infections. It is likely that both girls
transmitted Infections10. and boys internalize subtle and overt messages about
Premarital sex and early initiation of sexual activity gender roles from friends, family and society which, in
may prolong the period of exposure to risks of unwanted turn, shape different attitudes and beliefs about sexual
pregnancy and contracting Sexually Transmitted initiation. However, the process by which gender roles
Diseases (STDs) such as HIV/Aids during their influence the attitudes and beliefs about gender‑distinct
reproductive life span2. Ethiopia is one of the country sexual initiation has rarely been studied, especially in
where an increasing number of adolescents are involved Asian societies that are influenced by Confucianism
in unsafe sexual practices and hence face undesired having doctrines on gender role5.
outcomes such as unplanned pregnancy, early childbirth, Premarital behaviours of adolescents, tend to pose
unsafe abortion and sexually transmitted disease. High major threats to life and the future of the country as they
level synthesis may be enhanced as a result of an involved in reckless sexual activities10. Public opinion
increasingly large number of adolescent’s enrolment polls have consistently shown that premarital sex is
in preparatory schools11. Recently, early initiation to wrong and dangerous to health, resulting in abortions,
sexual intercourse without having proper protection has teenage mothers and sexually transmitted disease. In
been one of the concerns. Adolescents often encounter sub‑Saharan Africa, HIV infection is primarily spreading
high risk situations, such as contracting STDs, HIV/ through heterosexual relations. Young people are the
AIDS and often experience unintended pregnancy, illicit most vulnerable to HIV infection. They are also the most
abortion and its negative sequel7. affected as they are often called upon to carry the burden
In Southwestern Nigeria, sex before now was of caring for risk family members4.
regarded as sacred and limited only to adult males and Statement of the problem: The researcher
females within marriage but today, many adolescents observed that the prevalence of premarital sex among
engage in various delinquent behaviour such as drinking adolescents in Kulende, Sango Society in Ilorin South
of alcohol, smoking and premarital sexual activities. Local Government Area of Kwara State is high, and
Furthermore, it was discovered that the prevalence of this leads to high incidence of unintended pregnancies,
premarital sex among adolescents was caused as a result contraction of sexually transmitted diseases, induced
of certain social and demographic factors among which abortion and death. The prevalence of premarital
include age, gender, parental style, culture, religion, sex among the adolescents is due to the influence of
peer influence, among others. Concluded. Among the social and demographic factors such as gender, age,
background variables considered mother education, family background, peer pressure, parent education,
age, ethnicity and employment status were among the age, ethnicity, socio‑economic status, religion, and
most important predicators of attitudes towards women parents‑adolescents communication. The researcher
premarital activity3. observed that gender is one of the factors influencing the
prevalence of premarital sex among adolescent. It was
402 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
observed that male adolescents are more engaging in induced abortion, depression, feeling guilt and shame
premarital sex than their female counterparts because it among others. In this study, the issue of premarital
was believed that boys are the initiator of premarital sex. sexual practice among students is fast emerging as a
serial social and public health problem. Based on this
Adolescent is typified by great energy, pursuit of study the researcher intends to explore the prevalence
adventure, dating, experimentation with sex and the of premarital sex among adolescents in Kulende, Sango,
attendant outcomes most often compromise the young Ilorin South LGA, Kwara state.
person’s sexual and reproductive health. The desire to be
regarded as the “macho man” makes boys to start having Research Questions:
sex early and to indulge in risky sexual behavior. Most
girls are coerced into having sex by adolescent boy friends The following questions were raised to guide this
who want to prove masculinity. Furthermore, the age is study
also a predicator for the prevalence of premarital sex 1. Will peer pressure influence premarital sex among
among adolescents. The researcher observed that most adolescents in Kulende,Sango, Ilorin South Local
adolescents engage in premarital sex at early ages, and Government Area, Kwara State, Nigeria?
this has caused a lot of serious problem to them because
there is no background knowledge of what premarital 2. Will parent‑adolescents communication influence
sex is all about. For this cause, adolescents (11‑19years) premarital sex among adolescents in Kulende,
are under the risk associated with premarital sex such as Sango, Ilorin South Local Government Area, Kwara
psychological imbalance, anxiety, feeling guilt and loss State, Nigeria?
of self‑respect. Research Hypotheses:
The researcher also observed that adolescents The following hypotheses were formulated for
in Sango area of Ilorin South do not have good this study.
parent‑adolescents communication style such as talk on
sex education, sexual health matters among others, and Ho1. Peer pressure will not significantly influence
this contributes to the prevalence of premarital sex among premarital sex among adolescents in Kulende,Sango,
them. The supply and amount of parental emotional Ilorin South Local Government Area, Kwara State,
resources for control can have a significant influence Nigeria.
on the youth to have or not to engage in premarital sex.
Ho2. Parent‑adolescents communication will not
Due to ineffective communication and good upbringing
significantly influence premarital sex among adolescents
between parents and adolescents, most adolescents are
in Kulende,Sango, Ilorin South Local Government Area,
exposed to premarital sex. Also, due to lack of control,
Kwara State, Nigeria.
the adolescent can contract sexually transmitted diseases
or even thought of having abortion that may lead to death Research Methodology:
or obstetric complications. The researcher also observed
that peer influence is also considerable predicting factor Descriptive research design of survey type was
for prevalence of premarital sex among the adolescents. used for this study. The Population for this study
Peers like roommates, classmates, club associates and comprised all individuals between ages of 18 to 20 years
other members of one’s social group members equally in Ilorin South Local Government Area, Kwara State,
influence one to be a deviant or conformist. In the cause Nigeria. The target population of this study consisted
of peer pressure, most adolescents are lured into the of adolescents in Kulende, Sango Area in Ilorin South
practice of sexual deviant behaviors such as adulteries, Local Government Area, Kwara State, Nigeria.A Multi‑
alcohol dinking, premarital sex, drug abuse, smoking stage sampling technique was adopted for this research.
among others. Simple random sampling technique was used to select
respondents (adolescents) in four (4) Secondary Schools
These predicting factors has led to various health and Market places in Ilorin South Local Government.
and emotional issues among the adolescents among Purposive sampling technique was used to select
which include, dropping out from school, unintended or adolescents from ages (18‑20) due to their maturity. In
unwanted pregnancy, contraction of sexually transmitted the second stage proportionate sampling technique of
diseases (Human papilloma virus, herpes, HIV/Aids etc), 10% was used for the study. Simple random sampling
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 403
technique was used to select the actual respondents for Hypothesis 2: Parents‑adolescents communication
the study. The instrument that was used in collecting data will not significantly influence premarital sex among
for this research is a researcher designed questionnaire. adolescents in Kulende, Sango, Ilorin South Local
David (2007) stated that a questionnaire allows the Government Area, Kwara State, Nigeria. The calculated
researcher to collect required information quickly and chi‑square value of 149.491 was greater than the
accurately from a large number of people at the same critical value of 16.92 at degree of freedom of 9 @
time. The questionnaire titled “Prevalence of Premarital 0.05 alpha level, the result of hypothesis two revealed
Sex among Adolescents in Kulende, Sango, Ilorin South that parents‑adolescents communication influenced
Local Government Area, Kwara State, Nigeria” consist premarital sex among adolescents in Kulende, Sango,
of two (2) sections. Section A contain demographic Ilorin south Local Government Area, Kwara State,
information of the respondents, while section B elicit Nigeria. The result of this findings agrees with a
information on prevalence of Premarital Sex among research which affirmed that frequency of parent‑child
Adolescents in Sango, Kulende in Ilorin South Local communication about sex is the most common variable
Government Area, Kwara State, Nigeria. The items were used to study parental impact on adolescent’s sexual
based on the 4‑points Likert scale of Strongly Agreed attitudes and behaviours6.
= 4 (SA), Agreed =3 (A),Disagreed=2 (D),and Strongly
Disagreed=1 (SD).In order to ascertain the validity of Recommendations:
the instrument, three drafted copies of the questionnaire The following are the recommendations based on
was given to three (3) experts in Departments of Health the outcome of this research;
Promotion and Environmental Health Education,
University of Ilorin, Nigeria. Their suggestions and 1. Teachers and school guardians should sensitize
comments were used to make the final draft of the their students on the influence of peers in the engagement
instrument. The reliability of the instrument was carried of adolescents in premarital sex.
out using test re‑test technique. Twenty (20) copies of
questionnaire were given to twenty (20) respondents 2. Parents and guardians should take it as a thing
outside the case study area after two (2) weeks another of responsibility to create an intimacy and have a
twenty copies were administered to the same respondents. good relationship and communication skills with their
The result of the first administration was compared children as this will limit adolescent’s early exposure to
with the second administration using Pearson Product premarital sex.
Moment Correlation (PPMC).A coefficient of 0.75r was Ethical Clearance: Taken from Faculty of
arrived at which shows that the instrument is reliable Education Ethical Review Committee, University of
for the study. Description statistics of frequency count Ilorin. Ilorin, Kwara State, Nigeria.
and percentage was used to analyze the demographic
data of the respondents, while non‑parametric statistic Source of Funding: Self
of chi‑square was used to test the four (4) postulated
Conflict of Interest: Nil
hypotheses at 0.05 alpha level.

Results/Discussion of Findings References

Hypothesis 1: Peer pressure will not significantly 1. World Health Organization, Joint United Nations
influence premarital sex among adolescents in Kulende, Program on HIV/AIDS and United Nations
Sango, Ilorin South Local Government Area, Kwara Population Fund. Seen but Not Heard: Very young
State, Nigeria. The calculated chi square value of adolescents aged 10–14 years, UNAIDS, Geneva;
159.842 was greater than critical table value of 16.92 at 2004.
the degree of freedom of 9 @ 0.05 alpha level of 0.05, 2. Abdullahi M, Umar A. Consequences of Pre‑marital
the result of hypothesis one revealed that peer pressure Sex among the Youth: a study of University of
influenced premarital sex among adolescents in Kulende Maiduguri. Journal of Humanities and Social
Sango of Ilorin South Local Government Area of Sciences. 2013; 10 (1) 10 ‑17.
Kwara State, Nigeria. This was supported by a research 3. World Health Organization Region.HIV/AIDS
which was of the opinion that young people often face Epidemiological Surveillance Report for the WHO
enormous pressure from peers to engage in sex4. African Update Retrieved from 20 may 2017http://
404 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
www.who.int/hiv/pub/me/afro_epi_sur_2007.pdf. 9. Smith LH, Guthrie BJ, Oakley DJ. Studying
4. Alemayehu B. Premarital sexual practices and its Adolescent Male Sexuality: Where Are We? J
predictors among in school youths,north western Youth Adolescence. 2005; 34:361–377.
Ethiopia. Journal of Reproductive Health. 2013; 10. Kaljee LM, Green M, Riel R. Sexual Stigma, Sexual
11: 49. Behaviors, and Abstinence among Vietnamese
5. Wouhabe M. Sexual behaviour, knowledge and Adolescents: Implications for Risk and Protective
awareness ofrelated reproductive health issues Behaviors for HIV, Sexually Transmitted
among single youth in Ethiopia. African Journal of Infections, and Unwanted Pregnancy. Journal of
Reproductive Health. 2007; 11: 14‑21. the Association of Nurses in AIDS Care. 2007;
18(2): 4.
6. Seme A, Wirtu D. Premarital sexual practice
among school adolescents in Nekemte Town, East 11. Ayodele A, Ola O, Aliu Bose. prevalence of
Wollega. Ethiop J Health Dev. 2009; 22:167‑173. Pre‑marital Sex and Factors Influencing it among
Students in a Private Tertiary Institution in
7. Alo O, Akinsanya A, Israel S. Pre‑marital Sexual
Nigeria. International Journal of Psychology and
Activities in an Urban Society of Southwest –
Counseling,2012; 4 (1) 6 – 9.
Nigeria. 2012; 2 (1): 1‑ 14.
12. Maq OM, Cong L. Unintended Pregnancy and its
8. Wy L. Malaysian Youth Sexuality: Issues and
Risk Factors among University Students in Eastern
Challenges. JUMMEC. 2009; 12 (1): 3 – 14.
China. Contraception. 2008; 77(2):108–113. (Pub
Med: 18226674).
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 405

Perceived Effect of Sleep Deprivation on the Health of

Undergraduates in Kwara State University, Malete, Nigeria

Oniyangi, Shuaib Olanrewaju1, Jamiu Abdul Qudus Tosin1,

Umar Ibrahim Babangida2, Ahmad Makama Getso2, Sindama Helen3
1Department of Health Promotion and Environmental Health Education,University of Ilorin. Ilorin,
2Department of Physical and Health Education, Bayero University, Kano, 3University of Jos, Plateau, Nigeria

Abstract
Sleep is a physiological state occurring in alternation with wakefulness, and its duration and quality are
equally important for the quality of life, sleep deprivation on the other hand is described as not obtaining
adequate total sleep or a condition of not having enough sleep. This study therefore examined the Perceived
Effect of Sleep Deprivation on the Health of Undergraduates in Kwara State University Malete Kwara State.
The study investigated; (i) Physical Health; & (ii) Mental Health; as Perceived Effect of Sleep Deprivation.
A descriptive research design of survey method was used for the study. The population of the study consists
of all undergraduates in Kwara State University. A multi stage sampling techniques was used to select
284 respondents for the study, Researcher’s designed questionnaire was validated, by the supervisor and
three experts from the Department of Health Promotion and Environmental Health Education, University
of Ilorin. A correlation co‑efficient ‘r’ of 0.7 was obtained through split half method using Pearson Product
Moment Correlation. Data collection was conducted by the researchers and other trained research assistants.
The two postulated null hypotheses were tested using the inferential statistics of chi‑square @0.05 alpha
level. The findings from the study revealed that; i. Sleep deprivation have effect on undergraduates Physical
Health with the calc. X2 value of 247.01 ˃ table X2 value of 16.92 at the freedom df 9 @ 0.05 alpha level
and ii. Sleep deprivation have effect on undergraduates Mental Health with the calc. X2 value of 132.14
˃ table X2 value of 16.92 at the freedom df 9 @ 0.05 alpha level. Based on the findings,it was concluded
that sleep deprivation had effects on physical health and mental health, of Undergraduates in Kwara state
University, therefore it was also recommended that Undergraduates should be enlightened deeply on the
adverse physical and mental health effect that sleep deprivation can have on their health. These can be done
through public health sensitisation and advocacy by Federal Government, State Government, NGO’s, and
the University Lecturers and Health Worker. The mass media and social media also have their part to play
in public health education and also religion leaders can also invite health workers to enlighten the entire
congregation on the best sleeping practices.

Keywords: Perception, Effect, Deprivation, Health and Undergraduates.

Introduction fewer people are getting enough sleep each night and
more are slowly becoming sleep deprived. Sleep
Sleep deprivation consists either in a complete lack
deprivation is defined as a condition that occurs when
of sleep during a certain period of time or a shorter‑than
an individual does not get enough sleep each night.
optimal sleep time. The most common causes of sleep
We spend almost a third of our life sleeping, Good
deprivation are those related to contemporary lifestyle,
quality sleep is essential for good health and well‑being.
school‑related factors, and work‑related factors; thus the
However, lifestyle and environmental factors are
condition affects a considerable number of people. A
increasingly causing difficulties in sleeping. Sleep
chronic reduction in the sleep time or the fragmentation
disturbance is frequently considered the most serious
of sleep, leading to the disruption of the sleep cycle11.
consequence of environmental noise14.
Sleep is a major aspect in our everyday lives; however,
406 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Behaviors such as managing diet, exercising, When deprived of sufficient sleep, most of us feel sleepy
and getting regular health checks are all important to and physically drained, our mood is noticeably flattened
promoting good health. Likewise, avoiding harmful if not somewhat dour, and our thinking feels sluggish
behaviors like smoking and substance abuse are also very and unfocused. Even to the non‑expert, sleep has obvious
important behaviors. However, unlike these behaviors, importance for sustaining normal functioning at several
there is one behavior that is shared, regardless of levels, including basic alertness, emotional experience
background, and socioeconomic status. That behavior is and a host of complex cognitive processes13.
sleep. Like the passage of time, sleep is an absolute part
of life. Sleep is also a part of life that is often overlooked In a research study carried out, it was suggested
as it relates to health. While sleep is as important to that overall sleep deprivation strongly impairs human
life as nutrition, it is often taken for granted, and even functioning. Moreover, they found that mood is more
considered unimportant or unnecessary. Not only is affected by sleep deprivation than either cognitive or
sleep an absolute requirement for good health, like motor performance and that partial sleep deprivation
nutrition and exercise, the amount and type of sleep have has a more profound effect on functioning than either
a significant impact on both physical, social, and mental long‑term or short‑term sleep deprivation. In general,
health. Poor sleep health is a common problem, with 25% these results indicate that the effects of sleep deprivation
of U.S. adults reporting insufficient sleep or rest at least may be underestimated in some narrative reviews,
15 out of every 30 days3. Therefore, as a health behavior, particularly those concerning the effects of partial sleep
proper sleep has the potential to provide significant deprivation5.
health benefits. This is especially true for certain age However, over the last decades, there has been
groups; primarily those in the 18‑24‑year‑old age group growing evidence suggesting a strong association
who suffer the highest rate of sleep deprivation8. between sleep duration and mortality risk, with some
Sleep is essential for a person’s health and evidence suggesting that individuals sleeping between
wellbeing. Surveys conducted by the NSF reveal that at seven and nine hours’ nightly, experience the lowest
least 40 million Americans suffer from over 70 different risks for all‑cause mortality, whereas those who sleep
sleep disorders and 60% of adults’ are reported having for shorter or longer periods have significantly higher
sleep problems a few nights in a week or more9. A Study mortality risks11. Insufficient sleep duration has been
indicate that sleep problems result from abnormalities in linked with seven of the fifteen leading causes of death
both physiological systems such as: brain and nervous in the U.S. including cardiovascular disease, malignant
system, cardiovascular system, metabolic functions, neoplasm, cerebrovascular disease, accidents, diabetes,
and immune system as well as unhealthy conditions septicaemia and hypertension6.
such as: hypertension, emotional disorders, obesity, and Finally, insufficient sleep is often the norm among
substance abuse1.Recent findings show that acute sleep many professions, such as medical residents, military
deprivation and looking tired are related to decreased personnel and shift‑workers. Thus, scientific study of the
attractiveness and health, as perceived by others. This effects of sleep deprivation can provide unique insights,
suggests that one might also avoid contact with sleep not only regarding the nature and function of sleep but
deprived, or sleepy looking, individuals, as a strategy to also of practical importance for enhancing the Health
reduce health risk and poor interactions2. and wellbeing of workers who must perform optimally
Furthermore, it is well established that enough despite periods with little to no sleep13. Sleep at the same
and undisturbed sleep are essential for an individual’s time is well identified as a complex biological process
personal wellbeing and the ability to perform correctly. that is a very essential component of human health and
With the increasing economic and social demands wellbeing. The way that sleep is regulated in the body is
of the modern society, more and more people work similar to the manner in which other necessary function
and stay active outside the regular day and curtail are controlled, such as eating and breathing. Sleep pays a
their sleep. The negative effects of chronic sleep vital role in promoting Physical, Mental, and Emotional
restriction on productivity and Health have begun to Health12. This study therefore sought to determine the
appreciate as a Public Health concern, yet are still often Perceived Effect of Sleep Deprivation on the Health
underestimated4. Nothing seems to bring much clarity of Undergraduates in Kwara State University, Malete,
to the function of sleep as spending a night without it. Kwara State.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 407
Statement of the Problem: Receiving adequate Research Question:
sleep each night ensures proper maintenance of bodily
processes. Unfortunately, sleep deprivation is becoming This study aims at answering the following
an increasingly common problem in the society today. questions:
Many university undergraduates in the society suffer 1. Will sleep deprivation have effect on the Mental
from illnesses resulting in severe sleep deprivation. Health as perceived by Undergraduates’ in Kwara
Many other individuals, however, disregard the need State University?
for sleep in order to accommodate the daily activities
of life. Sleep deprivation is becoming especially 2. Will sleep deprivation have effect on the Physical
prevalent as longer study hours, medical problems and Health as perceived by Undergraduates’ in Kwara
voluntary behaviour are becoming an acceptable part of State University?
undergraduate’s culture1. Research Hypotheses:
The Centers for Disease Control and Prevention The following hypotheses will be tested in this
(CDC) in the United States has declared insufficient sleep study:
a public health problem. Indeed, according to a recent
CDC study, more than a third of American adults are 1. Sleep deprivation will not have effect on the Mental
not getting enough sleep on a regular basis10. However, Health as perceived by Undergraduates’ in Kwara
insufficient sleep is not exclusively a U.S. problem, State University.
and also concerns other industrialised countries such 2. Sleep deprivation will not have effect on the Physical
as the United Kingdom, Japan, Germany, or Canada9. Health as perceived by Undergraduates’ in Kwara
Everywhere you go, you hear people complain that they State University.
are tired and do not have any energy. Students stay up
late because they had to work the night before, in order Research Methodology: The research design
to pay for school, they are trying to finish an assignment adopted in this study is descriptive research design of
that is due the next day, there is some sort of issue at the survey type. The population for this study consists
home, or they decided they would rather do some other of all Undergraduates in Kwara State University,
leisure activity they enjoy rather than go to bed at a more Malete, Nigeria. The population is a total of 14,399
appropriate time. However, studies have shown that undergraduates, while the target population is a total of
sleeping is one of the most important things a person 4,734 undergraduates. Multi stage sampling techniques
must do. Sleep plays a vital role in learning and when was used for this study. Simple random sampling
a person fails to obtain enough sleep the night prior, technique of Fish Bowl method was used to select five (5)
neurons in the brain might not fire properly, the body colleges out of six (6) colleges in Kwara State University
becomes out of synch, and it can even lead to accidental Malete, Nigeria. Purposive sampling technique was
physical injuries1. used to select the 300 level and 400 level students in
all five selected colleges based on their experience and
According to recent evidence, the proportion of years spent in the university. Proportionate sampling of
people getting less than the recommended hours of sleep 6% was used to select the respondent. Simple random
is rising and is associated with lifestyle factors related sampling technique was used to select the actual
to a modern 24/7 society, such as psychosocial stress, respondent for the study. The instrument used for this
unbalanced diet, lack of physical activity and excessive study is a researcher‑designed questionnaire tagged
electronic media use, among10. This is alarming as Perceived Effect of Sleep Deprivation on the Health
insufficient sleep has been found to be associated with a of Undergraduates in Kwara State University. The
range of negative health and social outcomes, including questionnaire consists of two sections. Section A elicits
adverse performance effects at school and in the labour information on the demographic data of the respondents
market7. Insufficient sleep duration has been linked with such as gender, age, marital status etc. while Section
seven of the fifteen leading causes of death in the U.S. B consistof questions formulated from each of the
including cardiovascular disease, malignant neoplasm, hypotheses in the study. The instrument was presented
cerebrovascular disease, accidents, diabetes, septicaemia in a modified four points Likert rating scale of Strongly
and hypertension6. Agree (SA) = 4, Agree (A) = 3, Disagree (D) ‑ 2, Strongly
Disagree (SD) = 1. The instrument was validated
408 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
and tested for reliability and a coefficient of 0.7r was public health sensitization and advocacy by Federal
obtained which shows that the instrument is reliable for Government, State Government, NGO’s, and the
the study. Descriptive statistics of frequency count and University Lecturers and Health Worker.
percentage was used to analyze the demographic data
Ethical Clearance: Taken from Faculty of
while inferential statistics of chi‑square was used to test
Education Ethical Review Committee, University of
the hypotheses set at 0.05 alpha level.
Ilorin. Ilorin, Kwara State, Nigeria.
Results/Discussion of Findings Source of Funding: Self
Hypothesis 1: The calculated chi square value of
Conflict of Interest: Nil
247.01 is greater than critical table value of 16.92 at the
degree of freedom of 9 and significant level of 0.05, the References
result of hypothesis one revealed that Sleep Deprivation
have Effect on Physical Health as perceived by 1. Vgontzas AN, Liao D, Pejovic S, Calhoun S,
Undergraduates’ in Kwara State University, this finding Karataraki M, Basta M, Bixler EO. Insomnia with
was supported by a findings which affirmed that sleep short sleep duration and mortality. The Penn State
deprivation of less than 7 seven hours per night may cohort. Sleep. 2010. 33(9), 1159‑1164.
have wide ranging effect on the endocrine, immune and 2. World Health Organisation. Technical Meetion on
nervous system including obesity in adult and children, Sleep and Health. Bonn, Germany; 2004.
diabetes and impaired glucose tolerance, cardiovascular 3. Centers for Disease Control and Prevention.
diseases and hypertension, all these mirrors on the Perceived insufficient rest or sleep among adults.
physical health of an individual11. Epidemiology Program Office. 2008, 58(42), 1‑9.
Hypothesis 2: The calculated chi square value 4. National Center for Health Statistics. Health
of 132.14 is greater than critical table value of 16.92 indicators warehouse. Retrieved NOVEMBER
at the degree of freedom of 9 and significant level of 29, 2017, from http://www.healthindicators.gov/
0.05, the result of hypothesis two revealed that Sleep Indicators/Sufficient‑sleep‑adults‑percent_1472/
deprivation have effect on Mental Health as perceived Profile/Data. 2008.
by Undergraduates’ in Kwara State University. This was 5. National Sleep Foundation. International
supported by a research which ascertained that sleep Bedroom Poll. As of 28 November 2016.
deprivation increases your chance for health conditions Retrieved NOVEMBER 24, 2017, from NSF:
such as Alzheimer and frequent mental distress, also https://sleep foundation.org/sleep‑polls‑data/
affirmed that sleep affect our mental health as profoundly other‑polls/2013‑international‑bedroom‑poll.
as it does to our physical health. Sleep deprivation have 6. Axelsson, J, Sundelin T, Ingre M, Van Someren EJ,
been found to have strong connection with practically Olsson A, Lekander, M. Beauty sleep: experimental
every mental disorder we know of, especially depression study on the perceived health and attractiveness of
and anxiety6. sleep deprived people.2010. BMJ 341. doi:10.1136/
bmj.c6614).
Recommendations: Based on the findings and
conclusion of the study, the following recommendations 7. Goel N, Rao H, Durmer JS, Dinges DF.
were made. Neurocognitive consequences of sleep deprivation.
Neurol 2009(29), 320 –339.
1. Undergraduates should be enlightened deeply on the 8. William, D. S. Effect of Sleep Deprivation on
adverse physical health effect that sleep deprivation Cognition,. Progress in Brain Research. Retrieved
can have on their health. These can be done through december 13, 2017, from research gate: 2010 https://
public health sensitization and advocacy by Federal www.researchgate.net/publication/47790667/
Government, State Government, NGO’s, and the universityofarizona..
University Lecturers and Health Worker.
9. June JP, Allen H. Effects of Sleep Deprivation
2. Undergraduates should be enlightened deeply on the on Performance, American Sleep Disorders
adverse mental health effect that sleep deprivation Association and Sleep Research Society.
can have on their health. These can be done through Illinois,2010; 19(4), 318‑326.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 409
10. Kochanek J, Kenneth D, Murphy R, Sherry L0,Xu 13. Roenneberg T. The human sleep project.
CJ, Arias. Mortality in the United States, 2013. Chronobiology, 2013; 498(7455), 427‑428.
NCHS data brief, 2014; 178, 1‑8. 14. Marco, H. M. The Economic Cost Of Issurficient
11. Whitney L. The Effects of Sleep Deprivation on the Sleep (A Cross Country Comparative Analysis).
Body. Southern Utah University. 2011. In Why Sleep Matters. Santa Monica, Cambridge,
12. American Psychological Association. Why sleep UK: Rand Coopration. 2016; Retrieved from www.
is important and what happens when you dont get rang.org/t/RR1791.
enough, 2012 Retrieved from APA: http://www.
apa.org/topics/sleep/why.aspx?item=5.
410 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Noise Relationship with Complaints of Disorders of Hearing in

Crafts Industry with Iron in Parigi Moutong District

Abdul Hamid1, Abdul Rohim Tualeka1

1Department of Occupational Health and Safety, Faculty of Public Health, Airlangga University, Indonesia

Abstract
Hearings Invasive complaint constitute complaint that experienced by workers on Industrial Forger diligence
at Regency Parigi Moutong effect most obstreperous flat at forger work area. Result of measurement on
three dots at base area forges, panjak’s area and finishing’s area Forger diligence, utilize Sound is Meter
Level known by noise intensity zoom varies among 80,3, 82,2, 97,5, 97, 9 and 101,5 dB. Multi Center
Study naming Indonesia turns in at 4 invasive supreme South‑east Asia states hearings effect noise. If noise
exposure happening continually will beget energy loss hears that makes a abode and pulih can’t return. This
research intent to know noise relationship with hearings invasive complaint on industrial forger diligence
at Regency Parigi Moutong. This research gets quantitative character by design Cross sectional with trusty
level 95%. Observational result on 60 respondents, 39 among those experience hearing trouble complaints.
Protecting tool factor ear (APT) (ρ=0,003), working life (ρ=0,002), so long job (ρ=0,004) and condition of
work condition (p=0,003) in reference to hearing trouble complaint. Result observationaling to declare for
available relationship among APT’S purpose, working life, so long job and condition of work condition with
hearings invasive complaint on worker. Suggested that workers gets to reduce noise presentation by use of
ear shielding tool accords default and manage rotation working worker job so long at base area forges by
noise intensity the very top.

Keywords: Protecting tool factor ear, working life, long job, and condition of work condition.

Introduction children already suffer from hearing loss due to noise

and 30 million more can be affected by dangerous noise
Noise in the work environment is a major problem
every day and as many as 30 million workers are proven
in occupational health in various countries. At least 7
to have been exposed to noise that exceeds the threshold
million people (35% of the total industrial population
value2.
in America and Europe) are exposed to noisy 85 dB or
more1. 2012 World Health Organization (WHO) found
360 million (5.3%) deaf people in the world with a
National of Occupational Safety and Health (NOSH)
proportion of 91% adults and 9% children. This number
obtained data that NIHL (Noise Induced Hearing Loss)
is dominated in Asia. Southeast Asia has 278 million
is a major problem in the United States today. In the
people suffering from hearing loss, 75‑140 million in
United States around 10 million adults, and 5.2 million
adults. Whereas in infants, there are 0.1‑0.2 million
suffering from deafness from birth or every 1,000 live
Correspondence Author: births there are 1‑2 babies suffering from deafness. 16%
Abdul Rohim Tualeka of deafness suffered by adults is caused by noise in the
Department of Occupational Health and Safety, workplace, so NIHL (Noise Induced Hearing Loss)3 The
Faculty of Public Health, Airlangga University, 60115, Multi Center Study (MCS) states that Indonesia is one of
Surabaya, East Java, Indonesia four countries in Southeast Asia with a high prevalence
e‑mail: [email protected] or abdu‑r‑t@fkm. of hearing loss, which is 4.6% while the other three
unair countries are Sri Lanka (9%), Myanmar (8.4%), and
Handphone: +6281333519732 India (6.3%)4.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 411
Based on the results of a preliminary study Material and Method
conducted on blacksmiths using US‑628 Sound Level
The type of research used in this study is analytic
Meter measuring instruments, the value of noise intensity
observational research using a cross sectional approach
measured in 5 locations of blacksmith craftsmen is 87, 92,
where this study aims to find the relationship between
93, 88 and 89 dB. Of the many cases of noise and illness
a situation with other conditions contained in the same
caused by work that occur among workers throughout
population5
the world, every 15 seconds there are 153 workers in
the world experiencing work‑related accidents and This sampling is done by using a total sampling
diseases. From the results of this problem it is necessary method, which is a sampling technique where the number
to get good attention and handling considering the high of samples is equal to the population. The sample size in
prevalence and consequences. this study was 60 people where the population in this
study were craftsmen in 15 places in Parigi Moutong
Regency.

Findings:

Table 1: Relationship of Noise with Complaints of Hearing Disorders in the Blacksmith Craft Industry in
Parigi Moutong Regency

Hearing Loss Complaints

Causative factor Having disorders Not experiencing interference Total ρ value
n % N %
Penggunaan APT
Not Using 31 79,5 8 20,5 39 0,003
Use 8 38,1 13 61,9 21
Years of service
≥ 10 years 32 78,0 9 22,0 41 0,002
< 10 years 7 36,8 12 63,2 19
Length of working
≥ 8 hours/day 31 77,5 9 22,5 40 0,004
< 8 hours/day 8 40,0 12 60,0 20
Conditions of the Work Environment
≥ 85 dB 23 53,5 20 46,5 43 0,003
< 85 dB 16 94,1 1 5,9 17

Sumber: Data Primer, 2017

Table 1. The results of Chi Square test ρ value 0.003 workers to protect the entire body or part of his body
(ρ≤0.05) indicate a relationship between the use of APT from the possibility of potential hazards from the work
and complaints of hearing loss, years of work with environment against accidents and work‑related diseases
complaints of hearing loss with a value of ρ value 0.002 acquired during work 6
(ρ≤0.05), length of work with complaints of hearing
loss the value ρ value is 0.004 (ρ≤0.05), the working The results of research conducted on the blacksmith
environment condition with hearing loss complaints is ρ craft industry in Parigi Moutong Regency showed that
value 0.003 (ρ 5 0.05). the value of ρ = 0.003 (ρ <0.05), H0 was rejected and
Ha was accepted, meaning that there was a relationship
Discussion between the use of ear protectors and complaints of
hearing loss.
Ear Protective Equipment: APD in this case
ear protection device is a set of safety tools used by
412 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
The results of this study are also in line with 0.004) which means there is a statistically significant
research conducted by Hatim M, et al (2015). The results relationship between the duration of work and NIHL
of the analysis show that the values obtained from the on the Edge Stone Workers West‑Palestine. But it is
Pearson Chi‑Square test (p = 0.002), which means that different from the results of a study conducted by Suryani
p <0.05 there is a statistically significant relationship et al. (2015). The value of the results of the statistical
between PPE and NIHL in Batu Saw workers on the test with chi‑square between the variable working
West‑Palestinian Bank. However, this research is not hours per day with hearing sensorineural type disorders
in line with the research conducted by Leancy Ferdiana obtained X2 = 2,283 and p = 0,273 (0,273> 0,05) which
(2013). The results of the statistical test between the means that there is no significant relationship between
use of headsets in flight and an increase in the hearing working hours per day and sensorineural type hearing
threshold indicate a significance value greater than loss in noise workers in the Wood Furniture Industry in
0.05. This means that there is no significant relationship Pekanbaru City 11 12.
between the use of headsets with an increase in the
hearing threshold of respondents.7 Conditions of the Work Environment: The
work environment must be thoroughly evaluated, each
Years of Service: The longer the working period of workplace must be such that optimal workplace health
a worker is likely to be more easily exposed to noise in and work productivity can be realized. Where if the work
his workplace. If the longer it is in a noisy environment, environment is not always evaluated, the effects that
the more dangerous it is for hearing workers 6 will be caused are workplace accidents and work‑related
illnesses from the work environment 6
The results of research carried out on the blacksmith
craft industry in Parigi Moutong Regency showed that The results of research carried out on the blacksmith
the value of ρ = 0.002 (ρ <0.05) then H0 was rejected and craft industry in Parigi Moutong Regency showed that
Ha was accepted, meaning that there was a relationship the value of ρ = 0.003 (ρ <0.05) then H0 was rejected and
between years of work and complaints of hearing loss. Ha was accepted, meaning that there was a relationship
between working environment conditions and hearing
The results of this study are in line with the research loss.
conducted by Sam et al. (2017). From the results of the
study, there was a statistically significant relationship The results of this study are in line with the research
between the length of work and the condition of hearing conducted by Tjan et al. (2013). The results of the
loss among Small and Medium Business Workers in analysis showed a value of p = 0.032 (p <0.05) which
Selangor, Malaysia, with a score of χ (4) = 10.51, p means that there was a significant relationship between
= 0.033. The level of association as indicated by the the intensity of high noise and hearing loss in workers
Kendall tau‑c correlation is positive and weak (p = 0.18). in Sario District, Manado City, North Sulawesi. But it
But it is different from the results of research conducted is different from the results of research conducted by
by Defrin, E & Suyanto (2014). The results obtained that Rusiyanti et al (2012). The results of the analysis show p
the value of p = 0.91 which means the value of p> 0.05 value = 0.076 (p> 0.05), which can be interpreted as not
so that there is no significant relationship between years having a significant relationship between noise intensity
of work with complaints of hearing loss 8 9. and disturbance in the right ear hearing threshold in
blacksmith craft industry workers in Hadipolo village,
Length of working: Permenakertrans number Jekulo District, Kudus Regency 4 13.
PER.13/MEN/X/2011 is also mentioned that, time
is allowed for exposure to noise of 85 dB is 8 hours. Conclusion
The duration of a day’s work based on the Law of the
Republic of Indonesia Number 13 of 2003 article 77 (1) The conclusions from the results of this study are
is 8 hours a day and 40 hours a week with a minimum as follows: There is a relationship between ear protectors
half‑hour day’s rest time10. and complaints of hearing loss in the Blacksmith Craft
Industry in Parigi Moutong District with a value (ρ =
The results of this study are in line with the research 0.003 <0.05).
conducted by Hatim M, et al (2015). The results of the
analysis show that the long duration of the work was There is a relationship between years of work with
obtained with a value (OR 1.08; CI 1.02 ‑1.14; p = complaints of hearing loss in the Blacksmith Craft
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 413
Industry in Parigi Moutong District with a value (ρ = Are Loud Enough For A Long Period Of Time,
0.002 <0.05). Usually Due To K. J E‑Biomedicine. 2015; 3 (3):
1–5.
There is a relationship between the length of work
4. Tjan H, Lintong F, Supit W. Hearing Function In
and complaints of hearing loss in the Blacksmith Craft
Workers In Sario District. A E‑Biomedicine. 2013;
Industry in Parigi Moutong Regency with a value (ρ =
1 (1): 34–9.
0.004 <0.05).
5. Soekidjo N. Health Research Methodology. 2nd
There is a relationship between working Ed. Jakarta: PT. Rineka Cipta; 2012. 35‑40 P.
environment conditions and complaints of hearing loss 6. Suma’mur P. Hiegene Company And Occupational
in the Blacksmith Craft Industry in Parigi Moutong Health (HIPERKES). Jakarta: CV. Sagung Seto;
District with a value (ρ = 0.003 <0.05). 2009. 116‑132 P.
Conflicts of Interest: All authors have no conflicts 7. Kandou LF. Aviator Hearing At Health Centers.
of interest to declare. Indones J Occup Saf Heal. 2009; 2 (1): 1–9.
8. Sam WY, Anita AR, Hayati KS, Haslinda A,
Source of Funding: The source of this research
Lim CS. Prevalence Of Hearing Loss And
costs from self.
Hearing Impairments Among Small And Medium
Ethical Clearance: This study was approved by the Enterprises Workers In Selangor, Malaysia.
institutional Ethics Council of the Tadulako University Malaysians Science. 2017; 46 (2): 267–74.
Institute of Public Health. 9. Erman, D., Sukendi. S, Riau U. Issn 1978‑5283. J
Sciences Lingkung. 2014; 8 (2).
All subjects were fully informed about the
10. Minister Of Manpower And Transmigration. About
procedures and objectives of this study each subject
The Threshold Value Of Physical Factors And
prior to the study signed an informed consent form.
Chemical Factors In The Workplace. 10 Indonesia;
References 2011
11. Yulia, SS. T. Issn 1978‑5283. Ilmu Lingkung.
1. Rara Marisdayana, Suhartono N. Journal Of
2013 (Analysis Of Socio‑Economic Activities
Indonesian Environmental Health Relationship
Against Water Quality Of Oxbow Lake In Buluh
Intensity Of Noise Exposure And Work Period
China Village, Siak Hulu District, Kampar
With Hearing Disorders The Relationship Between
District, Riau Province): 187–200. 12.
Noise Exposure And Work Period With Hearing
El‑Salamoni O, Hi‑Mjc Univ, 2015 Undefined.
Disorder On Workers Of “Industry X.” A Health
Prevalence And Risk Factors Of Noise Induced
Environment In Indonesia. 2016; 15 (1): 22–7.
Hearing Loss And Other Work‑Related Health
2. Laras Dyah Permaningtyas, Anton Budi Darmawan Problems Among Stone Saw Workers In West
Dk. The Relationship Between The Duration Of Bank‑Palestine. Researchgatenet [Internet].
Work Period And Noise‑Induced Hearing Loss In 2016; (January 2015). Available From: Https://
Home Industry Exhaust Workers In Purbalingga Www.Researchgate.Net/Profile/Hanan_Mosleh2/
Lor Village. J Mandala Heal [Internet]. 2011; 5 Publication/304198115_Prevalence_And_Risk_
(3): 374–8. Available From: Http://Fk.Unsoed. Factors_Of_Noise_Induced_Hearing_Loss_And_
Ac.Id/Sites/Default/Files/Img/Mandala Of Health/ Other_Work‑Related_Health_Problems_Among_
Long‑Time Employment Relationships With Stone_Saw_Workers_In_West_Bank‑Palestine/
Noise‑Induced Hearing Loss In Home Industry Links/5769470708ae7d2478cd7e83.Pdf
Workers Knalpot.Pdf
13. Rusiyati, Nurjazuli S. Relationship Between Noise
3. Nina P. Lumonang MM And VRD. The Physics Exposure And Hearing Disorders In Blacksmith
Section Of The Sam Ratulangi University School Craft Industry Workers In Hadipolo Village, Jekulo
Of Medicine In Manado Or Unwanted Noise Will District, Kudus Regency. A Healthy Environment
Cause Health Problems In Hearing Problems That In Indonesia. 2012; 11 (2): 109–13.
414 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

The Role Of Cultural Social Factor In Decision Making Of

Choosing Female Family Planning Contraception

Abdul Jalil Amri Arma1, Surya Utama1, Iskandar Muda1

1Universitas SumateraUtara, Medan, Indonesia

Abstract
The purpose of this research is to determine the factors that influence the decision to choose the female
family planning contraception. This type of research is qualitative research by obtaining key informants
(family acceptors), supporting informants (husbands) with in‑depth interview method. Data analysis is
carried out by the method of focused group discussion. The results used are rational motives with only one
social variable, namely ‘husbands’ supports, the informants agree that these social variables do have a strong
influence on the contraception selection of the female family planning acceptors.

Keywords: Female Family Planning Acceptors, Cultural Social, Rational Motive, Emotional Motive.

Introduction The large population and population growth rate

which is still high or equal to 1.49% and equivalent to 4.5
Family Planning Program is not solely the
million people each year is a complicated problem faced
responsibility of women. The issue of women’s
by the Indonesian people today[22]. The results of the
empowerment in family planning programs needs to be
Population Census show that the population of Indonesia
properly understood so that there is no gender‑biased
is 237.6 million in 2010. This figure places Indonesia
view. However, full involvement and partnership
in the fourth rank of the most populous country in the
between women and men is important in efforts to control
world after the People’s Republic of China, India, and
population and improve quality of life. The Family
the United States. In 2010, around 118.3 million people
Planning Program (KB) not only aims to improve the
(50 percent of the population) lived in urban areas. At the
health of mothers and children or suppress population
same time the initial fertility rate in Indonesia has fallen
growth. However, this family planning program is
sharply since the 1980s. The Crude Birth Rate (CBR)
expected to improve the quality of the population through
is estimated at 28 per 1,000 populations in the period
the preparation of healthy and prosperous families[16].
of 1986‑1989, down to 23 per 1,000 populations in the
There is no single method of contraception that is safe and
period of 1996‑1999, resulting in an average decline of
effective for all clients, because each has the suitability
2.1 percent per year [5] [16].
and individual compatibility of the client[2],[9],[17]. Along
with the development of science and technology that Those numbers indicate that there has been an
bring many changes to human life both in terms of acceleration in the decline in birth rates. But in 2010,
lifestyle changes and social order including in the health the CBR again rose to 23 births per 1,000 inhabitants.
sector which is often faced with a matter that is directly Likewise, life expectancy at birth for both men and
related to the norms and culture adopted by the people women increases. Male life expectancy increased from
living in a certain place[10]. Whereas the embodiment of 58 years in 1990 to 69 years in 2010, and in women,
culture is objects created by humans as cultured beings, life expectancy increased from 62 years in 1990 to
in the form of behaviors and objects of a real nature, 73 years in 2010. [18]. Regardless of the extent of the
for example patterns of behavior, language, living tools, Family Planning (KB) program, and the Population of
social organizations, religion and art, etc., which all of Family Planning and Family Development (KKBPK),
which are intended to help humans carry out community the success of the family planning program still refers
life[7],[23][24]. to the Total Fertility Rate (TFR). The smaller the TFR
number, the more successful the KB program is. TFR
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 415
can go down when the Contraceptive Prevalence Rate In North Sumatra in 2015 showed that the number of
(CPR) rises consistently. Conversely, if CPR does not PUS (Fertile‑Age Couple) reached 2,201,509 people,with
increase, it is difficult to reduce TFR. CPR itself will the number of active family planning participants
not rise if the PB (New Participant) does not rise. CPR amounting to 1,525,388 people (69.29%),while the
in Indonesia has fluctuated from year to year, such as number of new family planning participants was 419,691
61.9% in 2012, 60.1% in 2014, and 66% in 2015, so it people (19.06%), while the number of dropped‑out KB
is appropriate if contraception is placed as a necessity acceptors which is 418,713 people or 18.57%. (Deli
for couples of childbearing age at the same time can Serdang Regency/BPS, 2016). In Deli Serdang District
improve the health of mothers, infants and children and in 2015 showed that the number of PUS reached 337,331
contribute to the reduction of Maternal Mortality Rate people, with the number of active family planning
(MMR) and Infant Mortality Rate (IMR) so as to help participants amounting to 232,372 people (68.88%),
realize a small, happy and prosperous family [5]. while the number of new family planning participants
was 2,653 (0.78%), while the number of dropped‑out
Based on the Indonesian Demographic and family planning was 175,917 (52.14%).Female Surgery
Population Survey, recorded that TFR this year reaches Method (MOW) as many as 38 people and Male Surgery
2.6 per woman of childbearing age. This means that on Method (MOP) of 29 people [8].The tendency of the
average women of childbearing age in Indonesia have an Non‑MKJP KB use pattern also occurs in North Sumatra
average of 3‑4 children. This achievement is far from the Province. Throughout the year 2013, turned out to be not
target to be achieved this year, which is 2.4. From this less than 80 percent of new family planning acceptors
year’s achievement, the BKKBN admitted that it was in West Java chose to use Non‑LTM. Non‑LTM user
almost certain that the opportunity to achieve the ideal is dominated by injectable contraceptives is equal to
TFR in 2015, which is 2.1 was closed. It is believed that 33 percent and 29 percent of contraceptive pills [6].
TFR is still high due to the high drop out of contraception. Similarly, the usage pattern in Deli Serdang reported
The level of participants dropping out of family planning the achievement of KB participants noted of 22 districts
programs is on the road due to the majority of family in Deli Serdang, active birth control pills the number of
planning participants currently using non‑MKJP participants as much as 23.18 percent, while the number
contraception, such as short‑term pills that are quite high of new family planning participants pills as much as 3.5
[11].At present, according to the calculations of experts,
percent. Operation Method Women (MOW) as much as
the ability of the earth to support the existence of the 3.4 percent and Operation Method Man (MOP) of 2.6
population has been 1.5 times its ideal capacity. In 2050 percent [6].
the condition has doubled andvery worrying[5].
Theoretical Review:
In overcoming the problem of high population
growth, the government has implemented a rational, Social Aspects Affecting Health Status and
effective and efficient contraceptive use policy including Health Behavior: Some social aspects that can affect
the use of Long Term Contraception Method (MKJP). participation in family planning, among them are Age,
According to the WHO and American College of Education of husband or wife, The work of a husband or
Obstetricians and Gynecologists (ACOG), MKJP is wife, Socio‑Economic, Number of children, Availability
the most effective contraceptive method. When viewed of contraception and Husband’s support[2].
from the data, there is a tendency for contraceptive
usage patterns to be considered irrational, of which 57.9 Socio Cultural Behavior: According to [1],[4]
percent of the Contraceptive Prevalence Rate (CPR) culture is all the behavior and results of human behavior
is 47.3 percent using Non‑Long Term Contraceptive that are organized by the behavior that must be acquired
Method (Non MKJP) and only 10.6 percent using the by learning, and which are all arranged in the life of the
Long Term Contraception Method (MKJP).The pattern community. There are three forms of culture, namely:
of use of the Long‑Term Contraceptive Method even 1. The form of thoughts, notions, ideas, norms,
tends to decrease ie 18.7 percent in 1991 to 10.6 percent regulations, and so on.
in 2012. The high use of Non MKJP also occurs in new
family planning acceptors, which is 82.48 percent, while 2. Human’s patterned behavior activity in society.
those using MKJP are only 17.52 percent even though 3. Physical form, is the total physical result of human’s
the national MKJP target is 27 percent. [5]. behavioral activities.
416 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Humans are considered cultured creatures if the conducted by [19] who said that the level of education
human has the mind and thought that are always actual had a considerable influence on the utilization of the
in filling his life without being tired of looking for any KB–MKJP method.This research is in line with the
knowledge to develop his personality. research conducted by [13]find that the occupation of a
woman did not have a big influence in determining the
Family Planning Program as Social Innovation: choice of a mother to become an injection KB acceptor.
Family Planning (KB) is one of the most basic and Thirteen informants said there was no influence on
primary preventive health services for women. Many socio‑economic status with the use of family planning,
women must determine the difficult contraceptive for various reasons, such as family planning costs were
choices, not only because of the limited number of still affordable, and family planning services were
method availability, individual health and female provided free of charge at the Center of Health Care and
sexuality or the costs of obtaining contraception [12]. Information (POSYANDU).
This is not only due to the limited method availability,
but also by ignorance of the requirements and safety of The Analysis of the Influence of Socio‑Cultural
the contraceptive method. There is no single method of Factors with the Strong Rational Motives on Decisions
contraception that is safe and effective for all clients, in Choosing a Female KB Contraception: The results
because each has an individual fit and suitability for the of the research concluded that out of 24 key informants
client [17]. there were 23 informants who had the support of their
husbands to participate in the family planning program,
Research Method: This research was conducted only 1 informant did not get husband’s support, but was
with a qualitative method, where data was collected allowed to join the family planning program. The results
from informants using in‑depth interviews and focus of this study are also reinforced by the [15] research which
group discussions (FGD)[22]. In‑depth interviews were states that there is an influence of husband’s support with
conducted for female KB acceptors (24 informants) and the use of contraception.
husbands (12 informants). The FGD was conducted
twice, FGD 1 extracted information on other female Discussion
family planning acceptors including those who were
discontinuing contraception (12 informants). FGD 2, for In general, it can be concluded that husband’s
sub‑district KB (PLKB) service officers, family planning support greatly influences his wife in choosing to use
service providers, family planning service providers contraception, because with the support of husband
for private clinics, religious leaders and district level and wife, they will be more motivated and easier to
community (15 informants). run family planning programs so that family harmony
can be maintained. Therefore the child’s welfare is
Results and Discussion very necessary to be considered including in terms of
providing a decent life for children [15]. The results of
Result: the FGD among female family planning acceptors,
The Analysis of the Influence of Socio‑Cultural stakeholders and the family planning community
Factor with Moderate Rational Motives on the also agreed that the number of children affected the
Decision in Choosing Females’ KB Contraception: decision of female family planning acceptors for family
According to [14], age was one of the factors that could planning, in addition to the number of children who
influence a person to behave, including in choosing the were sufficiently considering economic difficulties. This
type of contraception to be used. This research was not research is in line with the research conducted by [13]
in line with the research conducted by [15]which stated which states that the choice of contraceptive method is
that age affected couples of childbearing age in the use strongly influenced by the number of children it has. If
of contraceptives, especially MKJP.According to [14] Fertile‑Age Couple has many children, it is increasingly
education is needed to obtain information, therefore the great to choose solid contraception as an option to stop
higher the level of education of a person, the easier it fertility.
is to receive information, therefore more knowledge is The second variable is the availability of
owned, and the easier the person receives information, contraceptives. Completeness of service describes the
thus someone is more receptive to the newly developed level of service quality. The statement is in line with the
values. This research is not in line with the research
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 417
theory put forward by Greenet al., (1980) which states References
that service quality is included in the factors that support
1. Achmad, N; & Muda, I. Economic Activities of
the emergence of health behavior. The results of this
Karo Older Adults in Tanah Karo, Indonesia.
research are also in line with the research conducted
International Journal of Economic Research. 2017;
by [20] about the factors associated with the use of
14(17).377‑388.
long‑term contraceptive method in the work area of the
Pancoran Mas Public Health Center in Depok, which 2. Affandi. The Book of Practice Contraception
states that there is a significant relationship between Services. PT. Bina Pustaka. 2012; Jakarta.
the completeness of family planning services and the 3. Arma, A, Jalil,A. & Zulfendri. Analysis of
use of the term contraception method Length (MKJP). Socio‑cultural Factors Affecting Decisionson
According to [1] states that, as social beings, human Choosing Women’s Contraception in Deli Serdang
life cannot be separated from culture, and can even be and Implication for Family Plan Service Policy and
influenced by the culture where he lives. This research is Family Welfare. International Journal of Economic
in line with the research conducted by [21] which states Research. 2017;14(20).223‑233.
that there is a local socio‑cultural relationship with the 4. Badaruddin; Revida, E; Ermansyah & Muda, I.
selection of contraceptive method. Village Governance with Implementation of Law
Number 6 of 2014 On The Village and Village
Conclusion and Suggestion Administration. International Journal of Economic
Conclusion: There are 7 (seven) social factors Research. 2017; 14(17). 389‑402.
that characterize rational motives and there are also 5. BKKBN. Pocket Handbook of Assistance
8 (eight) cultural factors that characterize emotional in Population, Family Planning and Family
motives. The results of the analysis formed 4 (four) Development. 2015; Jakarta.
main factors, namely: socio‑cultural factors‑1 named 6. Central Statistics Agency of North Sumatra. North
“moderate rational motives”, socio‑cultural factors‑2 Sumatra Province in Figures. 2016; New Creative.
named “moderate emotional motives”, socio‑cultural
7. Clifford, Geertz. The Impact of the Concept of
factors‑3 named “strong rational motives”,
Culture on the Concept of Man.(The Interpretation
socio‑cultural factors‑4 named “strong emotional
of Cultures),Basic Books, 1973; New York.
motives”. Socio‑Cultural Factor‑1 consists of 5 (five)
indicators, namely: ‘Age of female and husband family 8. Deli Serdang Regency/BPS. Deli Serdang Regency
planning acceptors’, ‘Women’s and husband’s family in Figures. 2016; Republic of Indonesia.
planning acceptor education’, ‘Women’s and husband’s 9. Directorate General of Nutrition Development
family planning acceptor’s work’, ‘family social and Maternal and Child Health. Family Planning
economic status’, and ‘The fatalistic attitude of female, Services Guidelines. 2014; Jakarta.
family and community family planning acceptors in 10. Green, LW, Kreuter, MW, Deed, SG, Partridge.
the neighborhood’. Furthermore this dimension can be Health Education Planning Diagnostic Approach.
called “moderate rational motive”. California: 1980;Publishing Company.
Acknowledgements: This study is dedicated to the 11. Ministry of Health RI. Indonesia Health Data
DRPM Ministry Research and Technology, Republic of Profile 2011. 2012: Jakarta.
Indonesia that has been providing assistance funding for 12. Maryani, H. Choosing of Contraception for Women
this research. Family. 2008; Retrieved from www.tempo.co.id,
[Acceses on February 01, 2017].
Conflict of Interest: We have declared any potential
13. Nina, S.M. & Mega,R. Family Planning and
conflict of interest in there search. Any support from a
Contraception. Nuha Medika. 2013; Yogyakarta.
third party has been noted in the Acknowledgements.
14. Notoatmodjo, Soekidjo. Health Research
Ethical Clearance: We understand that, if, prior to Methodology. Rineka Cipta. 2010; Jakarta.
publication, IJPHRD Journal considers that the Work 15. Nuryati, S & Fitria, D. The Influence of Internal
should not be published due to ethical or legal reasons Factors and External Factors on Selection of
from Ethical Committee may decline to publish the Contraception on New Family Planning Acceptor
Work. in Bogor.2014;Working Paper.
418 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
16. Priyoto. Attitude Theory and Behavior in Health 22. Tarmizi, H.B., Daulay, M & Muda, I. The influence
Equipped Example Questionnaire. Nuha Medika. of population growth, economic growth and
2014; Yogyakarta. construction cost index on the local revenue of
17. Saifudin, A.B. Practical Handbook for tax on acquisition of land and building after the
Contraception Services. Bina Pustaka. 2006; implementation of law no. 28 of 2009. International
Jakarta. Journal of Economic Research. 2016: 13(5).
2285‑2295.
18. SDKI. Indonesia Demographic and Health Survey
Report (SDKI) 2012. Jakarta. 23. Nurlina & Muda, I. The Analysis of The Effects
of Capital Expenditure and Human Development
19. Sri,U. Relationship Side Effects With Event
Index on Economic Growth and Poverty in East
Drop Out On Acceptor Akdr In Poly Kb I Rsud
Aceh Regency. International Journal of Economic
Dr. Soetomo Surabaya. Journal Voice Forikes.
Research. 2017:14(17). 415‑428.
2011;2(3).20‑34.
24. Muda, I, M. Ismail & Marhayanie. Impact Allocation
20. Sulistyawati, A. Family Planning Services. Salemba
Capital Expenditure on The Improvement of
Medika. 2013;Jakarta.
the Local Government Assets in North Sumatra
21. World Population. World Population 2016; and Effect on Local Revenue Sustainability.
Retrieved on http://www.geohive.com/earth/ International Journal of Economic Perspectives.
population_now.aspx. [Acceses on February 01, 2017:11(2). 110‑123.
2017].
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 419

Epidemiology of Hypercholesterolemia among

Adults in Samara City

Abid Ahmad Salman Al‑Mahmood1, Ehan Abdulhadi Hussein Al‑Sharifi2, Asia Abed Al‑Mahmood3
1Collegeof Medicine, Tikrit University, Tikrit, 2College of Dentistry, Ibn Sina University of Medical and
Pharmaceutical Sciences, Baghdad, 3College of Dentistry, Al‑Iraqia University, Baghdad, Iraq

Abstract
Hyperchloremia is elevation of serum cholesterol level above normal (> 200 mg/dl). There are an
association between cardiovascular diseases and high level of blood cholesterol. There are many risk
factors of hypercholesterolemia as genetic, environmental, systematic disease as diabetes mellites and
some drugs factors. A cross sectional study was conducted on adults who were attending Samara general
hospital outpatients clinicduring the period from 5th February‑30th April 2017. The information regarding
the problem and demographic characterestics of persons was obtained according to a questionnaire and
the weight, height, blood pressure, total blood cholesterol level was recorded. The results shows that the
frequency of hypercholesterolemia among sample study was (54%).There is no significant association
between frequency of hypercholesterolemia according to gender, age group, body mass index, family history
and smoking habit but it has been reported that a significant association between high serum cholesterol and
presence of hypertension, cardiac diseases and diabetes mellites.

Keywords: Hyperchloremia, Epidemiology, Samara.

Introduction obstruct blood flow(7). There is a correlation between

hypercholesterolemia and coronary heart disease (8) and
Hypercholesterolemia is defined as the presence
it has been documented increase of risk five times than
of high levels of cholesterol in the blood (a form of
those with normal level of blood cholesterol(9).
hyperlipidemia)(1,2). Normal serum level of cholesterol
is < 200 mg/dl (< 5 mmol/l) and considered high (200 The most important risk factors of
mg/dl and above)(3,4). hypercholesterolemia are a combination of environmental
and genetic factors. Environmental factors include
Cholesterol is manufactured by all animal cells.
obesity, diet, and stress, diabetes mellites(8)and certain
Steroid hormones and bile acid precursors are cholesterol.
medications and other systematic diseases)(6). It has
It is transported in blood plasma as lipoproteins
been found an association between high level of blood
which classified according to their density (very low,
cholesterol and cigarette smoking,diabetes mellites and
intermediate, low‑ and high‑densitylipoprotein (5).
obesity(10). There is an effect of diet on blood cholesterol
It has been documented the relation between but the effect varies between individuals(11).
longstanding high serum cholesterol and
(6)
atherosclerosis. , these processes may lead to Patients and Method
narrowing of affected arteries and may cause a clot which A descriptive study was conducted on adults attending
outpatient clinic in Samrageneral hospital. The study
started from 5th February‑30th April 2017. The patients
Corresponding Author: were sent for investigation of blood total cholesterol. The
Abid Ahmad Salman Al‑Mahmood sample study individuals demographic information was
College of Medicine, Tikrit University, Tikrit, Iraq obtained according to structured‑designed questionnaire
e‑mail: [email protected] and by direct interview. The cholesterol level was
Telephone Number: +9647732553263 considered high if it exceeds 200 mg/dl. Blood pressure,
420 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
body weight, height, were measured in addition to obtain Regarding the gender in the sample study there are
from patients investigation the total blood cholesterol no differences in frequency of hypercholesterolemia
level. between male and female (54%). This result is nearly
to similar to that reported in Saudi Arabia(12). It is
Statistical Analysis: By using SPSS 25.0 statistical higher to that reported in Egypt (male 39.7%, female
software package the results were presented as the 38.3%) but there is no significant association (13) like
frequencies, per cent and Chi‑square test was used to other studies(26,27). Other studies in India revealed
assess association. Statistical analysis at p‑value < 0.05 that hypercholesteremia is more frequent among
was considered significant. female (67.6%) than male (57.6%) with a significant
association(22).
Results
It has been revealed that the frequency of In the current study the frequency of
hypercholesterolemia among study sample was hypercholesterolemia was more frequent among age
54%. Regarding the gender the frequency of group more than 40 years (55.9%) and below age group
hypercholesterolemia was 54% among each of male and below 40 years (48.7%) but there is no significant
female (Table 1). association (P value = 0.442). This result was nearly
similar to that reported in Saudi Arabia(12), while in
Table (2) shows that hypercholesterolemia was Egypt about (38.9%) above age 20 years and (38.7%)
more frequent among age group > 40 years (55.9%) below 20 years without significant association(13).
than those among age group <40 years (48.7%) but
without significant association. Table (3) shows that In the current study the frequency of serum
hypercholesterolemia was more frequent among hypercholesterolemia is more frequent among persons
those with body mass index (BMI > 25) (55.1%) than with body mass index more than 25 Kg/M2 (55.1%) than
those with BMI <25 (51.9%) but without significant those with body mass index less than 25Kg/M2 (51%) but
association. Table (4) shows that hypercholesterolemia there is no significant association (P value= 0.71). This
was more frequent among those with hypertension result is nearly similar to result reported by Al‑Nozha et
(65.5%) than those without hypertension (46.7%). al in Saudi Arabia (12). In India it has reported that about
There is a significant association. Table (5) shows that (69%)of those with body mass index more than 25Kg/
hypercholesterolemia was more frequent among those M2 having hypercholesterolemia and (59%) among
with cardiac disease (87%) than those without cardiac those with normal weight(22) while in Egypt the result of
disease (48%). There is a significant association. hypercholesterolemia among those with high BMI and
normal BMI was (48.8%,33.9%)respectively (13). Many
Table (6) shows that hypercholesterolemia was more studies reported that there are a significant association
frequent among those with diabetes mellites (71.4%) between obesity and hypercholesterolemia (28, 29, 30, 31).
than diabetes mellites those without hypertension (50%).
There is a significant association. In current study the frequency of
hypercholesterolemia among patients with and without
Discussion hypertension was (65.5%, 46.7% respectively) and
among patients with and without cardiac disease was
It has been documented in the current study that the (87%, 48% respectively). Statistically, there is a high
frequency of serum hypercholesterolemia was (54%). association (Pvalue = 0.025 for hypertension and P
This result is similar to result obtained by Al‑Nozha et al value = 0.001 for cardiac diseases). This result is more
in Saudi Arabia(12), and higher to that reported in Egypt than that reported in Fayoum in Egypt (frequency
(38%)(13), and by other study done by WHO (36%)(14), of hypercholesterolemia among hypertensive and
in Kuwait (10.6%)(15), in Oman (15.6%)(16), in Sudan non‑hypertensives 54.5%, 36.8% respectively) and
(7.8%)(17), in other studies in Saudia (32%)(18), in India also there is a significant association(13). A significant
(33.2%)(19), other studies (37%)(20), in Korea (1.2%)(21). relation was reported by hypercholesterolemia and high
The current result is lower than that reported in north blood pressure by other studies(27,32).
Kerala in India the prevalence of hypercholesterolemia
was 63.8% (22), in other studies (57%)(23), in Nigeria There was a significant association between diabetes
(62.5%)(24) and in Poland (66.4%)(25). mellitus disease presence and hypercholesterolemia
among study sample group (P = 0.04). The frequency
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 421
of hypercholesteremia in this study among diabetic and Acknowledgment: The authors are thankful to
nondiabetic patients was (71.4%, 50%) respectively. College of Medicine/Tikrit University for helping to
This result is going with results of other studies carry this research to a fruitful outcome.
which reveal that diabetes mellitus is one of causes of
hypercholesterolemia and there are a strong association Ethical Clearance: Protocol approval and the
between them(8,10). Ethical Committee Approval were achieved from the
College of Medicine/Tikrit University for the protocol
Conclusions of the study.

The current study revealed that there are a significant Conflict of Interest: The authors declare that there
association between hyperchloremia and hypertension, are no conflicts of interest.
cardiac diseases and diabetes mellites.
Source of Funding: Self‑funding.

Table (1): Distribution of study sample according to total blood cholesterol level and gender

Sex
Total
Male Female
Count 47 34 81
>200
% within Sex 54.0% 54.0% 54.0%
Total Cholestrol
Count 40 29 69
<200
% within Sex 46.% 46.0% 46.0%
Count 87 63 150
Total
% within Sex 100.0% 100.0% 100.0%

P value =0.995 ‑No significant association

Table (2): Distribution of study sample according to total blood cholesterol level and age group

Age
Total
<40 >40
Count 19 62 81
>200
% within AGE 48.7% 55.9% 54.0%
Total Cholestrol
Count 20 49 69
<200
% within AGE 51.3% 44.1% 46.0%
Count 39 111 150
Total
% within AGE 100.0% 100.0% 100.0%

P value =0.442 ‑No significant association

Table (3): Distribution of study sample according to total blood cholesterol level and BMI

Body Mass Index

Total
<25 kg/M2 >25 kg/M2
Count 27 54 81
>200
% within BMI 51.% 55.1% 54.0%
Total Cholestrol
Count 25 44 69
<200
% within BMI 48.% 44.9% 46.0%
Count 52 98 150
Total
% within BMI 100%.0 100.0% 100.0%

P value = 0.71 ‑No significant association

422 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table (4) Distribution of study sample according to total blood cholesterol level and hypertension

Hypertension
Total
Positive Negative
Count 38 43 81
>200
% within Hypertension 65.5% 46.7% 54.0%
Total Cholestrol
Count 20 49 69
<200
% within Hypertension 34.5% 53.3% 46.0%
Count 58 92 150
Total
% within Hypertension 100.0% 100.0% 100.0%

P value = 0.025 ‑ Significant association

Table (5) Distribution of study sample according to total blood cholesterol level and cardiac disease

Cardiac Disease
Total
Positive Negative
Count 20 61 81
>200
% within Cardiac Disease 87.0% 48.0% 54.0%
Total Cholestrol
Count 3 66 69
<200
% within Cardiac Disease 13.0% 52.0% 46.0%
Count 23 127 150
Total
% within Cardiac Disease 100.0% 100.0% 100.0%

P value = 0.001 – High significant association

Table (6) Distribution of study sample according to total blood cholesterol level and diabetes mellites

Diabetes Mellites
Total
Positive Negative
Count 20 61 81
>200
% within DM 71.4% 50.0% 54.0%
Total Cholestrol
Count 8 61 69
<200
% within DM 28.6% 50.0% 46.0%
Count 28 122 150
Total
% within DM 100.0% 100.0% 100.0%

P value =0.04 ‑ Significant association

Conflict of Interest: None 3. ATP III Guidelines At‑A‑Glance Quick Desk

Reference, National Cholesterol Education
Funding: Self Program. Retrieved 2013‑03‑09.
Ethical Clearance: Not required. 4. Third Report of the National Cholesterol Education
Program (NCEP) Expert Panel on Detection,
References Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III)
1. Durrington P. “Dyslipidaemia”. The Lancet.
final report. Circulation 2002; 106: 3143‑3421.
(August 2003). 362 (9385): 717–31.
5. Biggerstaff KD, Wooten JS. “Understanding
2. Kishor Jain S, Kathivarin MK, Rahul S, chamanal
lipoproteins as transporters of cholesterol and other
J.The biology and chemistry of hyperlipidemia.
lipids”. Adv Physiol Educ. 2004; 28 (1–4): 105–6.
Bioorganic And Medicinal Chemistry, 2007, 15,
4674‑4699. 6. Bhatnagar D, Soran H, Durrington PN.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 423
“Hypercholesterolaemia and its management”. HA. Metabolic Syndrome among Undergraduate
BMJ. 2008;337: a993 Students Attending Medical Clinics for
7. Finn AV, Nakano M, Narula J, Kolodgie FD, Obligatory Medical Screening. Tropical Journal of
Virmani R . “Concept of vulnerable/unstable Pharmaceutical Research 2015;14(2):317‑321.
plaque”. Arterioscler. Thromb. Vasc. Biol.2010; 30 18. El‑Shehri SN, Saleh ZA, Salama MM, Hassan YM.
(7): 1282–92. Prevalence of Hyperlipidemia among Saudi school
8. Harikumar K, Abdul Althaf S., Kishore children in Riydh. Ann Saudi Med 2004;24:6‑8
Kumar B., Ramunaik M., Suvarna CH. A 19. Gupta R, Sarna M, Thanvi J, Rastogi P, Kaul V,
Review on Hyperlipidemic. 2013, vol 3,N0 3. Gupta VP. High prevalence of multiple coronary
INTERNATIONAL JOURNAL OF NOVEL risk factors in Punjabi Bhatia community: Jaipur
TRENDS IN PHARMACEUTICAL SCIENCES Heart Watch‑3. Indian Heart J 2004; 56: 646‑652.
Available online at www.ijntps.org 20. Vijayakumar G, Arun R, Kutty VR. High
9. Washington RL. Interventions to reduce prevalence of type 2 diabetes mellitus and other
cardiovascular risk factors in children and metabolic disorders in rural Central Kerala. J Assoc
adolescents. Am Fam Physician 1999;59(8):2211‑8. Physicians India. 2009;57:563–7.
10. Lipman TH, Hayman LL, Fabian CV, DiFazio 21. Park Y, LeeH, KohCS, MinH.
DA, Hale PM, Goldsmith BM, et al. Risk factors Community‑basedepidemiologic study on
for cardiovascular disease in children with type I atherosclerotic cardiovascular risk factors. Diabetes
diabetes. Nurs Res 2000;49(3):160‑166. Res Clin Pract 1996; 34 Suppl: S65‑S72.
11. Mannu, GS; Zaman, MJ; Gupta, A; Rehman, HU; 22. Aslesh OP, Jayasree AK, Karunakara U,
Myint, PK . “Evidence of lifestyle modification in Venugopalan AK, Divakaran B, Mayamol TR,
the management of hypercholesterolemia”. Current Sunil CB, Minimol KJ, Shalini K,Mallar GB and
cardiology reviews.2013; 9 (1): 2–14. Sani TPM. Prevalence of hypercholesterolaemia
12. Al‑Nozha MM, Arafah MR, Al‑Maatoug MA,Khalil among adults aged over 30 years in a rural area of
MZ, Khan NB, Al‑Marzrouki K, Al‑Mazrou YY, north Kerala, India: a cross‑sectional study . WHO
Abdullah M, Al‑Khadra A,‑Al‑Harithi S,Al‑Shahid South‑East Asia Journal of Public Health | April
M,Al‑Mobeireek A and Nouh MS. Hyperlipidemia 2016 | 5 (1)
in Saudi Arabia. Saudi Med J 2008; Vol. 29 (2), 23. Thankappan KR, Shah B, Mathur P, Sarma PS,
282‑287 Srinivas G, Mini GK et al. Risk factor profile for
13. AbdelWahed WY, El‑Khashab K,Hassan SK. chronic non‑communicable diseases: results of a
Prevalence of Dyslipidemia among Healthy community‑based study in Kerala, India. Indian J
University Students: Fayoum Governorate, Egypt. Med Res. 2010;131:53–6
Epidemiology Biostatistics and Public Health ‑ 24. Opadijo OG, Akande AA, Jimoh AK. Prevalence
2016, Volume 13, Number 2, e11769 of coronary heart disease risk factors in Nigerians
14. WHO and ARE‑Ministry of Health & Population: with systemic hypertension. Afr J Med Med Sci
Egypt National STEP wise Survey of Non 2004; 33: 121‑125.
Communicable Diseases Risk Factors 2011‑2012. 25. Lopatynski J, Mardarowicz G, Nicer T, Szczesniak
15. AlMajed HT, AlAttar AT, Sadek AA, et al. G, Krol H, Matej A, et al. The prevalence of type II
Prevalence of dyslipidemia and obesity among diabetes mellitus in rural urban population over 35
college students in Kuwait. Alexandria Journal of years of age in Lublin region (Eastern Poland). Pol
Medicine 2011;47:67‑71. Arch Med Wewn 2001; 106: 781‑786.
16. Shawar SM, Al‑Bati NA, Al‑Mahameed A, Nagalla 26. Grabauskas, Miseviciene I, Klumbiene J, et al.
DS, Mohammed O. Hypercholesterolemia Among Prevalence of Dyslipidemias among Lithuanian
Apparently Healthy University Students Oman Rural Population (CINDI Program). Medicina
Medical Journal 2012;27(4):274‑80. Available (Kaunas) 2003;39(12):1215‑22
from: http://www.cdc.gov/chronicdisease/ 27. Al‑Kaabba AF, Al‑Hamdan NA, Ahmed El Tahir,
resources/publications/AAG/dhdsp.htm Abdalla AM, Saeed AA, Hamza MA. Prevalence
17. Ahmed AM, Elabid BH, Elhassan KH, Waggiallah and Correlates of Dyslipidemia among Adults
424 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
in Saudi Arabia: Results from a National Survey M, Lali P. Dyslipidemia and associated risk factors
Open Journal of Endocrine and Metabolic Diseases in a resettlement Colony of Delhi. J Clin Lipidol
2012;2:89‑97 2013;7:653–60.
28. Qi L, Ding X, Tang W, Li Q, Mao D, Wang Y. 31. Bays HE, Chapman RH, Grandy S. The relationship
Prevalence and Risk Factors Associated with of body mass index to diabetes mellitus,
Dyslipidemia in Chongqing, China. Int J Environ hypertension and dyslipidaemia: Comparison of
Res Public Health 2015;12:13455‑65. data from two national surveys. Int J Clin Pract
29. Saeed AA. Anthropometric predictors of 2007;61:737‑47.
dyslipidemia among adults in Saudi Arabia. 32. Guo ZR, Hu XS, Wu M, Zhou MH, Zhou ZY. A
Epidemiology Biostatistics and Public Health Prospective Study on the Association between
2013;10(1). Dyslipidemia and Hypertension. Chinese Journal
30. Sharma U, Kishore J, Garg A, Anand T, Chakraborty of Epidemiology 2009;30(6):554‑8
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 425

Corn Silk Based Ethosomal Gel: A New Treatment for

Periodontitis in Diabetic Albino Rats a Prelimenary Study

Riuwpassa I.E.1, Kim YR2, Tenrilili A.N.A.2, Untung J.S.3, Djamaludin N.S.4, Achmad M.H.5
1Oral Biology Department, Faculty of Dentistry, 2Undergraduate Student Faculty of Dentistry, 3Undergraduate
Student Faculty of Pharmacy, 4Departement of Public Health Dentistry, 5Departement of Pediatric Dentistry,
Hasanuddin University, Makassar, South Sulawesi, Indonesia

Abstract
Objective: Periodontitis and diabetes are related and high blood glucose level plays an important part in this
correlation. Corn silk has the property of anti‑hyperglycemic and anti‑inflammation. The aim of this study
was to determine the capability of corn silk based Ethosomal gel to reduce blood glucose level and degree
of inflammation in alloxan induced rats.

Material and Method: 15wistar male rats with initial weight of 150gram were included in this study.
Alloxan was used to induce diabetes and 5‑0 silk ligatures to induce periodontitis. Blood glucose level was
analyzed before and after induction, 3 days after administration, and 7 days after. Degree of inflammation
was examined with histopathology test.

Results: Blood glucose level in F1 is unstable (p=0.0583>p=0.05), whilst F2 and F3 both showed stable
blood glucose decrease (F2: p=0.0086<p=0.05; F3: p=0.035<p=0.05). Anti‑inflammation effects best shown
in F3, which has mild inflammation (p=0.001<p=0.05).Whereas both F1 and F2 have moderate inflammation
(F1: p=0.225>p=0.05; F2: p=0.423>p=0.05).

Conclusion: Corn silk based Ethosomal gel treatment manage to reduce blood glucose level and periodontitis
in alloxan induced diabetic rats.

Keywords: Corn silk extract, Diabetes Mellitus, Ethosomal gel, Periodontitis.

Introduction degree of glycemic control appears to play an important

part in this correlation.3 Diabetes is a clinically and
Periodontitis is a disease caused by specific
genetically heterogeneous group of metabolic disorders
micoorganism that derived from dental plaque. These
manifested by abnormally high levels of glucose in
bacterian can cause progressive periodontal tissue
the blood. This hyperglycemia results from either a
and alveolar bone damage by inducing the formation
deficiency of insulin secretion caused pancreatic b‑cell
of periodontal pocket, gingival ressesion, or both.
dysfunction or resistance to the action of insulin in liver
Clinical signs of periodontitis are gingivitis, periodontal
and muscles, or both.1Diabetes itself is a risk factor for
pocket, and loss of attachment.1,2 Diabetes itself is
gingivitis and periodontitis, and the degree of glycemic
a risk factor for gingivitis and periodontitis, and the
control appears to play an important part in this
correlation.4 High glucose level in gingival crevicular
fluid directly hinders fibroblast’s ability to heal itself
Corresponding Author: by inhibiting the attachment and spreading of cells
Yuri Kim needed for wound‑healing and normal tissue turnover).5
Undergraduate Student Faculty of Dentistry Abnormality in neutrophil’s adherence, chemotactic, and
Hasanuddin University, Makassar, South Sulawesi, phagocytosis has been observed in some DM patients.
Indonesia Neutrophil’s impairment may inhibit bacterial killing
e‑mail: [email protected] in the periodontal pocket and significantly increase
426 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
periodontal destruction. Apparently, this impairment can intestine. Alcaloid can decrease glucose absorption by
be subdued with better glycemic control. In conditions inhibiting a‑glucosidase enzyme. Tannins and phenol
of sustained hyperglycemia, protein binds with glucose can interact with protein and are capable of slowing
molecules and undergo glycationthus forms Advanced down carbohydrate catabolism. Phenolic compound also
Glycation End Products (AGEs). AGEs formed on has antioxidant properties therefore it can help repair
collagen increases collagen crosslinking. Due to this damaged β‑cell hence increasing insulin secretion.19
cross linking activities collagens formed become highly Aside from having anti‑hyperglycemic activities, corn
susceptible to enzymatic degradation by collagenase, silk extract also has anti‑inflammation, antioxidant,
which is mostly present in active form in people with anti‑depressant activity, diuresis, and many more.20
diabetes. Human gingival fibroblasts also produce
decreased amounts of collagen and glycosaminoglycans Ethosom gel is one of the Transdermal Drug Delivery
in the hyperglycemic state.6 As a result of collagen System (TDDS) that can increase drug penetration
crosslinking and collagen deficiency, collagen despite being applied topically. The Ethosom itself
metabolism is disturbed, thus affecting wound‑healing is a lipid vesicle modified from liposomes. Ethosom
process.7 AGEs bind with RAGE (Receptor for AGEs) on is comprised from phospholipid, relatively high
the surface of monocyte; therefore monocytes are forced concentration alcohol (ethanol or isopropyl alcohol), and
to stay in one place because it limits their migration. water. Ethosom vesicle sizes are varied from micrometer
AGE‑RAGE interaction induces phenotype changes in (μm) ‑ 10 nanometer (nm). Ethosom needs lesser time to
monocyte, which increase the production of cytokine penetrate the skin and significantly increase transdermal
TNF, Prostaglandin E (PGE), Interleukin (IL‑1b).8 drugs flux value. Ethosom also decrease the risk of GI
Host immune response stimulates pro‑inflammatory Tract irritation due to orally administered medication.21
mediators such as IL‑1, TNF‑ α, IL‑6, 1L‑7 and a whole
lot more PGE2, which promotes periodontal tissue
Materials and Method
damage.9 PGE2 is an important mediator in periodontitis Animals: Wistar strain rats weighing 150gram were
process and bone destruction also plays important part purchased from local breeder in South Sulawesi. The rats
in inflammatory response regulation. PGE2 surpresses were maintained at room temperature under alternating
limphocyte production, collagen synthesis by fibroblas, natural light/dark photoperiod and were fed twice a day
and bone osteoclast resorbtion.10 with standard feed water was available ad libitum.

Corn silk (Stigma maydis) is made from stigmas, the Chemicals: Alloxan was used to induce diabetes
yellowish thread like strands from the female flower of and were purchased from Tokyo Chemical Industry.
maize. It is a waste material from corn cultivation and Metformin used for positive control was of generic
available in abundance.10 Throughout the world corn brand.
silk has been used as a treatment of edema as well as for
cystitis, gout, kidney stones nephritis and prostatitis.10 Corn silk extract preparation: Corn silk from
Corn silk contains numerous bioactive compounds 40 days old corns were obtained from local farmers in
such as volatile oils, steroids, alkaloids, sitosterol and Jeneponto a region in South Sulawesi. The corn silk were
stigmasterol and natural antioxidants such as flavonoids, washed and dried at room temperature (24.2 ± 1.0°C) till
saponins, tannins, and other phenolic compounds.12,13 dried and an ethanol extraction was performed by adding
Variation in secondary metabolite compound would 5L of ethanol 80% and 200gram dried corn silk. After
affect its pharmacological activities. Phytochemical 3 days of maceration process, the ethanol solvent was
contents of plant are affected by various factors such evaporated using rotatory evaporator.
as environmental conditions, season, plant age, growth Corn silk extract based Ethosomal gel
factors, and leaf maturity.14,15,16,17Flavonoids has formulation: Three corn silk based Ethosom
the ability to inhibit a‑amylase and a‑glucosidase formulas were made (refer to Table 1). Lecithin and
activities in vitro, inhibit glucose transport, prevent phospatidilcolin were dispersed in heated distilled
cytokine induced β‑cell damage, and ameliorate insulin water (40°C). Corn silk extract entered lipid phase and
resistance peripherally.18 Saponins can reduce blood stirred with magnetic stirrer for 5 minutes and 700rpm
glucose level by increasing insulin secretion, glucose till it entered coloidal system. Propylene glycol and
uptake, and hamper glucose absorption in the small ethanol 96% were heated till 30°C and entered coloidal
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 427
system. Lechitin or phospatidilcolin, corn silk extract, waterbath in 37°C. The tissue sample were then taken
propylene glycol with ethanol 96% were mixed together out using slides that were numbered. Slide then heated on
and homogenized with magnetic stirrer for 5 minutes hot plate at 60°C till the paraffin that surrounds the tissue
and 700rpm till Ethosom suspension was formed. The melts. The section was examined after hematoxylin and
suspension were cooled in room temperature then stored eosin stainning.
in the refrigerator.
Statistical Analysis: All data were analyzed using
After the Ethosom formulas were made, they students t‑test. The data represents means and standard
were put in gel system (refer to table 2) and corn silk deviations. The significant level of 5% (P<0.05) was
ethosomalgel were made. Carbomer 940 was dispersed used as the minimum acceptable probability for the
in distilled water that contain methylparaben for 24 difference between the means.
hours. After that triethanolamine was added drop by
drop whilst being stirred till a clear gel mass was formed. Results and Discussions
Ethosom (Formula A, B, C) mixed with a small amount The blood glucose level of hyperglycemic rats are
of distilled water were added to the gel base and stirred presented in Fig. 1. The blood glucose level for negative
till homogenized, after that glycerin and distilled water control kept increasing because it hasn’t been given
were added to the mixture.21 any treatment just a clear gel base as a placebo. The
Experimental design: 15 rats were fasted for 8h positive control, F2, and F3 level of blood glucose kept
and blood glucose level was measured with blood drawn decreasing. In contrast with other experiments group, in
from the vein in tail. Each rat’s weight was measured F1 the blood glucose level decreased at first and starting
and then alloxan (150 mg/kg) dissolved in sterile to increase again. Eventhough, the final blood glucose
saline were injected intraperitoneally. Three days after level for F1 is still lower than it’s blood glucose level
inducing diabetes, periodontitis was induced as well. 5‑0 after being induced the p value shows no significance by
silk ligatureswas tied around the mandibular first incisor landing a p value at 0.0583 which is slightly bigger than p
and tied gently to prevent damage to the periodontal value 0.05. This indicates that F1 can not stabilize blood
tissue. The ligature was thought to facilitate local glucose level and has no significance in lowering blood
accumulation of bacteria and thereby enhance bacteria glucose level. Metformin administered orally to positive
mediated inflammation. One week after alloxan was control group shows decreasing blood glucose level but
administered blood sample were drawn again from the apparently has no significance statistically with p value
tail vein. One week after periodontitis was induced, 14 of 0.264. Experimental groups F2 (p=0.0086<p=0.05)
hyperglycemic rats (the blood glucose level greater than and F3 (p=0.035<p=0.05) both shown decrease in blood
126 mg/dL) were selected randomly and divided into 5 glucose level and both have significance statistically
groups. Metformin dissolved in water were administered Due to extremely large number of inflammatory cells
orally (positive control), each formula was administered such as leukocyte and PMN that are too many to count,
topically once a day to each specified group, and the the inflammation rate are shown with 3 different grades.
clear gel base without corn silk extract was administered 1 for mild, 2 for moderate and 3 for severe. As seen in fig.
once a day (negative control group). 3 days metformin, 2, negative control group has the highest inflammatory
Ethosom gel, and clear gel base was administered grade which is 3 and accompanied with cell necrosis (Fig.
blood sample were drawn again for analysis. 7 days 3). Second highest inflammation grade is F2, in contrast
after administration, blood sample were collected for to it’s blood glucose level and other experiment groups.
final analysis and periodontal tissue were collected for Supposedly, the degree of inflammation decreases as
histopathology test. the blood glucose level decrease. One other important
The periodontal tissues were embedded in factor to note when it comes to periodontitis is that stress
paraffin blocks after formalin fixation: After tissue also affects periodontitis by altering immune system
fixation in formalin, tissue samples were processed in response, delayed wound healing, hormonal changes,
tissue processor machine. After being processed, the and changes in behaviour that supports periodontitis
tissue samples then moved to embedding machine to formation.22,23,24,25,26
make paraffin blocks. Paraffin blocks were then cooled F2 control group has been observed to have high
down and trimmed with microtom after that moved to stress levels. In spite of having higher inflammation
428 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
grade than negative control, F2 has new connective p value of 0.001. This imply that corn silk extract based
tissue formation. F1 falls into moderate catagory but has Ethosomal gel has the ability to reduce blood glucose
no statistic significance with p value of 0.225. Only F3 level and inflammation response.
has low inflamation grade and statistic significance with

Table 1. Corn Silk Based Ethosom Formula

Phospatidilcolin (F)/ Propylene Glycol Corn Silk Extract

Formula Ethanol (g) Distilled Water
Lecithin (L) (g) (g) (g)
A 1 (F) 10 1 0,1
B 1 (F) 10 1 0,05 Till 50gram
C 1 (L) 10 1 0,025

Table 2. Corn Silk Based Ethosomal Gel Formula

Bahan
Formula Corn silk extract
Carbomer 940 Triethanolamin Glycerin Methyl paraben Water
Ethosom base
F1 Formula A 1 2 5 0,15
F2 Formula B 1 2 5 0,15 Till 100gram
F3 Formula C 1 2 5 0,15

Figure 1. Blood glucose level. Values are mean

Figure 2. Degree of inflammation. Values are mean

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 429

     

  
Figure 3. Inflammatory response in periodontal tissue represented by HE. (A) Negative control group
showed severe inflammation response accompanied with cell necrosis (B) Moderate inflammation shown in
rats administered with F1 (C) F2 administered rats shown moderate inflammation accompanied with newly
formed connective tissue (D) F3 administrated rats shown mild inflammation (E) Positive control group
showed severe inflammation response

Conclusion Brasileiraem Odontopediatria e ClinicaIntegrada.

ISSN 1519‑0501, 2019;19(1):e4250
The results showed that corn silk extract based
Ethosomal gel treatment markedly reduces blood glucose 3. Papapanou, PN. 1996. World workshop in clinical
level and periodontitis in alloxan induced diabetic rats. periodontics: periodontal diseases: epidemiology.
With F3, lecithin and 0.025gram corn silk extract as the Annual Periodontology 1996;1:1‑36.
formula that manages to have both anti‑hyperglycemic 4. Mealey, B. L. and Ocampo, G. L. Diabetes
and anti‑inflammation effects. mellitus and periodontal disease. Periodontology
2007;44:127‑153.
Conflict of Interest: There is no conflict of interest
5. Yabe‑Nishimura, C. Aldose reductase in glucose
in this study.
toxicity: a potential target for the prevention of
Source of Funding: Domestic government diabetic complications. Pharmacology Review
1998; 50:21‑33.
Ethical Clearance: This study obtained a label of
6. Indurkar, M. S., Maurya A. S., and Indurkar, S.
ethics escaped by the number: 0081PL09/KEPKFKG ‑
Oral manifestations of diabetes. Clinical Diabetes
RSGMUNHAS/2018 and register number UH 17120068
Journal 2016;34:54‑7.
on Oktober 9, 2018.
7. Wang, J. Glucose biosensors: 40 years of advances
References and challenges. Electroanalysis2001;13:983‑8
8. Reddy, S. S., Kripal, K., Anuradha, and Prasad, R.
1. Cotti, E., Dessi, C., Piras, A., and Mercuro, G. Can
V.Diabetes mellitus as a risk factor for periodontitis.
a chronic dental infection be considered a cause of
EC Dental Science 2017;1:12‑24.
cardiovascular disease? A review of the literature.
International Journal of Cardiology2010;1:1‑6. 9. Ugale, G. M., Kalburgi, N. B., Bilichodmath, S.,
Warad, S. B, Ugale, M. S., Koregol, A. C., and
2. Achmad H, Sri Ramadhany, Filipus Eric Suryajaya.
Bijjargi, S. C. Betacellulin in chronic periodontitis
Streptococcus Colonial Growth of Dental Plaque
patients with and without type 2 diabetes mellitus:
Inhibition Using Flavonoid Extract of Ants Nest
an immunohistochemical study. Journal of Clinical
(Myrmecodiapendans): An in Vitro Study. Pesquisa
and Diagnostic Research 2015;9: 1‑6.
430 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
10. Maksimović, Z., Malenčić, Đ., and Kovačević, N. and Poutanen, K. Impact of dietary polyphenols on
Polyphenol contents and antioxidant activity of carbohydrate Metabolism. International Journal of
Maydis stigma extracts. Bioresource Technology Molecular Science 2010;11:1365‑1402.
2005;96:873‑7. 19. Arif, T., Sharma, B., Gahlaut, A., Kumar, V., and
11. Guo, J., Liu, T., Han, L., and Liu, Y.The effects of Dabur, R. Anti diabetic agents from medicinal
corn silk in glycaemic metabolism. Nutrition and plants: A review. Chemical Biology Letters
Metabolism Biomed Central 2009;6:1‑6 2014;1:1‑13.
12. Velazquez, D. V. O., Xavier, H. S., Batista, J. 20. Hasanudin, K., Hashim, P., and Mustafa, S.
E. M., and Castro‑Chaves, C. D.Zea mays L. Corn silk (Stigma maydis) in healthcare: A
extracts modify glomerular function and potassium phytochemical and pharmacological review.
urinary excretion in conscious rats. Phytomed Molecules 2012;17:9697‑9715.
2005;12:363‑9. 21. Pratima, N. A. and Tiwari, S. Ethosomes: a novel
13. Liu, J., Wang, C., Wang, Z., Zhang, C., Lu, S., and tool for transdermal drug delivery. International
Lu, J. The antioxidant and free‑radical scavenging Journal of Research in Pharmaceutical Science
activities of extract and fractions from corn silk 2012;22:1‑20.
(Zea mays L) and related flavone glycosides. Food 22. Reners, M. and Brex, M.Stress and periodontal
Chemistry 2011;126:261‑269. disease. International Journal of Dental Hygiene
14. Fritz, R. S., Hochwender, C. G., Lewkiewicz, D. A., 2007;5:199‑203.
Bothwell, S., and Orians, C. M.Seedlingherbivory 23. Graves, D. T., Fine, D., Teng, Y. T, Van‑Dyke,
by slugs in a willow hybrid system: Developmental T. E., and Hajishengallis, G. The use of rodent
changes in damage, chemical defense, and plant models to investigate host‑bacteria interactions
performance. Oecologia 2001;129:87–97. related to periodontal diseases. Journal Clinical
15. Pasko, P., Barto, H., Zagrodzki, P., Gorinstein, S., Periodontology 2008;35:89
Fota, M., and Zachwieja, Z. Anthocyanins, total 24. Malathi, K. and Sabale, D. Stress and periodontitis:
polyphenols and antioxidant activity in amaranth A review. IOSR Journal of Dental and Medical
and quinoa seeds and sprouts during their growth. Science 2013;9:54‑7.
Food chemistry 2009;115:994‑8.
25. Abrishami, M., Zamharir, Z., and Ghorbanzadeh,
16. Achakzai, A. K. K., Achakzai, P., Masood, A., S. Association of periodontal diseases to anxiety
Kayani, S. A., and Tareen RB. Response of plant and stress. International Journal of Contemporary
parts and age on the distribution of secondary Dental and Medical Reviews 2015;1:1‑3
metabolites on plant found in Quetta. Pakistan
26. Adam, A.M, Achmad, H. et. al. Efficacy of
Journal of Botany 2009; 41:2129‑35.
Mouthwash From Aloe Vera Juice After Scaling
17. World Health Organization. 2014. WHO traditional Treatment on Patient With Gingivitis: A Clinical
medicine strategy 2002‑2005. Genève:WHO. Study. Pesquisa Brasilieraem Odontopediatriae
18. Hanhineva, K., Törrönen, R., Bondia‑Pons, I., Clinica Integrada (PBOCI journal). 2018;18 (1) :
Pekkinen, J., Kolehmainen, M., Myakkänen, H., 2018;e3959
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 431

Circuit Training to Increase Cardiorespiratory Endurance in

Male Basketball Players

Agung Wahyu Permadi1, I. Made Wisnu Adhi Putra2, Endang Sri Wahjuni3
1Departement of Physiotherapy, Faculty of Health, Science and Technology, University of Dhyana Pura,
Badung, Bali, Indonesia. Address: Br. Dinas Pohgcnding, Deaa Pitra, Penebel, Tabanan, Bali‑Indonesia, 82152,
2Departement of Nutrition Science, Facultyof Health, Science and Technology, University of Dhyana Pura,

Badung, Bali, Indonesia. Address: Br. Dinas Dauh Pengkung, Ds. Tista. Kerambltan, Tabanan, Bali‑Indonesia,
82161, 3Department of Sport Science, Universitas Negeri Surabaya, Indonesia. Address: Unesa kampus Lidah, JI
Lidah Wetan Surabaya, 60213

Abstract
In playing basketball, body fitness is important. It is closely related to biomotor abilities which consist
of several components, one of which is endurance. An attack movement in a basketball game would
require good cardiorespiratory endurance. Aerobic endurance is related to oxygen intake. This study
aims to determine the improvement of cardiorespiratory endurance in male students who took basketball
as a preferred extr­acurricular activity gained through circuit training. This is experimental research with
one‑group pretest‑posttest design. The sample of this research consisted of 15 male students. Circuit training
was carried out three times a week for four weeks at an exercise intensity of 65% ‒90% of maximum heart
rate. From hypothesis testingwitha paired t‑test,it was found out that P = 0.000 (0.000 < 0.05), suggesting
that there was a meaningful difference. This result shows that circuit training improved cardiorespiratory
endurance.

Keywords: Circuit training, cardiorespiratory when carrying out activities for a long time without
endurance, male basketball players. experiencing interference[3]. Resilience can be grouped
into anaerobic resistance and aerobic resistance[4],[5].
Introduction The training session applied by the coach was directed
Basketball games are considered to be one of the most more to technical training and games. This affected the
dynamic and flexible sports which require high levels physical strength of poorly trained players[1],[6].
of physical fitness[1]. Physical relations are associated Cardiorespiratory endurance can be increased by a
with biomotor abilities because biomotor abilities are variety of training techniques, one of which is circuit
the abilities to measure human performance[2]. One of training[1],[7]. Circuit training is a combination of several
these biomotor components greatly affects a person’s types of exercises carried out in several training posts
endurance, namely resilience. Resilience is the ability [2]
. At each training post, an athlete will perform a
of the heart, lung, and blood vessels to work optimally predetermined type of exercise[8]. One circuit training
set is said to be complete if an athlete has completed
training in all training posts according to the prescribed
Corresponding Author: dose. The movements included in this circuit training are
Agung Wahyu Permadi as follows: push‑ups, sit‑ups, vertical jumps, abdominal
Departement of Physiotherapy, Faculty of Health, curls, back extensions, astride jumping over benches,
Science and Technology, University of Dhyana Pura, pull‑ups, bench stepping, burpe, shuttle run, thrust
Badung, Bali, Indonesia. Br. Dinas Pohgcnding, Deaa squats, side bend, skipping, and running on the spot[9].
Pitra, Penebel, Tabanan, Bali‑Indonesia, 82152
e‑mail: [email protected]
432 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Material and Method physical activity and the training process and would let
the researchers know whether the respondents observed
Participants: The population in this study was
were not too large. Several circuit training posts
all male students who took extracurricular activities
consisting of running on the spot, shuttle run, skipping,
at a middle school in Denpasar, Bali. The sample in
squats, push‑ups, sit‑ups for each set were established.
this study was male students who took basketball as a
This exercise was performed in 2 repetitions (sets)
preferred extracurricular activity. The sample used had
with a break time of 15–20 seconds between stages and
to meet the following criteria: the participants were
between circuits.
male middle school students who took basketball as
an extracurricular activity, were aged 13–14 years, had a. Stage 1: Running on the spot. This training post
low cardiorespiratory endurance of < 35 (poor), and did lasted for 20 seconds.
not take part in any cardiorespiratory resistance training
b. Stage 2: Shuttle run. This training post lasted for
program other than circuit training during the study.
30 seconds (the students run back and forth and
After each of these posts the students were given a break
touched the predetermined boundary line).
period of 15 to 20 seconds before proceeding to the next
post. After completing one circuit, the students were also c. Stage 3: Skipping or jumping rope. This training
given a break period of 15 to 20 seconds. post lasted for 30 seconds (the students made a leap
using the rope provided).
Circuit Training Measures: In this study,
some interviews and observations were carried out, d. Stage 4: Squat. This training post lasted for 30
and information related to age and some complaints seconds (the students stood then bent both knees to
experienced was generated. This would affect the daily a half squatting position and repeated continuously
for a specified time period).

e. Stage 5: Push‑up. This training post lasted for 30 seconds.

f. Stage 6: Sit‑up. This training post lasted for 30 seconds.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 433

2 14 5 33,3
Total 15 100%

Table 2 shows the number of respondents based

on the VO2max values obtained from the Balke test
before the circuit training was performed: 5 respondents
(33.3%) obtained values of < 35 and fell into the very
poor category, 8 respondents (53.3%) obtained values
of 35–37 and fell into the poor category, and 2 other
respondents (13.3%) obtained values of 38–44 and fell
into the fair category.

Table 2: Distribution of VO2 max values through

Balke Test before being given Circuit Training

The VO2 max value Total

in the balke test Category F Percentage (%)
< 35 Very poor 5 33,3
35 – 37 Poor 8 53,3
38 – 44 Fair 2 13,3
Total 15 100%

Table 3 shows the number of respondents based on

the VO2max values from the Balke test after the circuit
training was performed: 1 respondent (6.7%) obtained
a value of < 35 and fell into the very poor category, 6
respondents (40.0%) obtained values of 35–37 and
Fig. 1: Circuit trainning[9] fell into the poor category, and 8 respondents (53.3%)
Statistical Analyses: This study used an obtained values of 38–44 and fell into the fair category.
experimental method with one‑group pretest‑post Table 3: Distribution of VO2 max values through
design. The data in the study were analyzed using SPSS. Balke Test after being given Circuit Training
The analysis was conducted to describe the results of
the research in the field without having to manipulate Total
VO2 max value
the facts. The data from the group were subjected to a Category F Percentage (%)
Shapiro‑Wilk test at a significance level of 0.05. It was < 35 Very poor 1 6,7
used to examine the average chest expansion before and 35 – 37 Poor 6 40,0
after treatment in each group. 38 – 44 Fair 8 53,3
Total 15 100%
Finding and Results: Table 1 shows the number of
respondents based on age:10 respondents (66.7%) were Table 4 shows that the average VO2max value
13 years old, and the remaining 5 respondents (33.3%) obtained by a sample of 15 from the Balke test before
were 14 years old. the circuit training was performed was 35.68, the median
Table 1: Age distribution of respondents was 36.2, the lowest value was 31.60, and the highest
value was 39.60. Meanwhile, from the Balke test after
No Age Frequency Percentage (%) the circuit training was performed to the same sample,
1 13 10 66,7
434 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
the average VO2max value was 38, the median was 38.5, [16].This exercise has a number of advantages: it can be
the lowest value was 33.30, and the highest value was performed in a short time period;it can be applied to one
44. person or a group of persons; and it does not require any
complicated equipment [2]. Circuit training is designed
Table 4: Results of Measurement The average VO2 to stimulate the cardiorespiratory organs, and, as a result,
max value through the balke pre‑test and post‑test. the resistance aspect is emphasized [17].
Variable Mean Median Min Max % Some research studies reveal that male basketball
Balke Pre‑test 35,68 36,20 31,60 39,60 players aged 10–12 years saw an increase of VO2max
6,5%
test Post‑test 38,00 38,50 33,30 44,00 after carrying out circuit training exercises for 6 weeks
as well as average initial score and average final score by
Table 5 shows the results of the normality test using
7.68 ml/kg BW/minute (20.68%) [18],[3]. According to the
the Shapiro‑Wilk test. The pre‑test VO2max was 0.980.
American College of Sports Medicine in 2006, the target
Because 0.980 > 0.05, the pre‑test data were normally
heart rate rangeone should achieve when conducting a
distributed. Meanwhile, the post‑test VO2max was 0.848.
circuit training exercise to experience cardiorespiratory
Because 0.848 > 0.05, the post‑test data were normally
benefits is 65% –90% of the maximum heart rate [15],[21].
distributed.
This is in accordance with the results of the research
Table 5: Data Normality Test Results Measurement conducted—that is,the dose used should be based on the
of VO2 max values through the balke test size of the maximum heart rate to achieve changes in
the cardiorespiratory aspect [19]. Recent studies related
Variable Statistics Sig, Interpretation to exercises that have an effect on cardiorespiratory
Balke Pre‑test 0,982 0,980 Normal function have shown that breathing exercises are able
test Post‑test 0,969 0,848 Normal to increase the amount of O2 intake, for instance, chest
expansion, with a p value of <0.05[20], [22]. Thus, the
Table 6 shows that the paired t‑test comparing the
exercise also has an impact on the aerobic capacity of
pre‑test and post‑test VO2max values obtained from the
both sick patients and healthy people.
Balke tests conducted on the sample yielded a significant
result of 0.000 (0.000 < 0.05), indicating that there was The results of this study show an increase in the
a change in cardiorespiratory endurance after circuit cardiorespiratory endurance of male students taking
training was performed. basketball as an extracurricular activity based on the
VO2maxvalues obtained from a Balke test (p= 0.000).
Table 6: Results of paired t‑test analysis
The students were given circuit training 3 times a
Results Df Sig Information week for 4 weeks of meetings with a training load of
Pre‑test
65% –90% of the maximum heart rate. Each circuit
Balke There are significant
14 0,000 training treatment consisted of 2 sets of exercises, each
test Post‑test differences
of which consisted of 6 types of exercises that had to
Discussion be carried out in each training post provided. Based on
the VO2max values before the circuit training was given
Cardiorespiratory endurance in males aged 13–14 to the sample, 20% of the respondents fell into the very
(adolescents) can increase if training is applied in poor category, 66.7% to the poor category, and 13.3% to
accordance with a stipulated dosage or training load[10], the fair category. The 6 types of exercises were running
[11].Age affects all components of physical fitness, and
on the spot, shuttle run, skipping, squats, push‑ups, and
VO2max plays an important role in respiratory fitness. sit‑ups. This study’s results are supported by previous
VO2max of children aged 8–16 years shows a progressive research that was conducted on middle school students,
and linear increase in peak aerobic ability. Thus, it which reveals that 6‑week circuit training exercises on
can be increased by applying active sports such as leg muscle strength could increase VO2max[18], [23], [8].
circuit training[12], [13], [14]. However, circuit training
produces different levels of VO2max, causingnon‑optimal The main limitation of our study is that we have yet
VO2maxachievement[6], [15]. Circuit training is designed to find anyother types of training comparative to circuit
to develop cardiorespiratory fitness, cardiovascular training for increasing the cardiorespiratory fitness of
endurance, flexibility, strength, and muscle endurance middle‑school basketball players, thus we are in need
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 435
of literature related to other types of aeorbic training. risk factors. Clin E Investig En Arterioscler
Therefore, more precisely, we recommend exercise to Publ Of La Soc Esp Arterioscler [Internet].
overcome the decline in cardiorespiratory fitness, for Sociedad Española de Arteriosclerosis; 2018;(xx).
example, a decrease in the functional aerobic capacity. Available from: https://ezproxy.southern.edu/
login?qurl=http% 3A% 2F% 2Fsearch.ebscohost.
Conclusions com% 2Flogin.aspx% 3Fdirect% 3Dtrue% 26db%
From the observations conducted three times a 3Dcmedm% 26AN% 3D29395495% 26site%
week for four weeks, it was found that the provision 3Dehost‑live% 26scope% 3Dsite
of circuit training could increase the cardiorespiratory 5. Getty AK, Wisdo TR, Chavis LN, Derella CC,
endurance of male students who took basketball as an Mclaughlin KC, Perez AN, et al. Effects of circuit
extracurricular activity. However, in order to gain further exercise training on vascular health and blood
insights regarding the improvement of cardiorespiratory pressure. Prev Med Reports [Internet]. Elsevier;
fitness of long‑term male basketball players, the sample 2018;10(February):106–12. Available from:
size should be greater because the fitness level of each https://doi.org/10.1016/j.pmedr.2018.02.010
man may vary. 6. Broch K, Urheim S, Massey R, Stueflotten W,
Fosså K, Hopp E, et al. Exercise capacity and peak
Conflict of Interest: The authors declare that there
oxygen consumption in asymptomatic patients
is no conflict of interest related to this study.
with chronic aortic regurgitation. Int J Cardiol.
Source of Funding: The authors declare that there 2016;223:688–92.
is no source of funding from anyone. 7. Ouergui I, Marzouki H, Houcine N, Franchini
E, Gmada N, Bouhlel E. Relative and absolute
Ethical clearance: The experiment was approved reliability of specific kickboxing circuit training
taken from by the Research Ethics Committee of Medical protocol in male kickboxers Reproductibilité
Faculty of Udayana University/Sanglah Hospital. relative et absolue d’ un protocole de circuit. Sci
Sport [Internet]. Elsevier Masson SAS; 2016;1‑8.
References Available from: http://dx.doi.org/10.1016/j.
1. Vasconcelos T, Hall A, Viana R. The influence scispo.2016.01.004
of inspiratory muscle training on lung function in 8. Bhambhani Y, Rowland G, Farag M. Effects of
female basketball players ‑ a randomized controlled Circuit Training on Body Composition and Peak
trial. Porto Biomed J [Internet]. PBJ‑Associação Cardiorespiratory Responses in Patients with
Porto Biomedical/Porto Biomedical Society; Moderate to. 2005;86(February):268–76.
2017;(xx):10–3. Available from: http://dx.doi.
9. Sousa M De, Zouita A, Abderrahmane A Ben.
org/10.1016/j.pbj.2016.12.003
Progressive circuit resistance training improves
2. Berner Y, Barer Y, Shefer G, Stern N. Circuit inflammatory biomarkers and insulin resistance in
resistance training is an effective means to enhance obese men. Physiol Behav [Internet]. Elsevier Inc;
muscle strength in older adults A Systematic 2018;#pagerange#. Available from: https://doi.
Review and Meta‑analysis. Ageing Res Rev org/10.1016/j.physbeh.2018.11.033
[Internet]. Elsevier B.V; 2017; Available from:
10. Gontarev S, Kalac R. Association between high
http://dx.doi.org/10.1016/j.arr.2017.04.003
blood pressure, physical fitness, and fatness in
3. Siahkouhian M, Khodadadi D, Shahmoradi K. adolescents. J Phys Educ Sport. 2016;16(2):1040‑5.
Effects of high‑intensity interval training on aerobic
11. Wu W, Yang Y, Chu I, Hsu H, Tsai F. Research
and anaerobic indices: Comparison of physically
in Developmental Disabilities Effectiveness of a
active and inactive men. Sci Sport [Internet].
cross‑circuit exercise training program in improving
Elsevier Masson SAS; 2013;28(5). Available from:
the fitness of overweight or obese adolescents with
http://dx.doi.org/10.1016/j.scispo.2012.11.006
intellectual disability enrolled in special education
4. Meseguer Zafra M, García‑Cantó E, Rodríguez schools. Res Dev Disabil [Internet]. Elsevier Ltd;
García PL, Pérez‑Soto JJ, Tárraga López PJ, Rosa 2017;60:83–95. Available from: http://dx.doi.
Guillamón A, et al. Influence of a physical exercise org/10.1016/j.ridd.2016.11.005
program on VO2max in adults with cardiovascular
436 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
12. Randers MB, Hagman M, Brix J, Christensen 15. Gmiat A, Micielska K, Koz M, Flis DJ, Smaruj M,
JF, Pedersen MT, Nielsen JJ, et al. Effects of 3 Kujach S, et al. Physiology & Behavior The impact
months of full‑court and half‑court street basketball of a single bout of high intensity circuit training on
training on health profile in untrained men. J Sport myokines’ concentrations and cognitive functions in
Heal Sci [Internet]. Elsevier B.V; 2018;7(2):132– women of di ff erent age. 2017;179(January):290–7.
8. Available from: https://doi.org/10.1016/j. 16. Romero‑arenas S, Blazevich AJ, Martínez‑pascual
jshs.2017.09.004 M, Pérez‑gómez J, Luque AJ, López‑román FJ, et
13. Sîrbu E. The effects of moderate aerobic training al. Effects of high‑resistance circuit training in an
on cardiorespiratory parameters in healthy elderly elderly population. EXG [Internet]. Elsevier Inc;
subjects. J Phys Educ Sport. 2012;12(4):560–3. 2013;48(3):334–40. Available from: http://dx.doi.
14. Kato Y, Suzuki S, Uejima T, Semba H, Nagayama org/10.1016/j.exger.2013.01.007
O, Hayama E, et al. The relationship between 17. Lehnert M, Stastny P, Sigmund M, Xaverova Z,
resting heart rate and peak VO 2: A comparison Hubnerova B, Kostrzewa M. The effect of combined
of atrial fibrillation and sinus rhythm. Eur J machine and body weight circuit training for
Prev Cardiol [Internet]. American College of women on muscle strength and body composition.
Cardiology Foundation; 2016;23(13):1429–36. J Phys Educ Sport. 2015;15(3):561–8.
Available from: http://journals.sagepub.com/ 18. Plevková L, Peráčková J, Pačesová P, Kukurová
doi/10.1177/2047487316633885 K. The effects of a 6‑week strength and endurance
circuit training intervention on body image in
Slovak primary school girls. 2018;(1):459–64.
19. Ponikowski P, Voors AA, Anker SD, Bueno H,
Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines
for the diagnosis and treatment of acute and chronic
heart failure. Eur Heart J. 2016;37(27):2129–
2200m.
20. Permadi AW. Comparison of respiratory training
method for chest wall expansion in patients with
chronic obstructive pulmonary disease. J Phys
Educ Sport. 2018;18(4):2235–9.
21. Galazoulas C. Effects of static stretching duration
on isokinetic peak torque in basketball players in
semi‑professional male basketball players. J Phys
Educ Sport. 2016;16(2):1058–63.
22. Ocak Y, Savas S, Isik O, Ersoz Y. The Effect of
Eight‑week Workout Specific to Basketball on
some Physical and Physiological Parameters.
Procedia ‑ Soc Behav Sci [Internet]. Elsevier
B.V; 2014;152:1288–92. Available from:
http://linkinghub.elsevier.com/retrieve/pii/
S1877042814054317
23. Sansone P, Tessitore A, Palauskas H, Lukonaitiene
I, Tschan H, Pliauga V, et al. Physical and
physiological demands and hormonal responses
in basketball small‑sided games with different
tactical tasks and training regimes. J Sci Med Sport
[Internet]. Sports Medicine Australia; 2018;11–5.
Available from: https://linkinghub.elsevier.com/
retrieve/pii/S1440244018304638
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 437

Relationship between Self‑Care for Fluid Limitation and

Interdialytic Weight Gain among Patients with Hemodialysis at
Ratu Zalecha Hospital, Martapura

Agus Rachmadi1,2, Ita Ratnasari2, Nursalam3, Arief Wibowo4

1Doctoral student, Public Health Faculty, Universitas Airlangga, Surabaya, 2Health Polytechnic Banjarmasin,
Ministry of Health, 3Faculty of Nursing, 4Public Health Faculty, Universitas Airlangga, Surabaya; Indonesia

Abstract
Chronic kidney failure is progressive and irreversible which caused metabolism disorder as well as electrolyte
imbalance. This condition makes the patients to conduct hemodialysis. Patients with hemodialysis must
have the ability to do self‑care for fluid limitation management. Self‑care deficit in managing fluids can
cause interdialytic weight gain. The aim of this study was to measure the correlation between self‑care for
fluid limitation and interdialytic weight gain among chronic kidney disease patients with hemodialysis in
RatuZalecha hospital Martapura. This study used cross‑sectional study, total sampling and the final sample
was 50 respondents. Data were collected in 2018. We used Spearman Rank Correlation to analyze the
data. The result showed that there was a correlation of self‑care for fluid limitation and interdialytic weight
gain among patients with hemodialysis in RatuZalecha Hospital Martapura (p‑value< 0,000; r= 0,589). The
capability of self‑care for fluid limitation and increase self‑confidence among patient with hemodialysis to
prevent interdialytic weight gain is needed.

Keywords: Self‑care, Fluid limitation, Interdialytic weight gain, hemodialysis.

Introduction maintenance metabolism and keep fluid and electrolyte

balance(5). Additionally, kidney failure caused endocrine
Kidney has an important role in the human body to
disorder and metabolic disorder, so it needs hemodialysis
maintain fluid volume and distribution (1). Kidney failure
or kidney transplantation (5). Hemodialysis is needed
requirements long treatment (1). More than 500 million
to remove metabolic residual from the blood such as
people had Chronic kidney failure (2)and only 0.1%
water, sodium, potassium, hydrogen, urea, creatinine,
of kidney failure was detected (3). 2,622,000 people
uric acid, and others substance through semi‑permeable
with kidney failure conducted end‑stage renal disease
membranes (6). Hemodialysis also assists to maintain
(ESRD), and 77% undergo hemodialysis treatment (3).
fluid balance, but the patients have to control their fluid
National Center For Chronic Disease Prevention and
regularly.
Health Promotion (2014) noted that the prevalence of
chronic kidney failure was increased (4). Patients with hemodialysis need to be trained to
calculate fluid balance within 24 hours so they can
Chronic kidney failure is progressive and irreversible.
control the fluid based on their needs. The fluid restriction
The urea creatinine will increase as the body inability to
will prevent fluid excess, because fluid excess can cause
disruption of function in other organs, such as lung and
cardio (7). Another consequence is interdialytic weight
gain, edema, wet rheumatism in the pulmonary, swollen
Corresponding Author:
eyelids and shortness of breath (5).
Nursalam
Faculty of Nursing, Universitas Airlangga, Surabaya, Patient with hemodialysis is required to do self‑care
Indonesia independently, it refers to self‑care. Self‑care is an
e‑mail: [email protected] individual effort to fulfill their needs by optimizing
438 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
intellectual abilities, behavior and utilizing the refers to knowledge regarding decision–making with
environment(8). Self‑care can be achieved by applying true‑false question (7 items), self‑care management
Dorothea E. Orem’s nursing self‑care theory. According refers to behavior regarding health maintenance (7
to Orem’s theory, every individual with a certain age items), with Likert scale (always‑never), and self‑care
and condition has the ability to treat, protect, control, confidence regarding self‑efficacy (6 items) with Likert
minimize and maintain the body to get healthy and scale (strongly disagree‑strongly agree). The score
well‑being as well as optimal life both healthy and sick, between 51‑80 means high score in self‑care, and score
or recovering from illness (5). between 20‑50 means low score in self‑care. This
questionnaire had good convergent validity (r> 0.2)
Self‑care deficit in managing fluids can cause an and adequate internal consistency with cronbach alpha=
increase in body weight between two dialysis times due 0.839.
to increased body fluid volume, it refers to interdialytic
weight gain (9). Interdialytic weight gain is one of the Interdialytic weight gain (IDWG): This is an
complications in patients with chronic renal failure observational instrument and measure body weight
who undergo hemodialysis caused by the inability of before hemodialysis, body weight after hemodialysis.
the renal excretion function. Increasing the value of the We used Nerbass theory to determine the different
interdialytic weight gain will cause a negative effect such bodyweight as well as the percentage of body weight
as hypotension, muscle cramps, hypertension, shortness (13). If the percentage of bodyweight < 5% refer to
of breath, nausea vomiting (10), also cause hypertension, normal.
peripheral edema, pulmonary edema, and increase
the risk of dilatation and cardiac hypertrophy (7). The Statistical analysis: We used SPSS for windows
problem in this study was to measure the relationship to analyze the data (p value of < 0.05 are considered to
between self‑care of fluid limitation and interdialityc describe statistically significant differences). Descriptive
weight gain among patients with chronic renal failure statistics (frequency and percentage) were used to
and hemodialysis in RatuZalecha Hospital Martapura. calculate all variables. A spearman correlation was used
to explore the relationship between self‑care for fluid
Method limitation and Interdialytic Weight Gain. Regarding
response rate we used the recommendation from the
Participants and Settings: All of the procedures previous study, that was 60% response rate (14).
of this study got permission from Institutional review
board in one of University in Indonesia. This study used Findings:
cross‑sectional design to analyze the correlation between
self‑care for fluid limitation and Interdialytic Weight Characteristic of Respondents: Table 1 shows
Gain. The Dependent variable was self‑care for fluid the characteristic of participants, included in this study:
limitation and the independent variable was Interdialytic age, gender, and length of hemodialysis. Regarding age,
Weight Gain. 34% of participants were 45‑55 and 56 ‑65 years old,
the proportion of male was 54% and female was 46%.
Data were collected from patient with hemodialysis Length of hemodialysis showed that 54% of participants
in RatuZalecha Hospital Martapura, South Kalimantan, undergo hemodialysis around 12‑24 months and 40% of
Indonesia, and used total sampling. We collected the data participants undergo hemodialysis > 24 months.
from Januari until February 2018. Total patients with
hemodialysis in this hospital were 81. It produced 60% Table 1. Demographic characteristic of participants
respond rate, so the final sample was 50 respondents. Characteristic N %
Instruments: We used self‑report questionnaires to Total = 50
collect the data. Age (Years)
18‑40 3 6
Self‑care for fluid limitation: We developed 41‑45 8 16
this questionnaire based on self –care concept from 46‑55 17 34
Orem theory (11, 12). It had 3 dimensions self‑care 56‑65 17 34
maintenance, self‑care management, and self‑care >65 5 10
confidence with total of 20 items. Self‑care maintenance
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 439

Characteristic N % self‑care maintenance (knowledge) followed by self‑care

Gender confidence (self‑esteem) and self‑care management
Male 27 54 (behavior). Previous study noted that quality of life
Female 23 46
could be achieved by increasing self‑care(3).
Length of Hemodialysis This study also showed most of the respondents had
<12 months 3 6 low self‑care management to manage the fluid intake.
12 – 24 months 27 54 The patients did not calculate the fluid intake and urine
>24months 20 40 output a day. They consume 2‑3 glasses of water in a
day, with urine output 500 ml/24 hours and also manage
Descriptive statistics among variables: Table
thirst by brush their teeth and gargling. However, they
2 shows 58% participants had good self‑care for fluid
did not know that they must restrict salty food that
limitation and 42% had low self‑care for fluid limitation.
induces thirstily. Previous study mentioned about the
In term of Interdialytic Weight Gain, 58% participants
obstacle of self‑care management among patients with
had normal Interdialytic Weight Gain and 42%
hemodialysis was internal and external factors. Internal
participants had abnormal Interdialytic Weight Gain.
factors were low of motivation to diet and fluid restriction
Table 2. Statistical Description of variables during activity. External factor was cost of hemodialysis
(16). Fluid restriction is needed to give comfort to patients

Variables N % before and after conducting hemodialysis (5).

Total = 50
Interdialytic weight gain among patients with
Self‑care for fluid limitation
hemodialysis in Ratu Zalecha Hospital Martapura:
High 29 58
Interdialytic weight gain is related to the patient’s fluid
Low 21 42 restriction. Fluid restriction is one of the treatments
Interdialytic Weight Gain for end‑stage renal disease (ESRD) to prevent worse
Normal 29 58 conditions. The amount of fluid was determined for a
Abnormal 21 42 day, and it depends on kidney function, the patient’s
edema and urine output (17). This study showed that
Correlation among Study Variables: Table 3
58% participants increased of body weight and it was
shows significant correlation between self‑care for
normal range. 42% of participants were an abnormal
fluid limit and Interdialytic Weight Gain with moderate
range (table 2). Fluid intake among patients with chronic
relationship (r = 0.589, p value < 0.01)
renal failure related to Interdialytic weight gain. This
Table 3. Relationship between self‑care for fluid study was similar to previous study (17). We assumed
limit and Interdialytic Weight Gain that Interdialytic weight gain due to thirsty condition
among participants, it was similar to Black and Hawks
Interdialytic Weight Gain theory(18).
Self‑care for fluid limit 0.589**
Increased interdialytic weight gain exceeding 5%
**p value < 0.01 of dry weight can cause several of complications such
as hypertension, interdialytic hypotension, left heart
Discussion
failure, ascites, pleural effusion, congestive heart failure,
Self‑care for fluid limitation among patients with and also can lead to mortality. Many factors contribute to
hemodialysis in Ratu Zalecha Hospital Martapura: interdialytic weight gain, such as internal factors (thirst,
Patients with hemodialysis generally have complex stress, and self‑efficacy) also external factors such as
problems and require to fulfill their needs. One of their family support and fluid intake (19).
needs was related with ability to care themselves. Patients
with hemodialysis must have ability to maintain their Relationship between self‑care for fluid limitation
fluid intake to achieve optimum quality of life. Self‑care and Interdialytic weight gain among patients with
in this study used Orem theory(11,12,15). Based on this hemodialysis in RSU Ratu Zalecha Martapura: In
study, 58% of respondents had good self‑care for fluid this study showed 82.8% respondents had high self‑care
limitation (table 2). Most respondents showed higher for fluid restriction experienced an increase in normal
440 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
interdialytic weight gain and the remain was respondents penderita gagal ginjal kronik (Self Care Model
with low self‑care for fluid restriction experienced an to Increase Quality of Life among Patients with
increase in abnormal interdialytic weight gain. This Chronic Kidney Disease). Jurnal Keperawatan
study also showed that self‑care for fluid restriction was Sriwijaya. 2016;3(2):25‑32.
statistically significant with interdialytic weight gain 4. Promotion NCfCDPaH. Indicator Definitions ‑
(table 3) with moderate correlation (r = 0.589). This study Chronic Kidney Disease USA2015 [cited 2019 28
was similar previous study about significant relationship May]. Available from: https://www.cdc.gov/cdi/
between fluid intake and interdialytic weight gain(17). definitions/chronic‑kidney.html.
Limitation: This study had some limitation. This 5. Fahmi FY, Hidayati T. Gambaran self care status
study used cross‑sectional study and relatively small cairan pada pasien hemodialisa (literatur review)
sample size. Therefore, the results may be generalized (Description of self care fluid status among
carefully. Further study is needed to increase self‑care hemodialysis patients (literature review)). Care:
for fluid limitation among patients with hemodialysis to Jurnal Ilmiah Ilmu Kesehatan. 2016;4(2):53‑63.
prevent Interdialytic weight gain. 6. Brunner S, Suddarth D. Buku ajar keperawatan
medikal bedah (Adult health nursing). Jakarta:
Conclusion EGC. 2002.
Besides the limitations, this study produced enough 7. Rahman A. Optimalisasi Pembatasan Cairan Pada
response rate. We are confident that self‑care for fluid Pasien Gagal Ginjal Kronik Yang Mendapatkan
limitation related to interdialytic weight gain. This Hemodialisa di RSUPN dr (Optimization of
study suggests evidence to increase self‑care for fluid Fluid Restrictions among Chronic Kidney Failure
limitation to prevent Interdialytic weight gain. Patients with Hemodialysis at RSUPN Dr.). Cipto
Mangunkusumo Jakarta Depok: Fakultas Ilmu
Source of Funding: We thanks to Poltekkes Keperawatan Depok. 2014.
Banjarmasin who provide grant to publish this article.
8. Sulistyaningsih DR. Penerapan Teori Model Self
Conflict of Interests: The authors declare no Care (Orem) Pada Gangguan Sistem Perkemihan
potential conflict of interests. (Studi Kasus Di Rumah Sakit Cipto Dan RSPAD
Jakarta) (Application Self Care theory among
Ethical Clearance: All procedure of this study was Patients with Urinary system Disorder (Case study
granted IRB from Health Research Ethics Committee, at Cipto Hospital and RSPAD Jakarta)). 2014.
PoliteknikKesehatan (Poltekkes) Banjarmasin, South 9. Umayah E. Hubungan Tingkat Pendidikan,
Kalimantan, Indonesia, number 158/KEPK‑PKB/2018. Pengetahuan dan Dukungan Keluarga Dengan
Kepatuhan Dalam Pembatasan Asupan Cairan
References Pada Pasien Gagal Ginjal Kronik yang Mejalanii
1. Arif M, Kumala S. Buku Ajar Asuhan Keperawatan Hemodialisa Rawat Jalan di RSUD Sukoharjo
Gangguan Sistem Perkemihan (Nursing Care Book (Relationship between Education Level,
of Urinary System Disorders). Jakarta: Salemba Knowledge, and Family Support and Compliance in
Medika. 2011. Fluid Restriction among Outpatients with Chronic
2. Rostanti A, Bawotong J, Onibala F. Faktor Faktor Kidney Failure at Sukoharjo Hospital): Universitas
Yang Berhubungan Dengan Kepatuhan Menjalani Muhammadiyah Surakarta; 2016.
Terapi Hemodialisa Pada Penyakit Ginjal Kronik 10. Smeltzer SC, Bare BG. Buku Ajar Keperawatan
Di Ruangan Dahlia Dan Melati Rsup Prof. Dr. Medikal Bedah Brunner dan Suddarth (Adult
R. D Kandou Manado (Factors Associated with Health Nursing Brunner and Suddarth). Alih bahasa
Compliance among Chronic Kidney Patients with oleh Agung Waluyo...(dkk), EGC, Jakarta. 2002.
Hemodialysis Therapy in the Dahlia Room and 11. Alligood MR. Nursing Theorists and Their
Jasmine Rsup Prof. Dr. R. D Kandou Manado). Work‑E‑Book: Elsevier Health Sciences; 2017.
JURNAL KEPERAWATAN. 2016;4(2).
12. Nursalam S. Metodologi Penelitian Ilmu
3. Nurcahyati S, Karim D. Implementasi self care Keperawatan Pendekatan Praktis (Research Method
model dalam upaya meningkatkan kualitas hidup Nursing Science). Jakarta: Salemba Medika. 2015.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 441
13. Nerbass FB, Morais JG, Santos RGd, Krüger and Interdialytic Weight Gains (IDWG) among
TS, Koene TT, Luz Filho HAd. Factors related Chronic Kidney Diseases Patients in Hemodialysis
to interdialytic weight gain in hemodialysis Unit PKU Muhammadiyah Hospital Yogyakarta).
patients. Brazilian Journal of Nephrology. Profesi (Profesional Islam): Media Publikasi
2011;33(3):300‑3005. Penelitian. 2013;10(01).
14. Dong Y, Peng C‑YJ. Principled missing data method 18. Riyanto W. Hubungan antara Penambahan
for researchers. Springer Plus. 2013;2(1):222. Berat Badan di Antara Dua Waktu Hemodialisa
15. Asmadi N, Kep S, editors. Konsep dasar (Interdialysis Weight Gain= IDWG) terhadap
keperawatan (Fundamental Nursing)2008: EGC. Kualitas Hidup Pasien Penyakit Ginjal Kronik yang
Menjalani Terapi Hemodialisa di Unit Hemodialisa
16. Arova FN. Gambaran self‑care management pasien
IP2K RSUD Fatmawati Jakarta (The Relationship
gagal ginjal kronis dengan hemodialisis di wilayah
between Weight Gain in Two Hemodialysis Time
Tangerang Selatan tahun 2013 (Description of
(Interdialysis Weight Gain = IDWG) and the
self‑care management among patients with chronic
Quality of Life of Chronic Kidney Disease Patients
kidney failure with hemodialysis in the South
with Hemodialysis Therapy in IP2K Hemodialysis
Tangerang area 2013). 2013.
Unit, Fatmawati Regional Hospital, Jakarta).
17. Istanti YP. Hubungan antara Masukan Cairan Depok: Universitas Indonesia. 2011.
dengan Interdialytic Weight Gains (IDWG)
19. Cahyaningsih ND. Hemodialisis (hemodialysis).
pada Pasien Chronic Kidney Diseases di
Jogjakarta: Mitra Cendikia; 2008.
Unit Hemodialisis RS PKU Muhammadiyah
Yogyakarta (Relationship between Fluid Intake
442 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Effect of Preoperative Biofeedback on

Anal Continence After Fistula in Ano Surgery

Ahmed Farag1, Hany M.S. Mikhail2, Ahmed S. Khalifa3, Mohamed T. Mostafa3, Abdrabou N. Mashhour2
1Professor of General Surgery, 2Assistant Professor of General Surgery,
3Assistant Lecturer of General Surgery, General Surgery Department, Cairo University, Egypt

Abstract
Objective: The aim of the present prospective study was to evaluate the role of preoperative prophylactic
biofeedback therapy on the anorectal continence of patients with high anal fistula who will be subjected to
fistulectomy operation.

Method: This was a randomized control study which included 40 patients who presented to the Out Patient
Department (OPD) of Kasr‑al ainy Hospitals, from March 2015 to September 2016. Allpatients (40) have
been presented with high complex anal fistulae. They were divided into two equal groups; group (A) has
twenty patients who had undergone prophylactic preoperative anorectal biofeedback and group (B) has
the other twenty patients who didn`t receive the prophylactic preoperative anorectal biofeedback therapy.
For group (A) patients, six sessions of biofeedback were done two weeks. All patients were assessed
postoperatively (0, 3 and 6 months) for continence by Cleveland Clinic Score for incontinence.

Results: Among these forty patients only four (10%) had developed anal incontinence with variable degrees
(two of them gas incontinence and another two developed frank stool incontinence), these four patients
belong to the group (B), on the other hand, none of group (A) patients had developed incontinence.

Conclusion: In conclusion, we can rely on preoperative prophylactic biofeedback has an important role to
minimize incontinence post high anal fistula surgery.

Keywords: Fistula in ano, Fecal Incontinence, Biofeedback.

Introduction preserving approaches such as core fistulectomy or

mucosal advancement flap are recommended for high
Surgery of perianal fistulas remains a challenge
complex fistulas as better approaches to preserve
because of potential sequences including fecal
continence.[2‑4]
incontinence (FI) that may impair quality of life. [1]
About 70% of the resting tone is achieved by internal
Reported incidences of incontinence following
anal sphincter (IAS). This is supported by the finding
fistulas surgery range from 5% to 60%. Sphincter
lateral internal sphincterotomy could be complicated by
fecal incontinence.[5]

The external anal sphincter (EAS), similar to the

Corresponding Author:
IAS, is in a state of tonic contraction even at rest and the
Ahmed S. Khalifa, MD
activity is reflexly raised when intra‑abdominal pressure
Assistant Lecturer of General Surgery, General Surgery is increased e.g. when coughing, laughing or lifting.
Department, Cairo University, Egypt Activity is maximally raised when the EAS is contracted
Cairo University, KasrAlainy Faculty of Medicine, voluntarily but contraction.[6]
Postal Code: 11562
e‑mail: [email protected] Both American College of Gastroenterology
Tel.: +201067445762 and the American Gastroenterological Association
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 443
recommend anorectal biofeedback for the treatment Endoanal Ultrasonography (EUS).
of FI. Biofeedback treatment protocols for FI aim to
strengthen pelvic floor muscles, to increasethe ability to After the agreement of the scientific and ethical
sense rectal filling and to teach patients to perceive and committee of the general surgery department, the
react even if the rectum is dilated slightly.[7‑9] procedure and the study were explained for all individuals
participating in the study and all of them consented for
Aim of work: The aim of this article was to describe agreement.
a standardized biofeedback anal exercises protocol as
aprophylactic measure prior to complex anal fistulas Biofeedback protocol: The biofeedback protocol
surgery to minimize the incidence of postoperative fecal was explained in details to patients in group (A). It
incontinence. was done in the colorectal unit with the subject in the
left lateral position a multi‑lumen catheter was placed
Material and Method in the rectum with 8 side holes with varying distances
from the anal verge. These were perfused with water
Patients: Our study included 40 patients who came and connected to water filled transducers. A 5 cm
to the Out‑Patient Department (OPD) of Kasr‑el Ainy latex balloon was attached to the catheter and linked
Hospital, from March 2015 to September 2016. to an air filled transducer. Catheter used: with 8 side
After agreement from the Scientific and Ethical holes 3,4,5,6,7,8,9 and 10 cm from the balloon and at
Committee of General Surgery Department and Faculty angles 0, 45, 90,135,180,225,270 and 315 respectively.
of Medicine Cairo University, the procedure and the Recordings were made on a computer using the machine
study were explained to all individuals participating in software to be printed when needed.
the study and informed written consents were taken. Six sessions were performed preoperatively each
Forty patients who were candidates for high anal of which lasting 20 ‑30 minutes, the sessions are
fistulas surgical treatment were randomized into two performed every other day with average three sessions
equal groups (A and B) using closed envelope. Neither per week. First sensation: the balloon of the catheter
patients nor physicians were blinded to the group is inflated until the first sensation is reached at which
assignment because of the nature of the study. Group (A) the patient is asked to contract his sphincters; this is
included 20 patients who had preoperative biofeedback done to improve sensation and coordination. Challenge
program while group (B) included 20 patients that were pressure, the patient is asked to pass the obstacle over a
not undergone biofeedback program. Patients’ selection bar (representing the challenge pressure) by maximum
was done using the closed envelope method. squeeze. The muscle response measured by pressure
transducers is translated into a visual display so that
Patients, not fit for surgery didn’t accept treatment the patient receives immediate feedback regarding the
modality, at extreme ages, and/or those with low anal strength and duration of pelvic floor muscle contraction.
fistulas were excluded from the study Challenge time, during which the patient squeezed.
Resting time, during which the patient rested. Challenge
Method pressure, challenge time and resting time could be
Pre‑operative: All patients were underwent proper adjusted through the program before starting the session
history taking (age, presentation, occupation, presence Operation: For all patients general anesthesia
of previous abscess, contributing factors, continence without muscle relaxant was used. Patients were operated
assessment by Cleveland Clinic Score for incontinence in lithotomy position. They were received prophylactic
and previous anal surgeries) and full general and local antibiotic.
examination (P/R examination) to determine: External
fistulous opening, Internal fistulous opening,primary, Core fistulectomy was done to all the patients. Its
secondary tract, sphincter tone, scars and presence of principle was to remove the chronic, epithelialized tract
abscess cavity. to allow healing by secondary intention of healthier
tissue. Dissection was typically carried out from the
Anatomical assessment of the fistula tract, its external opening up to the internal fistulous opening.
relation to the anal canal and muscular complex were
studied by magnetic resonant imaging (MRI) and/or Postoperative care: The patients started oral fluids
444 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
same day of procedure intake advanced gradually as Patients were discharged 24 hours postoperative
patient tolerating feeding. Analgesia (usually IV or with instruction for frequent dressing. Early assessment
IM nonsteroidal anti‑inflamatory) started immediately for anorectal continence was carried using Cleveland
postoperative. Clinic incontinence score (table 1)10.

Table (1): Cleveland Clinic continence score

The Wexner score

Frequency
Type of Incontinence
Never Rarely Sometimes Usually Always
Solid 0 1 2 3 4
Liquid 0 1 2 3 4
Gas 0 1 2 3 4
Wears pads 0 1 2 3 4
Lifestyle alteration 0 1 2 3 4

Never, 0; rarely, <1/month; sometimes, <1/week, 1/month; usually, <1/day, 1/week; always, 1/day. 0, perfect; 20, complete incontinence.

The patients were advised for follow up in (30%) with suprasphincteric fistulas and 9 (45%) with
outpatient clinic 7‑14 days to assess the wound and early high transphincteric fistulas.
postoperative complications. 6 months later, anorectal
continence was reassessed after complete wound healing. There were 4(20%) patients with recurrent fistulas
in group A and 3 (15%) in group B.
Findings: Both groups were matched regarding the
age and gender. The mean age for group (A) was 41.35 Four patients in each group had associated abscess
while that for group (B) was 39.5. collections that had been drained during fistula surgery.

In group A, there were 8 (40%) with extrasphincteric According to Cleveland Clinic incontinence score
fistulas, 4 (20%) with suprasphincteric fistulas and 8 for postoperative follow up, 4 patients developed
(40%) with high transphincteric fistulas while in group incontinence in group B while all patients in group A
B, there were 5 (25%) with extrasphincteric fistulas, 6 were fully continents postoperatively (p = 0.038).

Table (2): Analytical results of the patients with high anal fistulas without preoperative biofeedback who
had developed incontinence.

Fistula type Preoperative Wexner score Postoperative Wexner score

Extrasphincteric with abscess formation 0 8
Suprasphinctericfistulas with abscess 0 20
Suprasphincteric fistulas with abscess 0 20
Suprashincteric 0 4

Discussion of choice for fecal incontinence secondary to a variety of

medical and surgical disorders in all age groups12.
The fecal incontinence is a very frequent pathology,
the frequency considered in the general population being The preoperative biofeedback and pelvic exercises
2‑3%, although the studies of prevalence in the general improve urinary control and decrease severity of urine
population show a great variability11. Biofeedback incontinence following radical prostatectomy13.
training has been regarded as the conservative therapy
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 445
This was a randomized control study, which In 2006, Dobben et al. studied 266 patients
included forty patients who presented to the outpatient (91% female) and observed that the improvement
clinic of the colorectal unit in Kasr Alainy hospital in the in incontinence with the use of biofeedback was not
period between from March 2015 to September 2016for associated with results in tests including anorectal
colorectal surgery. manometry19.

The purpose of this study was to assess anorectal Conclusion

biofeedback as a prophylactic measure for fecal
incontinence after fistulectomy surgery for patients with In our study twenty patients with high anal fistulas
complex fistulas. had received prophylactic biofeedback therapy with
mean age of 41.35 years, all of them were completely
In 2003, Fernandez et al. studied the effect of continent postoperatively; another twenty patients
anorectal biofeedback on a total of 145 patients with with high anal fistulae had not received prophylactic
anal incontinence (118 female and 27 male) Four weeks preoperative biofeedback with mean age of 39.45
following completion of the sessions, 59 patients (76%) years, among them four patients had developed fecal
had improved significantly, 13 (17%) had improved incontinence with varying degrees (two patients had
slightly and 6 (8%) had not changed14. developed gas incontinence and another two had
developed complete incontinence), so it had been
In 2007, Byrne et al. studied 513 patients, 385 found that preoperative prophylactic biofeedback has
(75 percent) completed the treatment program. In an important role to prevent or minimize incontinence
those completed the treatment program maximum anal post high anal fistula surgery (with P value of 0.038
sphincter pressure increased by a mean 12 mmHg (14 when comparing both groups using the Wexner score)
percent; from 90 to 102 mmHg)15. as it enhances the contraction capacity of the external
In 2004, Kairaluoma et al. studied biofeedback sphincter muscles and has a role to teach the patients to
therapy in treating 22 patients with anal incontinence; perceive and react even the rectum is slightly dilated.
21 female and one male, with a median age of 57 (range Preoperative prophylactic anorectal biofeedback
27–84) years. In this study manometry results suggested reduces the incidence on anorectal incontinence after
that the external sphincter function is improved by anal operations for high anal fistulae.
biofeedback therapy. However, there is no effect on
resting pressure and internal sphincter function16. The use of biofeedback has shown that autonomic
functions can be conditioned by training the mind to
In 2003, Kienle et al. studied a consecutive patient control them.
series (N = 70) with anal sphincter deficiency and compare
the efficacy of biofeedback and electrostimulation as Biofeedback enhances the contraction capacity of
conservative treatment options. Forty patients were the external sphincter muscles.
treated by biofeedback therapy; Patients were not
specifically selected for one or the other treatment. Biofeedback teaches the patient to perceive and
Resting and squeeze pressure increased significantly react even if the rectum is slightly distended.
after biofeedback training (P < 0.05 and < 0.001)17. Funding: Self‑funding
In 1994, Keck et al. studied fifteen patients (13 Ethical Clearance: Cleared by the ethical
women and 2 men) with incontinence underwent a committee of general surgery department faculty of
mean of three (range, 1–7) biofeedback sessions. The medicine Cairo University
cause was obstetric (four patients), postsurgical (five
patients), and idiopathic (six patients). Total resolution Conflict of Interest: No
of symptoms was reported in four patients, favourable
improvement in four patients and some improvement References
in three patients. Manometric measurements showed a 1. Held D, Khubchandani J, Sheets J, Stasik J, Rosen
mean increase of 15.3 mmHg in resting pressure and L, Wether R. Management of anorectal horseshoe
35.7 mmHg in squeezing pressure after biofeedback18. abscess and fistula. Dis. Colon Rectum 1986; 29:
793–7
446 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
2. Ellis CN,Clark S. Fibrin glue as an adjuvant to flap Wilson‑Barnett, Sally Redfern, and Michael A.
repair of anal fistulas: a random ized, controlled Kamm. “Randomized controlled trial of biofeedback
study. Dis Colon Rectum 2006;49:1736–40. for fecal incontinence.” Gastroenterology 125, no.
3. Rao SS. Diagnosis and management of 5 (2003): 1320‑1329.
fecal incontinence. American College of 13. Burgio, K.L., Goode, P.S., Urban, D.A., Umlauf,
Gastroenterology Practice Parameters Committee. M.G., Locher, J.L., Bueschen, A. and Redden,
Am J Gastroenterol. 2004; 99(8):1585‑604. D.T., 2006. Preoperative biofeedback assisted
4. Halverson AL. Nonoperative Management of behavioral training to decrease post‑prostatectomy
Fecal Incontinence. CLINICS IN COLON AND incontinence: a randomized, controlled trial. The
RECTAL SURGERY. 2005; 18(1):17 – 21. Journal of urology, 175(1), pp.196‑201.
5. Andrews CN, Bharucha AE. The etiology, 14. Fernandez‑Fraga X, Azpiroz F, Aparici A, Casaus
assessment, and treatment of fecal incontinence. Nat M, Malagelada JR. Predictors of response to
Clin Pract Gastroenterol Hepatol. 2005;2:516‑525. biofeedback treatment in anal incontinence. Dis
Colon Rectum 2003; (46):1218– 1225.
6. Fritsch H, Aigner F, Ludwikowski B, et al.
Epithelial and muscular regionalization of the 15. Byrne, C.M., Solomon, M.J., Young, J.M., Rex,
human developing anorectum. Anat Rec (Hoboken) J. and Merlino, C.L., 2007. Biofeedback for
2007; 290(11):1449–1458. Enck P, Van fecal incontinence: short‑term outcomes of 513
der Voort IR, Klosterhalfen S. Biofeedback consecutive patients and predictors of successful
therapy in fecal incontinence and constipation. treatment. Diseases of the colon & rectum, 50(4),
NeurogastroenterolMotil 2009; 21(11):113341. pp.417‑427.
7. Kraemer M, Ho YH, Tan W. Effectiveness 16. Kairaluoma M, Raivio P, Kupila J, Aarnio M,
of anorectal biofeedback therapy for faecal Kellokumpu I. The role of biofeedback therapy
incontinence: medium‑term results. Tech in functional proctologic disorders. Scandinavian
Coloproctol. 2001; 5(3):125‑9. Journal of Surgery. 2004; (93): 184‑ 190.
8. Gladman MA, Scott SM, Chan CL, Williams NS, 17. Kienle P, Weitz J, Koch M, Benner A, Herfarth C,
Lunniss PJ. Rectal hyposensitivity: prevalence Schmidt J. Biofeedback versus electrostimulation
and clinical impact in patients with intractable in treatment of anal sphincter insufficincy. Dig Dis
constipation and fecal incontinence. Dis Colon Sci. 2003 Aug; 48(8):1607‑13.
Rectum 2003; (46):238–246. 18. Keck JO, Staniunas RJ, Coller JA, Barrett RC,
9. Johanson JF, Lafferty J. Epidemiology of fecal Oster ME, Schoetz DJ Jr, Roberts PL, Murray JJ,
incontinence: the silent fiction. Am J Gastroenterol Veidenheimer MC. Biofeedback training is useful
1996; (91):33–6. in fecal incontinence but disappointing constipation.
Dis Colon Rectum. 1994 Dec; 37(12):1271‑6.
10. Colquhoun, P., Kaiser, R., Weiss, E.G., Efron,
J., Vernava, A.M., Nogueras, J.J. and Wexner, 19. Dobben AC, Terra MP, Berghmans B, Deutekom
S.D., 2006. Correlating the fecal incontinence M, Baeten CG, Janssen LW, Boeckxstaens GE,
quality‑of‑life score and the SF‑36 to a proposed Engel AF, Felt‑Bersma RJ, Slors JF, Gerhards MF,
ostomy function index in patients with a stoma. Bijnen AB, Everhardt E, Schouten WR, Bossuyt
Ostomy wound management, 52(12), p.68. PM, Stoker J. Electrical stimulation and pelvic floor
muscle training with biofeedback in patients with
11. Macmillan AK, Merrie AE, Marshall RJ, Parry
fecal incontinence: a cohort study of 281 patients.
BR. The prevalence of fecal incontinence in
Dis Colon Rectum. 2006 Aug; 49(8):1149‑59.
community‑dwelling adults: a systematic review
of the literature. Dis Colon Rectum. 2004; (47):
1341‑9.
12. Norton, Christine, Sonya Chelvanayagam, Jenifer
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 447

Relation between Human Epididymis Protein 4 and

Endometrial Pathology in Women with Postmenopausal
Bleeding

Ahmed L. Aboul Nasr1, Ghada A. Abdel Moety1, Mostafa S. Salem2,

Marwa M. Elsharkawy3, Nada Kamal1, Ahmed M. Maged1
1Department of Obstetrics & Gynecology, Faculty of Medicine, 2Department of Pathology,
3
Department of Clinical Pathology Cairo University, Cairo, Egypt

Abstract
Objective: To evaluate the value of human epididymis protein 4 (HE4) in predicting endometrial pathology
in women with postmenopausal bleeding (PMB).

Method: A cohort study included 100 women with PMB. Women with endometrial thickness (ET) >5mm
were subjected to hysteroscopic guided fractional curettage (FC) followed by total abdominal hysterectomy
and bilateral salpingo‑oophorectomy with or without pelvic lymphadenectomy.

After exclusion of 10 patients, the value of serum HE4 was tested in 90 patients for the ability to predict
endometrial pathology based on hysterectomy specimen.

Results: Level of HE4 showed a significant difference among women with different endometrial pathologies.
HE4 showed a significant positive correlation with the severity of the endometrial lesion, with mean values
of 38.33±27 pmol/L for atrophic endometrium (11 cases), 51.26±28.59 pmol/L for simple endometrial
hyperplasia (SEH, 51 cases), 148.4±67.34 pmol/L for atypical endometrial hyperplasia (AEH, 16 cases) and
390.9±351.72 pmol/L for endometrial carcinoma (EC,12 cases) Using the cut‑off value of 69.5 pmol/L for
preoperative HE4 yielded a sensitivity of 75% and a specificity of 88.5% in prediction of EC.

Conclusion: HE4 can predict endometrial pathology in women with PMB with a high specificity and a fair
sensitivity.

Keywords: Human epididymis protien4 (HE4); postmenopausal bleeding; endometrial carcinoma;

endometrial pathology.

Introduction diabetes, and prolonged life expectancy, the incidence

and mortality of endometrial carcinoma have risen
Endometrial carcinoma accounts for 20% to 30%
lately, with a tendency for onset at a younger age 1. The
of malignant tumors in the female reproductive system.
prognosis is closely related to the disease stage. If the
As a consequence to increased obesity, hypertension,
diagnosis is during stage I, then the survival rate is about
90% 2.

Corresponding Author: There are no specific tumor markers for endometrial

Nada Kamal carcinoma. CA‑125 was detected in 1983 by Bast et al.3
Department of Obstetrics and Gynecology, 27 Nafezet as the epithelial ovarian carcinoma antigen. However,
Sheem El Shafaey St KasrAl Ainy Faculty of Medicine, CA‑125 is less effective in the diagnosis of EC compared
Cairo University, Cairo, Egypt with the diagnosis of other gynecological carcinomas.
e‑mail: [email protected] CA‑125 can only produce obvious effect in diagnosing
some common tumors in advanced stage 4 .
Tel.: +20 1011322138
448 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
HE4 biomarker has been recently studied. It was Definitive management was later performed in
identified in the epithelium of the distal epididymis the form of total abdominal hysterectomy, bilateral
and was predicted to be a protease inhibitor involved in salpingooophrectomy, with or without pelvic lymph
sperm maturation 5. In 2003, HE4 was approved by the nodal dissection and histopathological examination.
FDA as a serum tumor marker for ovarian carcinoma
and attracted great attention6. Recent studies indicate Results
that HE4 is highly expressed in ovarian and endometrial Women with malignancy had significantly older
carcinoma tissues with increased serum level in these age, lower parity, higher BMI and longer duration of
patients as well7. menopause when compared to those with non‑malignant
Materials and Method lesion (table 1).

This prospective cohort study included 100 women ET of the malignant group was significantly higher
with PMB who were recruited from Kasr Al Aini than that of the non‑malignant group (20.33 ± 7.4 versus
Hospital, Cairo University, Egypt between June 2014 12.68 ± 4.22mm, p: <0.001), level of preoperative serum
and August 2016. An informed written consent was HE4 was significantly higher in the malignant group as
obtained from all participants prior to inclusion. compared to the non‑malignant group (390.92 ± 351.72
versus 61.25 ± 31.65pmol/L, p: <0.001) (table 1).
All patients included in the study had single or
multiple episodes of PMB with an ET of more than The level of HE4 in different endometrial pathologies
5mm. Exclusion criteria were having history of other of the cases group is presented in (table 2).
malignancies, history of intake of chemotherapy or A scale was proposed in which the endometrial
radiotherapy, the use of hormone replacement therapy, pathologies were arranged in a descending manner
and being unfit for surgical intervention. according to the severity of the lesion, where malignancy
Full history was taken (including the duration was the severest, followed by AEH, then SEH, and
of menopause, the number of episodes of PMB, and atrophic endometrium being the least severe form. Hence,
previous investigations and current medications), correlation between the preoperative HE4 level and the
general examination was performed (including blood severity of the endometrial lesion could be evaluated.
pressure measurement, calculation of body mass index This study showed that there was a significant strong
(BMI= weight (kg)/[height (m)]2, and the presence of positive correlation between the preoperative level of
any signs of systemic diseases), and local examination HE4 and the severity of the endometrial pathology (r=
was performed for all patients. 0.735, p: <0.001).

Transvaginal ultrasound (TVS) done by the same ROC curve was generated to evaluate the performance
observer to nullify the effect of inter observer variability. of the preoperative level of HE4 in distinguishing
malignant from non‑malignant endometrium (figure 1).
For the level of HE4: 5 ml of venous blood were
withdrawn from all patients. The samples were left to Using the cut‑off value of 69.5 pmol/L for
clot. The separated sera were stored at ‑20˚ until all preoperative HE4 yielded a sensitivity of 75%, a
samples were obtained. Frozen samples were allowed to specificity of 88.5% and an AUC‑ROC of 0.933 (table 3).
reach room temperature prior to use. Samples were then All malignant cases (12 cases) were of the
mixed thoroughly by gently inverting multiple times endometrioid type, 5 were stage Ia, 5 were stage Ib, and
before analysis. HE4 was quantitatively assayed using 2 were stage II. All were operable and a total abdominal
the enzyme immunoassay (EIA) method (Fujirebio hysterectomy and bilateral salpingo‑oophorectomy with
Diagnostics, Inc. Göteborg, Sweden). The functional pelvic lymphadenectomy was performed for all.
sensitivity of the HE4 EIA is ≤ 25pM. The analytical
specificity is 100 ± 15%. For the degree of differentiation, 2 cases were grade
1 (G1), 8 cases were grade 2 (G2), and 2 cases were
All patients were then submitted to hysteroscopy grade 3 (G3).
under general anesthesia and guided endometrial biopsy.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 449
Multivariate stepwise linear regression for factors AEH and EC cases, HE4 value of 62.5 pmol/L yielded a
with significant differences between malignant and sensitivity of 85.9% and specificity of 62.9% with AUC
non malignant cases as age, parity, and duration of of 0.832 .
menopause are shown in table 4.
Similar to our findings, previous study on 2015
The level of HE4 in the malignant cases according reported the sensitivity and specificity of HE4 in
to the tumor stage, grade and lymph node involvement distinguishing EC patients from healthy females were
is described in table 5. 62.2% and 95% respectively, with an AUC of 0.996 .
Another one on the same year reported a sensitivity of
Discussion 72.4% and a specificity of 75.4% for the cut‑off 76.5
In this study, we focused on examining the role of pmol/L 15. Also, Capriglione et al in 2015 16 reported
HE4 in distinguishing malignant from non‑malignant sensitivity and specificity that are near to ours in
lesions of the thickened endometrium in women detecting EC patients 83.3% and 96% respectively.
with PMB through histopathological examination of An earlier study on 2013 has reported that the
hysteroscopic directed endometrial curettage followed sensitivity of HE4 in detecting malignant cases was 75%
by hysterectomy, and to correlate HE4 level with the and the specificity was 65.5%, and that the sensitivity
endometrial lesion. was improved after combining HE4 with other markers
The prevalence of EC in the present study was (CA‑125, CEA, and serum amyloid –A) to be 84% 13.
13.3%. This is similar to that reported in previous Another publication in the same year revealed that the
studies8. sensitivity of HE4 in detecting malignant endometrium
HE4 is a new detection index. Being highly was 59.4% with 100% specificity for the cut‑off value
expressed in ovarian and endometrial carcinoma cells 7. of 70pmol/L. After adding CA‑125, the sensitivity was
elevated to be 60.4%. The authors concluded that HE4
In this study, the preoperative level of HE4 was at cutoff of 70 pmol/L yields the bestsensitivity and
significantly higher in the endometrial carcinoma cases specificity 12. The lower sensitivity of the marker in their
than its level in the non‑malignant cases. study compared to ours might be due to that they took
into consideration other types of EC while all our cases
HE4 actually exists in normal tissues e.g. male were of the endometrioid type.
vas deferens, mammary gland epithelium, female
genital tract including the endometrium 9. So its level Previous study on 2016 have reported that HE4
is suspected to increase with increased endometrial was significantly higher in grade 3 (G3) carcinomas
thickness. As suspected its level is increased in cancers compared with grade 1 (G1) and 2 (G2), and that patients
arising from these tissues 10. who needed lymphadenectomy had significantly higher
HE4 level than those who had no indications for this
The National comprehensive cancer network in procedure14.
2012 signified the value of HE4 as a tumour marker for
epithelial ovarian tumors and as both the uterus and the A recent study on 2017 stated that preoperative
ovary share a common embryological origin so HE4 can serum HE4 is significantly correlated with primary tumor
be used as a marker for endometrial tumors 11. diameter and depth of myometrial invasion, but not with
tumor grade or cervical involvement and lymphovascular
In the present study, upon examining the diagnostic infiltration and that serum HE4 levels could be useful in
performance of HE4 in predicting the presence of EC identifying EC patients at high risk of lymphatic spread
among patients with PMB, using the cut‑off value of 69.5 who would benefit from lymphadenectomy17.
pmol/L for preoperative HE4 yielded a sensitivity of 75%
and a specificity of 88.5%, and an AUC‑ROC of 0.933, A meta‑analysis done in 2014 reported that HE4 is
Having more serious consequences separating AEH the most accurate and sensitive EC marker identified
and EC patients from SEH and atrophic endometrium to date. In particular, this new marker seems to have a
cases,HE4 was significantly higher in the former group good performance in diagnosis. The best cut‑off of HE4
218.14 ± 273.46 versus 54.2 ± 22.45, p <0.001 with a in diagnosis ranges between 50 and 70 pmol/L, resulting
new cut off value calculated to help differentiation of at least in 78.8% of sensitivity and 100% of specificity in
450 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
all stages. Another important aspect to consider is HE4 The present study is strengthened by its prospective
capacity in predicting the stage of disease and myometrial nature, and that it depended on hysterectomy specimen
involvement, which can help scheduling the appropriate for diagnosis of different endometrial pathologies as well
timing of imaging and surgery in a more individualized as malignancy, beside the analysis of positive results of
fashion and as indicator of patient prognosis18. lymphadenectomy.

Our study confirmed the known fact that malignancy The main limitation of the study is the small sample
is suspected to be found in women with postmenopausal size included which resulted in a limited number of
bleeding when they are older, lower parity, higher malignancy cases with the resultant limited variations
BMI and have longer interval between menopause and in malignancy stages and pathological subtypes. Larger
presentation. number of participants would have better detected the
value of the studied marker (HE4) in diagnosis and
ACOG confirmed these findings by stating that the prognosis of endometrial malignancies. Nevertheless,
clinically identified risks for carcinoma endometrium the study highlighted the presence of this new marker
include age and high body fat 19. and pointed to its possible value in diagnosis of the
disease and the prediction of its occurrence at certain
cut‑off value with the reported sensitivity and specificity.

Table (1): Characteristics of the studied population

Malignant Group (n=12) Non‑malignant Group (n= 78) P value

Age (Years) 63.5 ± 6.86 55.97 ± 5.68 <0.001
Parity 2.67 ± 1.49 4.71 ± 2.15 0.002
BMI (Kg/m2) 37.19 ± 5.58 32.95 ± 6.49 0.034
Duration of menopause (Years) 11.67 ± 5.41 4.83 ± 4.26 <0.001
Endometrial thickness (mm) 20.33 ± 7.4 12.68 ± 4.22 <0.001
Preoperative HE4 (pmol/L) 390.92 ± 351.72 61.25 ± 31.65 <0.001

Data are presented as mean±SD

Table (2): Level of HE4 in different endometrial pathologies

EC (n= 12) AEH (n= 16) SEH (n= 51) Atrophic endometrium (n= 11) P value
HE4 (pmol/L) 390.92 ± 351.72 148.44 ± 67.34 51.26 ± 28.59 38.33 ± 27 <0.001

Data are presented as mean±SD

Table (3): Tests of diagnostic accuracy of preoperative HE4 level in distinguishing malignant from
non‑malignant endometrium

Cut‑off value Sensitivity (%) Specificity (%) AUC‑ROC PPV NPV Accuracy
Malignant
HE4 level
versus non‑ 69.5 75 88.5 0.933 50 95.8 86.7
(pmol/L)
malignant cases

Table (4): Multivariate stepwise linear regression for age, parity, and duration of menopause

Beta Coefficient 95% CI for OR

S.E. Wald p value OR
(Adjusted) Lower Upper
Age 0.259 0.294 0.779 0.377 1.296 0.729 2.304
Parity ‑1.064 0.492 4.676 0.031 0.345 0.132 0.905
Duration of Menopause 0.189 0.253 0.557 0.455 1.208 0.735 1.985
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 451
Table (5): The level of HE4 in the malignant cases approved by the department, Clinical trial registry no.
according to the tumor stage, grade and lymph node NCT03558321.
involvement
References
No.
HE4 level P value 1. Brennan DJ, Hackethal A, Metcalf AM. Serum HE4
Patients
Figo stage as a prognostic marker in endometrial carcinoma:
I 10 322.56±182.66 a population based study. Gynecologic Oncology
Ia vs Ib =0.012
Ia 5 262.32±319.51 2014; 132(1): 159–165.
Ib vs IIa=0.241
Ib 5 435.4±293.59 2. Bie Y, Zhang Z. Diagnostic value of serum HE4 in
I vs II=0.001
IIa 2 501.72±423.74 endometrial carcinoma: A meta‑analysis. World J
Grade Surg Oncol. 2014; 12:169.
G1 2 82.16±55.23
3. Bast RC, Klug TL, St John E, et al. A
G2 8 308.89±275.85 <0.001
G3 2 920.54±166.17
radioimmunoassay using a monoclonal antibody to
monitor the course of epithelial ovarian carcinoma.
Lymph nodes
Positive 3 635.42±426.88
N Engl J Med 1983; 309: 883–887.
<0.001
Negative 9 167.84±112.43 4. Liu X, Zhao F, Hu L, et al. Value of detection of
serum human epididymis secretory protein 4 and
carbohydrate antigen 125 in diagnosis of early
endometrial carcinoma of different pathological
subtypes. Onco Targets Ther. 2015 May 26;
8:1239‑1243.
5. Kirchhoff C. Molecular characterization of
epididymal proteins. Rev Reprod 1998, 3: 86–95.
6. Helistrom I, Raycraft J, Hayden‑Ledbetter M. The
HE4 (WFDC2) protein is a biomarker for ovarian
carcinoma, Cancer Research 2003; 63 (13): 3695–
3700.
7. Xia C, Ping Z, Xiaoyan L. Relationship between
the serum human epididymis secretory protein 4
and clinical pathological features in patients with
epithelial ovarian cancer. Labeled Immunoassays
Clin Med. 2010; 17(6):365–367.
8. Damle RP, Dravid NV, Suryawanshi KH, et al.
Clinicopathological Spectrum of Endometrial
Changes in Peri‑menopausal and Post‑menopausal
Abnormal Uterine Bleeding: A 2 Years Study. J
Clin Diagn Res. 2013 Dec; 7(12):2774‑2776.
Figure 1: ROC curve 9. Mehri Jafari‑Shobeiri,MarzyeJangi, Ali Dastranj
Tabrizi, ManizhehSayyah‑Melli, Parvin
Conclusion Mostafa‑Gharabaghi, ElahehOuladsahebmadarek,
EsmailNeginfar, Yasmin Pouraliakbar. Diagnostic
HE4 can predict endometrial pathology in women
Value of Novel Biomarker Human Epididymis
with PMB with a high specificity and a fair sensitivity.
Protein 4 (HE4) in Detecting Endometrial Cancer.
Conflict of Interest: The authors have no conflicts International Journal of Women’s Health and
of interest. Reproduction Sciences Vol. 4, No. 1, January 2016,
29–33
Source of Funding: Personal fund.
10. Simmons AR, Baggerly K, Bast RC Jr. The
Ethical Committee Approval: Ethically emerging role of HE4 in the evaluation of epithelial
452 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
ovarian and endometrial carcinomas. Oncology 15. Minář L, Klabenešová I, Jandáková E. The
(Williston Park) 2013;27:548‑556. importance of HE4 in differential diagnosis of
11. Xiao Li, Yiping Gao, Mingzi Tan, et al., “Expression endometrial cancer .CeskaGynekol. 2015 Aug;
of HE4 in Endometrial Cancer and Its Clinical 80(4):256‑63.
Significance,” BioMed Research International, vol. 16. Capriglione S, Plotti F, Miranda A, et al. Utility
2015, Article ID 437468, 8 pages, 2015. https://doi. of tumor marker HE4 as prognostic factor in
org/10.1155/2015/437468 endometrial cancer: a single‑center controlled
12. Angioli R, Plotti F, Capriglione S, et al. The role study. Tumour Biol. 2015 Jun; 36(6):4151‑4156.
of novel biomarker HE4 in endometrial cancer: a 17. Fanfani F, Restaino S, Cicogna S, et al. Preoperative
case control prospective study. Tumour Biol. 2013; Serum Human Epididymis Protein 4 Levels in Early
34:571–576. Stage Endometrial Cancer: A Prospective Study.
13. Omer B, Genc S, Takmaz O, et al. The diagnostic Int J Gynecol Cancer. 2017 Jul; 27(6):1200‑1205.
role of human epididymis protein 4 and serum 18. Angioli R, Miranda A, Aloisi A, et al. A critical
amyloid‑A in early‑stage endometrial cancer review on HE4 performance in endometrial cancer:
patients. Tumour Biol. 2013 Oct; 34(5):2645‑50. where are we now? Tumour Biol. 2014 Feb;
14. Gąsiorowska E, Magnowska M, Iżycka N, et 35(2):881‑887.
al. The role of HE4 in differentiating benign and 19. ACOG Committee Opinion No. 734 Summary:
malignant endometrial pathology. Ginekol Pol. The Role of Transvaginal Ultrasonography in
2016; 87(4):260‑264. Evaluating the Endometrium of Women With
Postmenopausal Bleeding. Obstet Gynecol.
2018 May;131(5):945‑946. doi: 10.1097/
AOG.0000000000002626.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 453

Evaluation of Eye Relaxation to Decrease Eye Strain in

PT Japfa Comfeed Indonesia Unit Sragen

Aisy Rahmania1, Noeroel Widajati1, Abdul Rohim Tualeka1

1Departement of Occupational Health and Safety, Faculty of Public Health,
Airlangga University, 60115, Surabaya, East Java, Indonesia

Abstract
Office worker currently relies heavily on the role of the computer to make work easier to input, processing,
storage and transmission of data. The work at the office of PT Japfa Comfeed Indonesia Sragen is a job
that demands labor staring at a computer screen for 8 hours per day, 5 days a week. However, looking at a
computer screen for a long time can give negative effects called eyestrain which complaints such as: dry eye,
red eye, eye sore, feels the eyes of blur, the eyes become doubles, headaches and neck strain. This research
is a study of experiments provide relaxation eye on workers. Before working, eyestrain of worker group A
and B were measured, then group A was given a relaxation of the eyes while the B was not. At the end of the
work, the eyestrain of group A and B were measured again. The results of this research show that there are
significant differences between the group A and B of workers with eyestrain. It can be drawn the conclusion
that granting eye relaxation on workers using computer were able to decrease the complaints of eyestrain.
The eye relaxation will have an optimal positive effect in reducing eye fatigue if the workers do correctly
and routinely on every working day.

Keywords: Eye Relaxation, Eye Strain.

Introduction prevalence of eyestrain in the world has reached 64‑90

percent3. If the complaint of the eyestrain experienced
Currently, computer users in Indonesia recorded
by the workers are not prevented, that could arise more
about 55 percent of 88.1 million internet users1. Staring
serious things such as strain on eyes and a decrease the
at the computer screen can cause an impact such as the
ability of the eye’s accommodation or loss of vision
strain‑muscles of the eyes, neck pain, headaches, and
function4. One of the solution for the eyestrain is Eye
dry eye. In 2016, as much as 90 percent of computer
Relaxation which is called 20’s Rule.
users in the United States are exposed to radiation from
a computer screen more than 9 hours of work, while Field survey was done by the researcher at PT. Japfa
the common complaints can arise at least after the Comfeed Indonesia Tbk Unit Sragen found that about
first two hours of work, and there were 57.8 percent of 70% of workers using computer complained of dry eye,
computer users had experienced the eyestrain2. Globally, and eye strain. These condition needs to be worried and
should be given a prevention so as not to be worse.

Materials and Method

Corresponding Author:
This study is experimental study with a certain
Abdul RohimTualeka
eye relaxation. This research conducted at PT. Japfa
Departement of Occupational Health and Safety, Comfeed Indonesia Tbk Unit Sragen on Juni 2017. The
Faculty of Public Health, Airlangga University, population of the research are workers using computer
Kampus C, Jalan Mulyorejo, Surabaya, 60115, at PT. Japfa Comfeed Indonesia Tbk Unit Sragen, with
Indonesia number 50 workers.
e‑mail :[email protected]
Tel: +62 81 333 519 732
454 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Relaxation is a series of eye relaxation activities Table 3: Statistical Analysis
which include: close the eyes for 10 seconds and open
the eyes for 10 seconds with viewing direction ahead Characteristics p‑value r
as far as 6 meters. That must be done three times, a. Age Group A 0.177 0.279
conducted every 20 minutes of exposure to radiation b. Term of work Group A 0.700 ‑0.081
electromagnetic waves. c. Sex Group A 0.154 0.294
d. Age Group B 0.227 ‑0.251
Measurement of the eye strain is using Questionaire e. Term of work Group B 0.769 0.062
CVSS17 that adopted from Gonzalez‑Perez et al on f. Sex Group B 0.974 ‑0.007
20145.
Source: Primary Data, June 2017.
Findings:
From the statistical analysis above show that
Table 1: Respondents’ Characteristics Respondents’ Characteristics including age, work period,
and sex of each group are not significantly related with
Characteristics Min Max Mean SD eye strain of the workers. Then, the statistical analysis
a. Group A by Independent T‑test shows that there is a significant
1. Age (Years) 20.00 45.00 34.92 7.79 differences between eye strain of workers in the group A
2. Work period 0.33 22.00 9.57 7.67 and B, with the p value = 0.000.
3. Eye Strain (Score) 15.00 33.00 21.00 5.16
Eye relaxation activities can reduce the fatigue or
b. Group B
strain of workers’ eyes because of staring at computer
1. Age (Years) 23.00 45.00 33.04 7.12
screen. This decrease occurs because of changes in
2. Work period 2.00 22.00 7.88 7.25
the condition of the eye muscles. When looking at a
3. Eye Strain (Score) 15.00 31.00 21.52 4.92
computer screen, the eye muscles work to focus on the
Source: Primary Data, June 2017. computer screen and experience tension due to maximum
accommodation. Eye relaxation is done by changing the
This research show that characteristics of
visibility of workers, seeing objects with a distance of
respondents is like bellow:
six meters. Visibility change causes the eye muscles to
Table 2: Distribution of Respondents’ relax and relax. Eyes that focus on a computer screen can
Characteristics trigger dry eyes. Eye relaxation is done by blinking at
the object with a distance of six meters can help even the
Characteristics Frequency Percentage tears to the entire surface of the eye, so that the eyes stay
Age (Years) awake in humid conditions. Statistically it also shows
20‑29 16 32% that there is a significant effect of eye relaxation on eye
30‑39 18 36% strain. The results of the study of Barthakur (2013) also
40‑49 16 32% showed that eye relaxation significantly affected eye
Work Period strain6.
<5 20 40%
The group A who did eye relaxation had a lower
5‑9 14 28%
eye strain score compared to the group B who did not
10‑14 3 6%
relax the eye with an average difference of 0.52. The
15‑19 3 6%
difference shows a decrease in eye strain by 2.4%. The
>19 10 20%
results of the study by Lertwisuttipaiboon et al (2016)
Sex
also showed that giving eye relaxation can significantly
Male 40 80% reduce eye strain7. Another study was conducted by
Female 10 20% Gupta et al (2014) and it was proven that eye relaxation
Source: Primary Data, June 2017. can reduce eye strain by 46.5% 8.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 455
Eye strain can arise as the duration of a person the difference in eye strain was obtained in both groups
stares at a computer screen9. Thorud et al (2012) of workers by 0.52 or 2.4%, may caused by the technique
showed that eye muscle strain arises after sixty minutes of implementing inappropriate to eye relaxation, history
of accommodation. Eye relaxation activities are carried of eye disease (myopia, hypermetropy and astigmatism).
out every twenty minutes after staring at the computer
screen. This activity is one of the steps to prevent eye Conclusion
strain, which is done before the eye muscles begin to Based on this research, it can be conclude that:
experience significant tension10. There is a difference of the eye strain significantly
Workers in this study have characteristics ranging between Group A and B due to granting eye relaxation,
in age from 20 to 45 where at that age a person naturally amounted to 2.4% decrease eyestrain of workers who
has normal functioning vision. Guyton and Hall (2014) perform a eye relaxation.
also stated that someone over the age of 45 years will 1. Characteristics of the workers in this research
experience a decrease in accommodation power which include age, period of employment and gender have
will then affect the working of the eye muscles11. Test of no risk to experience eyestrain.
correlation between age and eye strain in the two groups
in this study showed a non‑significant relationship, 2. Doing the eye relaxation as well as the workers’ try
namely p value = 0.177 and p value = 0.227. The results to do, relax the eye correctly and routinely on every
of this study are supported by previous studies indicating working day so that workers can get optimal results
that age does not have a significant relationship to eye of doing the eye relaxation.
strain (p value = 0.716)12. Das et al (2016) research also Conflicts of Interest: All of Authors have no
shows that age under 45 years does not have a significant conflicts of interest to declare.
relationship to eye strain (p value = 0.939)13.
Source of Funding: This article “Evaluation of Eye
A total of 40 workers (80%) in this study were men Relaxation to Decrease Eye Strain in PT Japfa Comfeed
where the remaining 10 workers (20%) were women. Indonesia Sragen” was funded by the Author.
Correlation test in the control group and intervention in
this study showed that gender did not have a significant Ethical Clearance: The study was approved by the
relationship to eye strain, p value = 0.154 and p value institutional Ethical Board of Dr. Moewardi Hospital,
= 0.974. This research is in line with the research of Surakarta with the registration number: R0213002‑
Zainuddin and Isa (2014) with p value = 0.20512. Another 4547.
characteristic inherent in the workers of this study is the
All of subjects were fully informed about the
period of work. The results of the correlation test between
procedures and objectives of the study then each subject
work period and eye strain in the two groups showed
signed an informed consent form.
a non‑significant relationship, amounting to p value =
0.700 and p value = 0.769. This result is in line with
References
the Arumugam study (2014) which shows that there is
no relationship between years of service with complaints 1. APJII. Internet User Profil Pengguna in Indonesia
of eye strain(p‑value = 0.328) and Zainuddin and Isa 2014 [Internet]. Apjii. 2014. 56 p. Available from:
(2014) with p value = 0.66414. This study shows that all https://www.apjii.or.id/survei2016
inherent characteristics of workers are not significantly 2. The Vision Council. 2016 Digital Eye
related to the perceived strain of workers. Strain Report Released. 2016;14. Available
from: https://www.thevisioncouncil.org/
This study shows that all the characteristics inherent
blog/2016‑digital‑eye‑strain‑report‑released
in the respondents were not significantly related to the
perceived eye strain of the respondents. Giving eye 3. R AT, J MY. Medical Practice and Review Impact
relaxation in the intervention group produced an average of computer technology on health: Computer
eye strain score of 21.00 while in the control group had an Vision Syndrome (CVS). Med Pract Rev [Internet].
average eye strain score of 21.52. Statistically, the strain 2014;5:20–30. Available from: http://www.
scores of the two groups had significant differences. As academicjournals.org/MPR
for other factors that can trigger eye strain so that only 4. Parihar JKS, Jain VK, Chaturvedi P, Kaushik J,
456 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Jain G, Parihar AKS. Computer and visual display 9. Singh H, Tigga MJ, Laad S et al. Prevention of
terminals (VDT) vision syndrome (CVDTS). ocular morbidity among medical students by
Med journal, Armed Forces India [Internet]. prevalence assessment of asthenopia and its risk
2016;72:270–6. Available from: http://www. factors. 2016;3(15):532–6.
ncbi.nlm.nih.gov/pubmed/27546968% 0A http:// 10. Thorud, HMS, Helland M et al. Eye‑Related Pain
www.pubmedcentral.nih.gov/articlerender. Induced by Visually Demanding Computer Work.
fcgi?artid=PMC4982978 Kongsberg. Optom Vis Sci. 2012;89:452–64.
5. González‑Pérez M, Susi R, Antona B, Barrio A, 11. Guyton and H. Buku Ajar Fisiologi Kedokteran
González E. The Computer‑Vision Symptom Scale Edisi 12. Singapore: Elsevier B.V; 2014.
(CVSS17): Development and initial validation.
12. Huda Zainuddin IM. Effects of Human and
Investig Ophthalmol Vis Sci. 2014;55:4504–11.
Technology Interaction: Computer Vision
6. Barthakur R. Computer Vision Syndrome. Syndrome Among Administrative Staf in a Public
Mauritius Internet J Med Updat. 2013;8(2):1–2. University. Int J Business, Humanit adn Technol.
7. Lertwisuttipaiboon S, Pumpaibool T, Neeser 2014;4(3):39–44.
KJ KN. Associations of preventive strategies 13. Das S, Das R, Kumar A. Computer Vision Syndrome
with symptoms of eye strain among Sukhothai and Its Risk Factors Among Professional College
Thammathirat open university staff in Thailand. Students of Agartala. Int J Sci Res. 2016;135:27–9.
2016;30(1).
14. Arumugam S, Kumar K, Subramani R, Kumar S.
8. Gupta R, Gour D MM. Interventional Cohort Study Prevalence of Computer Vision Syndrome among
for evaluation of Computer Vision Syndrome among Information Technology Professionals Working in
Computer Workers. Int J Med. 2014;2(1):40–4. Chennai. World J Med Sci. 2014;11:312–4.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 457

Effectiveness of Dorsata Honey Suplement on Interleukin‑3

Levels in Breast Cancer Patients Who Underwent
Chemotherapy

Aji Kurniawan1, Daniel Sampepajung1, Salman Ardy Syamsu1, Prihantono Prihantono1

1Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia

Abstract
Chemotherapy causes debilitating side effects include a decrease in blood cell counts. Interleukin‑3 (IL‑3)
is a hematopoietic growth factor with extensive and multipotent activity. Honey is a natural product that
has been widely used and researched for its therapeutic effects including increase the formation of blood
cells. The purpose of this study was to determine the effect of honey supplement to IL‑3 levels in breast
cancer patients who underwent chemotherapy. The study sample included all populations diagnosed with
breast cancer by the clinician in the Surgical Oncology Department of Dr. Wahidin Sudirohusodo Hospital
Makassar who met the criteria for the period September to November 2018, divided into two groups,
intervention and control. The intervention group was given honey orally three times a day at a dose of
15 ml (2 tablespoons) for 15 days. Examination of blood samples to measure IL‑3 levels through ELISA.
The statistical analysis performed is descriptive statistic calculation, frequency distribution and Chi Square
statistical test, Independent‑t and Paired‑t test, with P <0.05. The results of this study showed a significant
increase in mean IL‑3 levels in the group that received honey which was 70.07 pg/dL compared to 143.46
pg/dL with an average increase of 73.4 pg/dL (104.7%; p < 0.05), while the group that did not get honey did
not experience a statistically significant change of 88.88 pg/dL compared to 84.36 pg/dL, the mean decrease
was 4.52 pg/dL (5.1%; p> 0.05). Conclusion: Honey supplementation increases IL‑3 levels in breast cancer
patients underwent chemotherapy.

Keywords: Breast Cancer, Chemotherapy, Interleukin‑3, dorsata, honey.

Introduction surgical removal of tumors for healing or preventing

recurrence and as palliative therapy in patients with
Breast cancer is the most malignancy in women
metastatic disease. Chemotherapy causes a wide range
and affects the lives of one in 10 women. Breast cancer
of effects that cause symptoms that weaken and greatly
is the leading cause of death in women worldwide,
affect the quality of life of patients. Nausea, vomiting,
representing 38 million (23%) of total new cancer cases
hair loss and a decrease in the number of blood cells
and 458,400 (14%) of total cancer deaths in 2008.1 In
are the most frequent acute side effects. Decreasing the
2015 an estimated 231,840 new breast cancer cases were
number of blood cells can be a decrease in the number of
found in women and 40,730 deaths due to breast cancer
erythrocyte cells (anemia), platelets (thrombocytopenia)
occurring in the United States. 2
and white blood cells (leukopenia). In chemotherapy,
Breast cancer therapy requires multiple therapeutic neutropenia associated with chemotherapy doses is
modalities, each of which has its own advantages and at risk for infection. Thrombocytopenia is another
disadvantages. Some of them are surgery, chemotherapy, problem with the toxicity of chemotherapy which can
radiotherapy, hormonal therapy and molecular lead to delayed chemotherapy, reduction in dosage and
therapeutic targeting. As one of the modalities in the requiring platelet transfusion
treatment of breast cancer, chemotherapy still has a
Interleukin‑3 (IL‑3) is a hematopoietic growth
major role in the treatment of patients with breast cancer.
factor with clear thrombopoietic activity and extensive
Widely used as adjuvant therapy after patients undergo
458 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
and multipotent activity. IL‑3 is a glycoprotein which for disease conditions and therefore the use of honey in
is produced mainly by activated T cells. IL‑3 regulates clinical care is highly recommended.5 Some studies have
the proliferation and differentiation of pluripotent stem mentioned the effects of honey as an antioxidant, natural
cells and progenitor cells from various hematopoietic antimicrobial, immune booster, anti‑inflammatory,
lineages, including megakaryocytes, granulocytes, potentially in cancer therapy and can increase the
and erythrocytes. IL‑3 also stimulates the function of formation of blood cells. From studies it has been found
several adult cells, including neutophils, eosinophils and that there is an increase in CD4, CD8, erythrocytes,
monocytes. Available for clinical trials since 1993, IL‑3 leukocytes, platelets, neutrophil counts and lymphocytes
has been used by more than two thousand patients. From after 30 days of honey intake.6 This is important because
the research data so far it has been shown that IL‑3 alone CD4, CD8 and lymphocytes are the main sources of
or in combination with other cytokines has become the IL‑3. From other studies honey is also effective in
first thrombopoietic factor available for clinical use which reducing the incidence of anemia in 64% of patients and
allows patients to undergo chemotherapy at intervals and decreases the incidence of severe neutropenia, although
doses according to standards that are expected to increase 40% of patients still need CSFs.7
recovery rates. Recombinant human (rh) IL‑3 has been
evaluated in patients undergoing cancer chemotherapy, From the above, it is necessary to study the effects of
after bone marrow transplantation, bone marrow failure, honey on the levels of Interleukin‑3 breast cancer patients
for blood mobilization and hematopoietic progenitor who are undergoing chemotherapy because Interleukin‑3
cell transplantation and in combination with other greatly affects the process of hematopoiesis, especially
Colony‑stimulating factors (CSF) including Granulocyte in breast cancer patients who underwent chemotherapy
‑macrophage (GM) ‑CSF and granulocyte (G) ‑CSF. with the potential for interference. The purpose of this
Results from stage I‑II studies indicate that IL‑3 alone study was to determine the effect of giving honey to
or in combination with G‑ or GM‑CSF can reduce or IL‑3 levels in breast cancer patients who underwent
eliminate the duration and severity of thrombopenia and chemotherapy
reduce neutropenia. 3
Materials and Method
Honey is a natural product that has been widely Collection of Samples: This study was a
used for its therapeutic effects. It has been reported experimental study using the pretest‑posttest group
that honey contains more than 200 substrates. Its main control model, the experimental effects were measured
composition is glucose and fructose but also contains before and after treatment. The study sample was the
fructo‑oligosaccharides and many amino acids, mineral population of breast cancer patients, diagnosed by the
vitamins and enzymes. The composition of honey clinician in the Surgical Oncology Department of RSUP
varies depending on the plant’s nectar source. But Dr. Wahidin Sudirohusodo Makassar, from September
almost all honey contains flavanoids (such as apigenin, to November 2018.
pinocembrin, kaemferol, quercetin, galangin, chrysin
and hesperin), phenolic acids (such as ellagic, caffeic, Inclusion criteria: Adult women diagnosed with
p‑coumaric and ferulic acid), ascorbic acid, tocopherols, locally advanced breast cancer by the clinician in the
catalase (CAT), superocside dismutase (SOD), reduced Surgical Oncology Departement and confirmed by
glutathione (GSH), Milard reaction products and histopathological examination, had never received
peptides. Most of these components work together to breast cancer therapy, were willing to take part in the
provide a synergistic antioxidant effect. Honey has study by signing an informed consent.
long been used in health, both as a supplement and in
medicine. Because of its potential, research on honey Exclusion criteria: Lipemic, jaundice or hemolysis
has begun to be carried out.4 Flavanoids and polyphenols specimens, patients detected with other primary
are the two main bioactive molecules present in honey. malignancies.
According to modern scientific literature, honey has a The study began with random sample selection for
protective effect for therapy in various conditions such the control group and intervention group. Each informed
as diabetes, respiratory, gastrointestinal, cardiovascular consent was given, for the treatment group, dorsata
and nervous systems, even useful in cancer therapy. honey was given orally three times a day (morning/
Honey should be considered a natural therapeutic agent afternoon/night) at a dose of 15 ml (2 tablespoons) for
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 459
15 days. And for the control group recommends patients Faculty of Medicine, Hasanuddin University,
to take vitamin supplements and nutritious foods. Blood Makassar, Indonesia. Number; 732/H4.8.4.5.31/
sampling as inspection is done twice, before the start PP36‑KOMETIK/2018.
of the intervention (day 0 chemotherapy), and then
continued the examination of 2nd samples on day 16th Results
(post chemotherapy). Interleukin‑3 levels were measured Sample Characteristics: The samples analyzed
from blood plasma samples and measured by ELISA. were 30 breast cancer patients, consisting of groups who
Data Analysis: All collected data are grouped received honey supplements (intervention) and groups
according to the purpose and type of data, then that did not get honey supplements (controls), each of
analyzed using SPSS version 22. The statistical analysis them 15 people. The age of subjects was 23‑61 years
performed is descriptive statistic calculation, frequency with a mean of 47.3 ± 7.5 years (median 47 years). The
distribution and Chi Square statistical test, Independent‑t results of IL‑3 measurements before chemotherapy
and Paired‑t test, with P <0.05. varied between 11.78‑350.00 pg/dL with a mean of
79.47 ± 70.70 pg/dL (median 63.6), whereas after
Ethical Clearance: Ethical approval for this study chemotherapy had a value between 35.64‑350.00 with
was obtained from the Research Ethics Committee, an average of 113.91 ± 87.54 pg/dL showed in Table 1.

Table 1. Age and IL‑3 Descriptive Statistics (n = 30)

Variable Min (pg/dL) Max (pg/dL) Median Mean SD

Age 23 61 47,00 47,30 7,51
IL-3 Before Chemotherapy 11,78 350,00 63,60 79,47 70,70
IL-3 After Chemotherapy 35,64 350,00 82,83 113,91 87,54

The distribution of samples based on chemotherapy cyclophosphamide) chemotherapy (76.7%), grade

regimens, histopathology grading and stadium showed moderate (83.3%) and stage III B (73, 3%) showed in
that most subjects received TAC (docetaxel, adriamicin, Table 2.

Table 2. Distribution of Chemotherapy Regiment, Histopathological Results, Grading and Stage of

Carcinoma Mammae

Variable n %
TAC (Docetaxel, Adriamycin, Cyclophosphamide) 23 76,7
Chemotherapy Regiment
CAF (Cyclophosphamide, Adriamycin, Fluorouracil) 7 23,3
Low 1 3,3
Grade Moderate 25 83,3
High 4 13,3
III A 2 6,7
Stadium III B 22 73,3
III C 6 20,0

Comparative Analysis of IL‑3 Levels by Group: group, which was 88.88 pg/dL compared with 70.07 pg/
The mean IL‑3 level before chemotherapy was found to dL, although it was not statistically significant (p> 0.05).
be higher in the control group than in the intervention showed in table 3.
460 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 3. Distribution of Chemotherapy Regiment, Histopathological Results, Grading and Stage of
Carcinoma Mammae

Variable Group N Mean SD P

15 70.07 69.45
IL‑3 Before Chemotherapy Intervention Control 0.476
15 88.88 73.08
15 143.46 112.20
IL‑3 After Chemotherapy Intervention Control 0.070
15 84.36 37.61

The mean IL‑3 levels after chemotherapy were In the intervention group, there was a significant
found to be higher in the intervention group than in the increase in IL‑3 levels after chemotherapy compared
control group, namely 143.46 pg/dL compared to 84.36 to before chemotherapy, which was 143.46 pg/dL
pg/dL, although it was not statistically significant (p > compared to 70.07 pg/dL (p <0.05). The mean increase
0.05). showed in table 3. in IL‑3 after chemotherapy was 73.4 pg/dL or increased
by 104.7%. showed in table 4.

Table 4. Comparison of IL‑3 levels before and after chemotherapy

Group Variable N Mean SD P

IL‑3 Before Chemotherapy 15 70.07 69.45
Intervention 0.01
IL‑3 After Chemotherapy 15 143.46 112.20
IL‑3 Before Chemotherapy 15 88.88 73.08
Control 0.84
IL‑3 After Chemotherapy 15 84.36 37.61

In the control group, there was a decrease in Stage III B (73.3%) is the most common stadium
IL‑3 levels after chemotherapy compared to before found in this study. Partini in 2016 stated that the most
chemotherapy, namely 84.36 pg/dL compared to 88.88 stadiums were stage III B. So this study had stadium
pg/dL, but not statistically significant (p> 0.05). The distribution conformity with the research.10
mean reduction in IL‑3 after chemotherapy was 4.52 or
decreased 5.1%. showed in table 4. The mean IL‑3 level before chemotherapy was found
to be higher in the control group than in the intervention
Discussion group, which was 88.88 pg/dL compared with 70.07
pg/dL, although it was not statistically significant (p>
In this study, there were 30 samples of breast cancer 0.05). This shows that although the average IL‑3 level
patients where 15 were given treatment and 15 were before chemotherapy in the control state is higher than
controls. The age of subjects was 23‑61 years with a the intervention group does not have a statistical effect.
mean of 47.3 ± 7.5 years (median 47 years). From this
study, the average age of respondents was 47 years. This The mean IL‑3 levels after chemotherapy were
is in line with the journal presented by Irwan in 2014 found to be higher in the intervention group than in the
which stated that the incidence of breast cancer was control group, namely 143.46 pg/dL compared with
more in patients over the age of 40 years. The Partini 84.36 pg/dL, although it was not statistically significant
study in 2016 showed the same pattern.8 (p> 0.05). This shows that although the rate of IL‑3
levels after chemotherapy in the intervention group was
Based on grade, the highest was moderate grade higher than the control group did not have statistical
(83.3%). This is in line with the intensive study in 2010 effect. When viewed from changes in IL‑3 levels
where it was stated that moderate grade was the most between before and after chemotherapy, in the control
common tumor grading. Research data by Irwan also group there was a decrease in the mean IL‑3 levels in
showed the same thing.7,8 the control group 84.36 pg/dL compared to 88.88 pg/
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 461
dL, but not statistically significant (p> 0.05). The mean Conflicts of Interest: The authors had no conflicts
reduction in IL‑3 after chemotherapy was 4.52 pg/dL or of interest to declare.
decreased 5.1%.
References
According to Verma et al .’s study, it was said
that T lymphocyte levels, B lymphocytes and NK 1. Jemal A, Bray F, Center MM, Ferlay J, Ward E,
cells decreased significantly within 2 weeks after Forman D. Global cancer statistics. CA: A Cancer
chemotherapy even especially B cells and CD4 T cells Journal for Clinicians [Internet]. 2011 [cited
remained significantly decreased in 9 months post 2018Jan7];61(2):69–90. Available from: http://
chemotherapy. 11 In another study, Mackall said that www.cancer.org
although the number of neutrophils, monocytes and 2. Harvey J, Down S, Bright‑Thomas R, Winstanley
platelets consistently improved due to therapy at the J, Bishop H. Breast cancer—facts and figures.
end of each cycle, the number of lymphocytes did not Breast Disease Management [Internet]. 2013 [cited
improve in the same period of time. Because CD4, CD8 2017Aug18];:34–40. Available from: http://www.
and lymphocytes are the main sources of IL‑3, of course cancer.org
this affects the IL‑3 levels.12 3. Gianella‐borradori A. Present and future
clinical relevance of interleukin 3. Stem Cells.
Whereas in the intervention group there was
1994;12(S1):241–8.
an increase in the mean IL‑3 level of 143.46 pg/
dL compared to 70.07 pg/dL (p <0.05). The mean 4. Eteraf‑Oskouei T, Najafi M. Traditional and Modern
increase in IL‑3 after chemotherapy was 73.4 pg/dL or Uses of Natural Honey in Human Diseases: A
increased by 104.7%. Honey supplementation according Review. Iranian Journal of Basic Medical Sciences.
to Heidari in his research led to an increase in CD4, 2013;16(6):731–42.
CD8, erythrocytes, leukocytes, platelets, neutrophil 5. Samarghandian S, Farkhondeh T, Samini F. Honey
counts and lymphocytes after 30 days of honey intake. and Health: A Review of Recent Clinical Research.
6 In addition, Porcza in a review of his study said that Pharmacognosy research. 2017;9(2):121–7.
consumption of honey 1.2 g/kg body weight dissolved 6. Heidari A, Heidari N, Amiri G, Afsahi S, Sarahroodi
in 250 cc of water could produce a 50% increase in the S. Has The Natural Raw Honey Any Effect on HIV
number of peripheral monocytes and slightly increase Infection? International Journal of Pharmaceutical
the presentation of lymphocytes and eosinophils. 13 This Research and Bio‑Science. 1(5):205–10.
increase in cells can increase IL‑3 levels according to this 7. Zidan J, Shetver L, Gershuny A, Abzah A, Tamam S,
study. Even honey supplements are also given to reduce Stein M, et al. Prevention of Chemotherapy‑Induced
the incidence of anemia in 64% of patients and reduce Neutropenia by Special Honey Intake. Medical
the incidence of severe neutropenia in chemotherapy Oncology. 2006;23(4):549–52.
patients whose treatment is by giving CSFs including
8. Irwan I, Azamris A, Bachtiar H. Perbandingan
human IL‑3, although 40% of patients still need CSFs.7
Prognosis Subtipe Molekuler Kanker Payudara
Conclusion Antara Pasien Kanker Payudara Wanita Usia Muda
Dan Tua Di Rsup Dr. M. Djamil Padang. Majalah
The result of this study shows that honey Kedokteran Andalas. 2016;38(4):208.
supplementation increases IL‑3 levels in breast cancer
9. Albrektsen G, Heuch I, Thoresen SØ. Histological
patients underwent chemotherapy. Suggested to for
type and grade of breast cancer tumors by parity,
honey supplements in breast cancer patients undergoing
age at birth, and time since birth: a register‑based
chemotherapy so that the patient’s IL‑3 levels are
study in Norway. BMC Cancer. 2010;10(1).
maintained.
10. Partini PDO, Niryana IW, Adiputra PAT.
Acknowledgments: We give our gratitude to Karakteristik kanker payudara usia muda di Sub
Hasanuddin University Hospital staff and also for breast Bagian Bedah Onkologi Rumah Sakit Umum Pusat
cancer patients who supported and participated in this Sanglah tahun 2014‑2016. Intisari Sains Medis.
research. 2018;9(1):76–9.
11. Verma R, Foster RE, Horgan K, Mounsey K,
Funding: Self Funding
Nixon H, Smalle N, et al. Lymphocyte depletion
462 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
and repopulation after chemotherapy for primary 1994Oct1 [cited 2018Nov14];84(7):2221–8.
breast cancer. Breast Cancer Research. 2016;18(1). Available from: http://www.bloodjurnal.org
12. Mackall CL, Fleisher TA, Brown MR, Magrath 13. Porcza L, Simms C, Chopra M. Honey and Cancer:
IT, Shad AT, Horowitz ME, et al. Lymphocyte Current Status and Future Directions. Diseases.
Depletion During Treatment With Intensive 2016Sep30;4(4).
Chemotherapy for Cancer. Blood jurnal [Internet].
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 463

Effect of Blood Sampling Method During a

Mating Time in Male Camels (Dromedary Camels)

Alaakamil Abdulla1, Ali Habeeb Jaber AL‑bdeery2, Basim Hameed Abed Ali2
1Department of Medical Biotechnology, Faculty of Biotechnology, 2Department of Surgery and Obstetrics,
Faculty of Veterinary Medicine, University of Al‑Qadisiyah, Iraq

Abstract
This study was to shed light on levels of testosterone and cortisol hormones in male dromedary camels
during the mating time, by collection the blood samples using the manual method and compared with
the remote‑controlled blood sampling (RBS) method, to assess whether either these method had affected
changes in the concentration of the hormones or not. The blood samples were collected from fifteen adult
male camels, via two experiment with one‑day intervals: first experiment by manual method during three
periods (pre‑mating, mating, and post‑mating) one hour between each period, and the second experiment
by the RBS in the same protocol. The serum testosterone and cortisol concentrations of all animals were
determined via ELISA technique. The result which appearance a significant difference in the mating time
used RBS compared with manual method. These findings might be due to the withdrawal of blood remotely
which could cause a reduction of excitement in animals using the manual blood sampling at the presence
of veterinarians, so it was considered as an ideal method to measure hormonal concentrations, especially in
experiments which need accurate results.

Keywords: Camels, Cortisol, Mating, Remote‑Controlled Blood Sampling, Testosterone.

Introduction alternative measurements of hormone levels(8). In this

respect, remote‑controlled blood sampling (RBS) is a
The breeding season of dromedary camels is at
powerful device to take blood samples and consequently
the coldest winter months of the year(1). In this season,
give important information on animal health status, like
these camels become very aggressive towards other
hormonal access(9), yet the traditional or manual blood
males and humans and their handling is thus considered
sampling method has its own restrictions and it cannot be
very difficult and the copulation begins with foreplays
possibly used due to male camel aggression during this
and such behaviors are disappeared after rutting(2).
time. The same restrictions can also lead to stress reactions
Most researchers have adopted different procedures
even in animals accustomed to the given procedure(10)
to determine the blood testosterone level in order to
which results in increased levels of cortisol due to the
clarify the characteristics of reproductive phenomena,
activation of hypothalamic stimulation‑pituitary‑adrenal
reach an understanding of physiological status, and also
axis during this sampling(11). It is clear that the RBS
determine libido and sexual behaviors in these animals(3).
device placed on animals will be more convenient than
The cortisol hormone has been similarly used as an
the manual blood sampling method, especially when a
indicator of stress in dromedary camels(4) and in other
series of blood samples are needed (12). Accordingly, the
animals(5), the serum cortisol which increases during
present study aimed to verify the levels of testosterone
acute stress is largely made up of free cortisol; therefore,
and cortisol hormones in the breeding season of male
its concentration can be influenced by stress and physical
dromedary camels during the mating time. To this end,
stimulation of dromedary camels when they are exposed
blood samples were taken using the traditional method
to stressors which also cause deregulation of sexual
and compared with the levels of these hormones using
hormones(6,7). Collection of blood samples to measure
the RBS device, to assess whether either the given
hormones can be invasive, and values can potentially
method had affected changes in the concentration of
be confounded by handling stress which may lead to
464 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
the hormones or not, and to improve understanding of period occurred one hour following the first period
reproductive mechanisms and development. during the copulation time (mating period), and the
third period took place after one hour from copulation
Materials and Method (post‑mating). In this experiment, the researchers had
The present study was conducted in the bio‑molecular great difficulty in blood sample collection due to the
laboratory of the College of Biotechnology at the camels became very dangerous and often unfriendly, so
University of Al‑Qadisiyah, Iraq. The blood samples were the camels were frequently motion and kicking. They
then collected from camel herds in southern of Iraq, during also lost the jugular vein was puncture and occasionally
the rutting season (December‑February/2017‑2018), the needle and the syringe were broken.
with intervals. There were a fifteen of adult males (8‑10 Second Experiment: Following one day after the
years of age) with good bodily conditions. Animals’ age first experiment, the blood samples were taken remotely
was also determined based on dental formula described in the same periods by the made locally modified RBS
in Ibrahim et al (13). device of the AUTOMATIC BLOOD SAMPLING
Experimental Protocol: All samples were collected which used by Fonss A and Munksgaard(9) which was to
by two experiments with a one‑day interval from a total reducing the weight, size and facilitate its fixation on the
numbers of the male camels marketed from dromedary camel’s neck using installation belts to prevent animal
camels which were clinically healthy. sensitivity and reduce nervousness (Figure 1). All blood
samples were further allowed to clot for two hours at
First Experiment: The blood samples (5 ml) room temperature and then centrifuged for 20 minutes
were collected from the jugular vein by the manual at 3000 rpm., the supernatants were also collected
(traditional) method via syringe (gauge 18) in three carefully, and then placed in the eppindroph tub before
periods. The first period was before the male camel’s storage at ‑20°C until hormonal analysis.
exposure to estrus she‑camel (pre‑mating), the second

(a) (b) (c) (d)

Fig. 1: (a) a chart of the RBS device (modified): 1‑Restraint rings, 2‑Motor base, 3‑ Receiver, 4‑batteries (6 volt),
5‑Plastic crosslink, 6‑Test tube, 7‑Pipes, 8‑Peristaltic pump, 9‑Cannula, 10‑Pipes, 11‑Motor of pump, 12‑Bulb
let, 13‑Antenna, 14‑Power switch; (b) a chart of the remote control: 1‑Cover, 2‑Battery (9 volt), 3‑Control switch,
4‑Power switch, 5‑Power light, 6‑Antenna, 7‑Transmitter; (c): the RBS device (modified); (d) Remote Control

Hormonal Assay: The serum testosterone the enzyme‑linked immunosorbent assay (ELISA) in
and cortisol levels of all animals were determined adult male camels, validated and accredited by male
in the bio‑molecular laboratory of the College of dromedary camel’s serum (all samples were analyzed
Biotechnology at the University of Al‑Qadisiyah using in duplicate). The results were then expressed in ng/ml
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 465
in which both kits (MyBioSource Company, TESTO pre‑mating, mating, and post‑mating periods were
Elisa kit, Camel Testosterone ELISA Kit ‑ MBS107991 14.1438±0.5833, 26.2675±0.8523, and 24.037±1.0071
and CORT Elisa kit, Camel Cortisol ELISA Kit‑ ng/ml of; respectively, yet the serum cortisol in these
MBS082766/USA) were also processed, according to periods were 44.8725±5.0133, 32.4775±1.9738,
the manufactory protocol. and 40.7688±3.0897 ng/ml; respectively (Table 1 &
Figure 2).
Statistical Analysis: All the values were expressed
as mean ± standard error (SE) and subjected to analysis Second Experiment: Using the RBS device,
using two‑way analysis of variance (ANOVA). The the concentration values of the serum testosterone
significance level among different parameters was concentration were reported by 16.8925±0.7008,
calculated at p<0.05. The software used was the IBM 32.8563±1.3292, and 29.8519±1.0736 in pre‑mating,
SPSS program package (Version 23)(14). mating, and post‑mating periods respectively. However,
the means of serum cortisol concentration in three periods,
Results such values were 30.1918±3.0299, 21.4425±1.8629,
First Experiment: The findings revealed that the and 22.4013±1.8645 ng/ml; respectively (Table 1 &
mean±SE of the serum testosterone concentration in Figure 2).

Table 1: Concentrations of testosterone and cortisol hormones (ng/ml) using the manual method and the
RBS device in three periods for fifteen samples.

Testosterone (Mean±SE)* Cortisol (Mean±SE)

Periods
Manual RBS device Manual RBS device
Aa Ba
Pre‑mating 14.1438±0.5833 16.8925±0.7008 44.8725±5.0133 Aa 30.1918±3.0299 Aa
Mating 26.2675±0.8523 Ab 32.8563±1.3292 Bb 32.4775±1.9738 Ab 21.4425±1.8629 Bb
Post‑mating 24.037±1.0071 Ab 29.8519±1.0736 Bb 40.7688±3.0897 Aa 22.4013±1.8645 Bb
*mean±Stander Error (mean±SE), A,BDifference within a row (p<0.05), a,bDifference within a column (p<0.05).

Fig. 2: Patterns of serum testosterone & cortisol concentrations in camels (ng/ml) suing the manual method
and the RBS device. Significant differences were indicated (p<0.05) in mean comparisons between the three
periods

Discussion serum testosterone level increased in the mating time

compared with those in the pre‑mating and post‑mating
The present data obtained from the manual method
ones (Table 1 & Figure 2). The given rise may be due to
of blood sampling (first experiment) indicated that the
466 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
interactions with libido in male camels, these findings level had declined because cortisol had been increased
were in agreement with Aubè et al(15). The testosterone in response to physiological stress and fear which was
hormone acting as a positive regulator of sexual desire in line with studies such as Chen et al, (24), Erickson et
has been also reported in many animals like horses, al (25). According our result, we suggested the cortisol
camels(15), monkeys(16) and in humans(17). that were can be blocked by the testosterone actions and cause
confirmed by studies of Goldey and Van Anders(18) in less testosterone which influences behaviors like mating
which recorded decrease the testosterone level in men had since, but finding of Tajik et al (5) it was argued that the
led to reduced libido; moreover, increase in the activity serum cortisol did not change significantly due to stress
of enzymes synthesizing the testosterone hormone was in the sheep and cattle; however, yet Chen et al (24)
greater in the breeding than the non‑breeding season (19). showed a significant increase which did not consistently
The activation of the hypothalamus‑pituitary‑adrenal axis change. The findings of this study were in line with other
and this can lead to a suppression of luteinizing hormone research investigations like Gordon et al (26) in which
release because of the dysregulation of homeostasis it was indicated that there were numerous interactions
(stress) and triggers an adaptive stress response (20). Our between stress and reproductive functions, and stress
study results were discrepancy with concluded of Exton lead to stimulation of the hypothalamic‑pituitary‑adrenal
et al (21) that orgasm in humans did not acutely affect axis might have reduced fertility in horses, caused
testosterone levels in the blood. It was also argued that by stress. In addition to the cortisol hormone in most
sex in men did not have any effects on testosterone levels mammals as well as fish and amphibians, corticosterone
but rather it could positively influence the production of in reptiles and birds also plays an important role in
testosterone (22). Yet, a statistically significant increase all stasis as they are involved in the regulation of the
in serum testosterone concentration in our study during hypothalamic‑pituitary‑adrenal axis (27).
mating time by using both sampling method were in
consonance with those experiments in men in which Conclusion
plasma levels of testosterone were compared and There was a statistically significant difference
examined before and after mating periods, yet in the between the concentrations of the testosterone hormones
second experiment, the RBS device as another method during the mating period and intercourse. Using the RBS
employed for blood collection which was applied on the device which led to reduced cortisol concentrations, the
same camels after one day following the first experiment testosterone levels increased. These findings might be
to record the results in the same periods of libido. These due to the withdrawal of blood remotely which could
findings confirmed the relationship between testosterone cause a reduction of excitement in animals using the
hormone levels and mating efficiency. On the other manual blood sampling at the presence of veterinarians,
hand, the concentration of this hormone was highly so it was considered as an ideal method to measure
significant (p˂0.05) in a way that it had elevated greater hormonal concentrations, especially in experiments
compared with the manual method (Table 1 & Figure 2), which need accurate results.
The manual method might have caused stress or fear in
animals, so the mean testosterone level in the pre‑mating, Conflict of Interest: None
mating and post‑mating periods were significantly
lower than those in the second experiment. The reason Funding: Self
for given elevation was significantly reduced tension, Ethical Clearance: Not required.
stress, and fear in animals induced by veterinarians. So,
the withdrawal of blood in routine method by syringe Acknowledgements: The authors are much thankful
or cannula may lead to the secretion of some hormones to Colleges of Biotechnology and Veterinary Medicine
like cortisol, that may cause a reduction of secretion at the University of Al‑Qadisiyah Al Diwaniyah, Iraq for
in the testosterone hormone during intercourse. That providing all necessary help for conducting this research
testosterone hormone could influence libido in male work. This study was supported in part by a grant from
camels. According to Peeters et al (23), one needs to faculty of Biotechnology, University of Al‑Qadisiyah,
assess the stress state when measuring free cortisol in Al Diwaniyah, Iraq.
serum. In this regard, the cortisol hormone level was
elevated in all three periods using the manual method References
compared with the second experiment in which this 1. Padalino B, Monaco D, Lacalandra GM. Male camel
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 467
behavior and breeding management strategies: How stimulatory, and preparative actions. Endocr Rev.
to handle a camel bull during the breeding season? 2000;21(1):55–89.
Emirates J Food Agric. 2015;27(4):338–49. 12. Goddard PJ, Gaskin GJ, Macdonald AJ. Automatic
2. Fatnassi M, Padalino B, Monaco D, Khorchani blood sampling equipment for use in studies of
T, Lacalandra GM, Hammadi M. Evaluation of animal physiology. Anim Sci. 1998;66(3):769–75.
sexual behavior of housed male camels (Camelus 13. I.F.M. Marai1*, A.E.B. Zeidan2, A.M.
dromedarius) through female parades: Correlation Abdel‑Samee3 AA and AF. Available in: http://
with climatic parameters. Trop Anim Health Prod. www.redalyc.org/articulo.oa?id=93912989002.
2014;46(2):313–21. Trop Subtrop Agroecosystems [Internet].
3. El‑Bahrawy KA, Khalifa MA, Rateb SA. Recent 2009;10:129 – 149. Available from: https://www.
advances in dromedary camel reproduction: An redalyc.org/pdf/939/93912989002.pdf
Egyptian field experience. Emirates J Food Agric. 14. McDonald JH. Handbook of Biological Statistics
2015;27(4):350–4. ‑ Paired t–test. Sparky House Publ [Internet].
4. El Khasmi M, Chakir Y, Bargaâ R, Barka K, Lektib 2014;180–5. Available from: http://udel.
I, El Abbadi N, et al. Impact of transport distance edu/~mcdonald/statpermissions.html% 0Ahttp://
on stress biomarkers levels in dromedary camel www.biostathandbook.com/pairedttest.html
(Camelus dromedarius). Emirates J Food Agric. 15. Aubè L, Fatnassi M, Monaco D, Khorchani
2015;27(6):507‑12. T, Lacalandra GM, Hammadi M, et al. Daily
5. Tajik J, Eshtraki R, Nazifi S. The influence of rhythms of behavioral and hormonal patterns in
transportation stress on serum cortisol, thyroid male dromedary camels housed in boxes. PeerJ.
hormones, and some serum biochemical parameters 2017;2017(3).
in Iranian cashmere (Raini) goat. Vet Arh. 16. Phoenix CH, Dixson AF, Resko JA. Effects of
2016;86(6):795–804. ejaculation on levels of testosterone, cortisol,
6. Majchrzak YN, Mastromonaco GF, Korver W, and luteinizing hormone in peripheral plasma
Burness G. Use of salivary cortisol to evaluate of rhesus monkeys. J Comp Physiol Psychol.
the influence of rides in dromedary camels. Gen 1977;91(1):120–7.
Comp Endocrinol [Internet]. 2015;211:123–30. 17. Podlasek CA, Mulhall J, Davies K, Wingard CJ,
Available from: http://dx.doi.org/10.1016/j. Hannan JL, Bivalacqua TJ, et al. Translational
ygcen.2014.11.007 Perspective on the Role of Testosterone in
7. Dickens MJ, Romero LM. A consensus endocrine Sexual Function and Dysfunction. J Sex Med.
profile for chronically stressed wild animals 2016;13(8):1183–98.
does not exist. Gen Comp Endocrinol [Internet]. 18. Goldey KL, van Anders SM. Sexual Modulation
2013;191:177–89. Available from: http://dx.doi. of Testosterone: Insights for Humans from Across
org/10.1016/j.ygcen.2013.06.014 Species. Adapt Hum Behav Physiol. 2015;1(2):93–
8. Johnstone CP, Reina RD, Lill A. Interpreting indices 123.
of physiological stress in free‑living vertebrates. J 19. El‑kon L, Heleil B, Mahmoud S. Effect of age
Comp Physiol B Biochem Syst Environ Physiol. and season on the testicular sperm reserve and
2012;182(7):861–79. testosterone profile in camel (camelus dromedarius).
9. Fønss A, Munksgaard L. Automatic blood Anim Reprod. 2011;8(3–4):68–72.
sampling in dairy cows. Comput Electron Agric. 20. Gadek‑Michalska A, Spyrka J, Rachwalska P,
2008;64(1):27‑33. Tadeusz J, Bugajski J. Influence of chronic stress
10. Hopster H, Van Der Werf JTN, Erkens JHF, on brain corticosteroid receptors and HPA axis
Blokhuis HJ. Effects of Repeated Jugular Puncture activity. Pharmacol Reports. 2013;65(5):1163–75.
on Plasma Cortisol Concentrations in Loose‑Housed 21. Exton MS, Krüger THC, Bursch N, Haake P, Knapp
Dairy Cows. J Anim Sci. 1999;77(3):708–14. W, Schedlowski M, et al. Endocrine response
11. Sapolsky RM, Romero LM, Munck AU. to masturbation‑induced orgasm in healthy men
How do glucocorticoids influence stress following a 3‑week sexual abstinence. World J
responses? Integrating permissive, suppressive, Urol. 2001;19(5):377‑82.
468 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
22. Dabbs JM, Mohammed S. Male and female salivary 25. Erickson K, Drevets W, Schulkin J. Glucocorticoid
testosterone concentrations before and after sexual regulation of diverse cognitive functions in normal
activity. Physiol Behav. 1992;52(1):195–7. and pathological emotional states. Neurosci
23. Peeters M, Sulon J, Beckers JF, Ledoux D, Biobehav Rev. 2003;27(3):233–46.
Vandenheede M. Comparison between blood serum 26. Gordon ME, McKeever KH, Betros CL, Manso
and salivary cortisol concentrations in horses using Filho HC. Exercise‑induced alterations in plasma
an adrenocorticotropic hormone challenge. Equine concentrations of ghrelin, adiponectin, leptin,
Vet J. 2011;43(4):487–93. glucose, insulin, and cortisol in horses. Vet J.
24. Chen Y, Arsenault R, Napper S, Griebel P. Models 2007;173(3):532–40.
and method to investigate acute stress responses in 27. Haase CG, Long AK, Gillooly JF. Energetics of
cattle. Animals. 2015;5(4):1268–95. stress: Linking plasma cortisol levels to metabolic
rate in mammals. Biol Lett. 2016;12(1).
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 469

Hyaluronidase Versus Magnesium Sulphate as Adjuvants to

Bupivacaine in Ultrasound Guided Supraclavicular Brachial
Plexus Block in Upper Limb Surgeries

Amany K abo Elhusein1, Mamdouh Hassan1, Nagat A. Ali1

1Department of Anesthesiology, Faculty of Medicine, Minia University, Minia, Egypt

Abstract
Background: Aim of this trial was to assess the effect of hyaluronidase and MgSo4 when added separately
or in combination to bupivacaine on the onset of sensory and motor block, quality of block and effect on
duration of action.

Method: Eighty ASA I, II patients of either sex undergoing upper limb Surgery under ultrasound‑guided
supraclavicular brachial block were recruited in this prospective randomized double blinded controlled study
and divided in to four groups each group contain 20 patients. First group received (28 ml 0.5% bupivacaine
and 2 ml 0.9% normal saline). Second group received (28 ml 0.5% bupivacaine and 1000 unit hyaluronidase
dissolved in 2 ml 0.9% normal saline). Third group received (28 ml 0.5% bupivacaine and 2 ml of MgSo4
containing 200 mg). Fourth group received (28 ml 0.5% bupivacaine and 2 ml of MgSo4 containing 200 mg
mixed with 500 unit hyaluronidase).

Results: Hyaluronidase fastened the onset but didn’t affect the duration however MgSo4 prolonged the
duration of postoperative analgesia without effect on the onset of block

Keywords: Regional, brachial plexus; local anesthetics, bupivacaine, equipment, ultrasound machines;
hyaluronidase; MgSo4.

Introduction Magnesium sulphate acts as an adjuvant in analgesia

due to its properties of calcium channel blocking and
Supraclavicular nerve block is ideal for procedures
N‑methyl‑D‑aspartate antagonism. Magnesium has been
of the upper arm, from the mid humeral level down to the
shown to decrease peripheral nerve excitability and to
hand. It has a rapid onset, with a dense and predictable
enhance the ability of lidocaine to raise the excitation
level of pain control [1].
threshold of A‑beta fibers[3].
Hyaluronidase, the mucolytic enzyme which acts on
Ultrasound guidance has dramatically improved
the muco‑polysaccharide hyaloronic acid, is generally
nerve localization and offers several advantages as
considered to be “spreading factor”. When used with
direct visualization of nerves and anatomical structures,
local anesthetics, hyaluronidase hastens the onset of
facilitated visualization of local anesthetic spread in
analgesia and shortens its duration of effect[2].
real time, produced good compensation for anatomical
variation, reduced incidence of complications[4].

Corresponding Author:
Method
Nagat A. Ali This prospective, randomized, double blind
Department of Anesthesiology, Faculty of Medicine, controlled clinical study was carried out after obtaining
Minia University, Minia, Egypt. the local ethics committee of El‑Minia university
e-mail: [email protected] hospital approval and written informed consent was
Contact No.: 01005651501 taken from the patients. It was done between September
470 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
2017 to December 2018, 90 patients of both sexes, was sterilized and infiltrated with 1‑2 ml of lidocaine 2%
ASA I and II, aged between 18‑65 years old scheduled at the needle entry site.
to undergo elective and urgent distal arm, forearm and
hand surgeries under ultrasound guided supraclavicular The brachial plexus was visualized by placing
brachial plexus block, 80 patients were enrolled in this ultrasound probe in the sagittal plane in the
study and ten were excluded due to block failure. supraclavicular fossa behind the middle‑third of the
clavicleas 3 hypoechoic circles with hyperechoic outer
Preoperative assessment and preparation: A rings or as a grape like cluster of 5 to 6 hypoechoic
careful assessment of medical history was done. Routine circles, lateral and superior to the subclavian artery
preoperative general examination and local examination between the anterior and middle scalene muscles at the
of the site of injection for signs of infection or any other lower cervical region.
pathology were carried out. Routine investigations were
done. Explanation of visual analogue pain scale was
done VAPS is consisted of a straight, vertical 10‑cm
line; the bottom point represented “no pain”= (0 cm) and
the top “the worst pain you could ever have. Two mg
midazolam IV was given as a premedication 5 minutes
before the block.

Equipment: The ultrasound device Sonosite,

micromaxx, Lubricating gel, 21‑gauge 50 mm length
short bevel insulated stimulating needl, 10‑ml syringes
for injection, Sterile gloves, 25‑gauge needle for skin
infiltration, Sterile towels and sterile antiseptic solution Fig (1): Ultrasonographic imaging of brachial plexus
(Povidone‑iodine 10%).
Parameters Assessed: The anesthesiologist
All medications were prepared in similar who gave the block recorded the onset of sensory and
sterile coated bottles and coded then passed to the motor block and recorded intraoperative data then the
anesthesiologist who is blind to its manner. In this postoperative care physician recorded the duration of
prospective randomized double blinded controlled study block and postoperative data.
80 bottles numbered from 1 to 80 were prepared and
divided in to four groups each group containe 20 bottles. The hemodynamic variables were assessed and
Then the patients were randomly assigned to study recorded 5 minutes before the block as a baseline value,
groups. immediately after the block 0,10,20,30,60, 90 minutes
during the operative time then 1,2,4,6, and 12 hours
Group (I): Received 28 ml bupivacaine (0.5%) + 2 after the end of operation. Quality of sensory block was
ml saline (0.9%). assessed by pin prick test using a 3‑point scale [5] Grade
0 = normal sensation, Grade 1 = loss of sensation of pin
Group (II): Received 28 ml bupivacaine (0.5%) + prick (analgesia), and Grade 2 = loss of sensation of
1000 unit hyaluronidase dissolved in 2 ml saline (0.9%). touch (anesthesia).
Group (III): Received 28 ml bupivacaine (0.5%) + Also motor block quality was determined by thumb
2 ml MgSo4 containing 200 mg. abduction (radial nerve), thumb adduction (ulnar nerve),
Group (IV): Received 28 ml bupivacaine (0.5%) + thumb opposition (median nerve), and flexion of elbow
2 ml MgSo4 containing 200 mg mixed with 1000 unit (musculocutaneous nerve) according to the modified
hyaluronidase. Bromage scale 1997 [6] on a 3‑point scale. Grade 0:
Normal motor function with full flexion and extension
Block Technique: A 20 G intravenous cannula was of elbow, wrist, and fingers. Grade 1: Decreased motor
inserted in a peripheral vein of unaffected upper limb strength with ability to move the fingers only. Grade2:
and standard monitoring was provided. Patient lie down Complete motor block with inability to move the fingers.
supine with head turned to the contralateral side and
ipsilateral arm adducted gently by the assistant. Skin Pain intensity was assessed using VAPS. It was
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 471
measured before starting the nerve block then 15, 30, of local anesthetic toxicity were recorded during the
60, 90, 120 minutes after nerve block. When it is more operation and for 24 hours postoperative.
or equals 4 cm we gave analgesia or sedation using
fentanyl and propofol during operation. Then Patients Results
were asked to rate their pain intensity at 2, 4, 8, 12, During studying hemodynamic data changes among
and 24 hours postoperative and if it was more than groups, The Mean Arterial blood pressure (mmHg) and
four paracetamol 1000 mg bottle was given. Time of arterial oxygen saturation changes during intraoperative
first analgesic request: The time from supraclavicular or postoperative period were statistically insignificant
brachial plexus block administration to the patient’s between the four groups. As regard the Heart rate (beat\
first request for analgesic medication by hours. Total min) we found it was lower in group (II, IV) than the
analgesic requirements in 24 hours: The total amount other two groups (I, III) at time intervals of 10,20,30
of intravenous paracetamol which was given to the and 60 minutes intraoperative but these changes were
patient as a rescue analgesia or maintenance during statistically insignificant.
24 hours. Adverse effects: any adverse effects such as
hypotension (i.e. 20% decrease relative to baseline), Sensory, motor block onset and density of block
bradycardia (HR <50 beats/min), nausea, vomiting, were faster in groups (II & IV) than in groups (I & III)
hypoxemia (SpO2 <90%),local hematoma, hemothorax, but the duration of sensory and motor block was found
pneumothorax,recurrent laryngeal nerve block, to be longer in groups (III & IV) than in groups (I & II)
intravascular injection, Horner’s syndrome and signs as presented in fig (2, 3, 4).

Fig (2)

Fig (3)
472 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Fig (4)

Pain measurement presented by VASP during Intraoperative need for sedation and fentanyl was
intraoperative period at 15 min post injection the pain insignificantly different between the four groups. But the
score was significantly lower in patients received mean time of for postoperative 1st analgesic (minutes)
hyaluronidase in groups (II & IV) than in groups (I & request was significantly longer in groups (III & IV)
III) but no significant difference was found after that (360‑900) and (540‑950) minutes in comparison to
during operation. In the postoperative period the VASP groups (I & II) (300‑620) and (300‑700) minute. And
was significantly lower at 4, 8, 12, 24 hours in patients total analgesic requirement (mg) in groups (III & IV)
received MgSo4 in groups (III & IV) than in groups (I was less than groups (I & II).
& II).

Fig (5)

As regard complications happened during the study Discussion

no significant differences were found between the four
Brachial plexus block is a safe reliable anesthetic
groups.
technique for upper limb surgery with fewer
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 473
complications, especially with the introduction The mean motor onset was (14±5.1) minutes in
of ultrasound which decreased the complications hyaluronidase group in comparison to the mean motor
dramatically. onset (22.5±4.9), (21.3±5) minutes in control and Mgso4
groups respectively, and both results were significant
Hyaluronidase, the mucolytic enzyme which acts on with p value < 0.001. However it didn’t affect the
the muco‑polysaccharide hyaloronic acid, is generally duration of sensory or motor block or the postoperative
considered to be “spreading factor”. When used with analgesic requirement in comparison with other groups.
local anesthetics, hyaluronidase hastens the onset of
analgesia and shortens its duration of effect [7]. Mgso4 can act as an adjuvant in analgesia due
to its properties of calcium channel blocking and
A number of studies have shown that addition of N‑methyl‑D‑aspartate antagonism. Magnesium has been
hyaluronidase during ocular blocks has beneficial effects shown to decrease peripheral nerve excitability and to
including higher quality of anaesthesia and improved enhance the ability of lidocaine to raise the excitation
success rates. threshold of A‑beta fibers [10].
In a study done by Koh et al investigated the Haghighi et al. in Guilan, Iran, in 2014, investigated
hypothesis that addition of hyaluronidase to ropivacaine the effect of Mgso4 in axillary brachial plexus block
may reduce the time to achieve complete sensory block when added to lidocaine in upper limb surgeries,
after axillary brachial plexus block. The patients were and reported that the addition of Mgso4to lidocaine
randomly assigned into a hyaluronidase group (n = significantly increased the duration of sensory and motor
24) and a control group (n = 24). The hyaluronidase blocks in comparison with the use of lidocaine alone [11].
group received ropivacaine 0.5% with 100 IU.ml_1
of hyaluronidase, and the control group received Rao et al, found thatThe addition of MgSo4 to 0.5%
ropivacaine alone. The primary endpoint was the time bupivacaine increased the duration of motor and sensory
to achieve complete sensory block. The hyaluronidase supraclavicular brachial block in the upper extremities
group demonstrated significantly shorter mean (SD) during surgeries when compared to the use of 0.5%
sensory block onset time (13.8 (6.0) min) compared with bupivacaine alone,The mean sensory block duration
the control group (22.5 (6.3) min), p < 0.0001). Addition in the group MgsSo4 was 249±9.36 and in control
of hyaluronidase to ropivacaine resulted in a reduction in Group was (160±5.62) (p<0.39). The mean motor block
the time needed to achieve complete sensory block [8]. duration in the group MgsSo4 was (232±9.64) and in
control group was (147±26.52) (both p<0.32). The mean
Another previous study by Keeler et al reported the onset of sensory block in group MgsSo4 was (15.5±2.16)
effect of the addition of hyaluronidase to bupivacaine and the onset of block in control group was (12.73±1.18)
0.5% for axillary brachial plexus blocks. In that (p<0.4) statistically not significant). Alsothe mean onset
study, 3000 IU hyaluronidase mixed with bupivacaine of motor block in group Mgso4 was (23.5±1.1) and
significantly reduced the duration of the sensory the onset block in control Group P was 41±3 (p<0.53;
and motor block, and had no effect on the number of statistically not significant) [12]
patients experiencing a complete sensory block after
30 min while the duration of sensory anesthesia was In our study the addition of Mgso4 to 0.5%
significantly shorter in the hyaluronidase group and the bupivacaine in supraclavicular brachial plexus block for
duration of motor block showed a shorter trend [9]. upper limb surgeries increased the duration of sensory
and motor blocks with mean sensory block duration
In our study hyaluronidase had obvious effect on (643.1±144.8) in Mgso4 group vs (423.5±89.4) in control
decreasing the sensory onset that recorded by pinprick group or (387.2±78.3) in hyaloronidase group and mean
test at 5 min interval after performing the block till motor block duration (546.6±99.8) vs (337.5±77.6) in
complete sensory block occurred and motor onset control group or (310±84.9) in hyaloronidase group
detected by detection of complete thumb block also with (p value <0.001) for both. Also Mgso4 decreased
detected at 5 min interval after the block in comparison the postoperative pain with mean VAPS at 4, 8, 12, 24
with control group and Mgso4 group. The mean sensory (0‑2.8), (0‑3), (2‑6), (5‑6) vs (2‑3), (4‑6), (6‑7), (7‑7.8)
onset was (8.9 ± 3.3) minutes in hyaluronidase group in in control group vs (2‑3), (3.3‑6), (6‑7), (6‑7.8) with
comparison to the mean sensory onset (14.5±4.5), (14± (p value <0.001) for all. Also Mgso4 reduced total
3.8) minutes in control and Mgso4 groups respectively.
474 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
analgesic requirements in comparison with the use of study of the School of Medicine, Minia University,
0.5% bupivacaine or bupivacaine plus hyaluronidase Egypt, and all patients gave informed consent before
with mean total analgesic requirement (1‑2) in Mgso4 participation in this study. The study conducted in
vs (2‑3) in both control and hyaluronidase groups and accordance with the ethical guidelines of the 1975
the change was statistically significant with (p value Declaration of Helsinki and International Conference on
<0.001). However MgSo4 didn’t affect the onset of Harmonization Guidelines for Good Clinical Practice.
sensory or motor block when compared to the control
and hyaluronidase group. Source of Funding: None

The most recent in our study is the addition of both Conflict of Interest: The authors declare that there
MgSo4 and hyaluronidase to bupivacaine 0.5% which is no conflict of interests.
resulted in significant decrease in the onset of motor
and sensory block and also significant increase in the
References
duration of the block which produced rapid surgical 1. Sadowski M, Tułaza B and Łysenko L.
anesthesia, reduced postoperative pain and decrease Renaissance of supraclavicular brachial plexus
postoperative analgesic requirement, the mean sensory block.Anaesthesiology intensive therapy. 2014; 46
block onset was (8.7±2.7), the mean motor block onset (1):37‑41.
was (14.5±4).mean VAPS at 4, 8, 12, 24 hours was (0‑0), 2. Bailard NS, Ortiz J and Flores RA, Additives
(0‑2), (2.3‑5), (5‑6) which was significant in comparison to local anesthetics for peripheral nerve blocks:
with control and MgSo4 groups with p value < 0.001. Evidence, limitations, and recommendations.
Mean sensory duration was (660.3±94.9), Mean motor American Journal of Health‑System Pharmacy,
duration was (546.6±99.8) both was significantly 2014. 71(5): p. 373‑85.
increased than control and hyaluronidase groups with
3. Vastani N, Seifert B, Spahn DR, et al., Sensitivities
p value < 0.001. Mean total postoperative analgesic
of rat primary sensory afferent nerves to magnesium:
request was (1‑1.8) also it was significantly less than
implications for differential nerve blocks, European
control and hyaluronidase groups.
Journal of Anesthesiology(EJA). 2013. 30(1): P.
21–28.
Conclusion
4. Price A, Walker KJ, McGrattan K, et al. Ultrasound
The present study shows that the use of hyaluronidase guidance for upper and lower limb blocks. The
reduces the time to reach complete sensory and motor Cochrane of Systematic Reviews. 2015; (9).
block and therefore shortens the total anesthetic time
5. Lee I. O., Kim W. K., Kong M. H., et al.,
before operation, hyaluronidase has no influence on
No enhancement of sensory and motor
the total analgesic duration or the consumption of
blockade by ketamine added to ropivacaine
postoperative analgesics.
interscalene brachial plexus blockade. Acta
Also the study shows that the use of Mgso4 increases anaesthesiologicascandinavica. 2002. 46, 821‑6.
the duration of motor and sensory block, increases 6. Bromage P, Epidural analgesia. st Ed. Philadelphia,
the analgesic duration and reduces the postoperative WB Saunders; 1997:144.
analgesic consumption. However MgSo4 has no effect 7. Wohlrab J, Finke R, Franke WG, et al. Efficacy
on the sensory or motor onset of block. study of hyaluronidase as a diffusion promoter for
Last conclusion was that the combination of both lidocaine in infiltration analgesia of skin. Plastic
MgSo4 with hyaluronidase as adjuvants to bupivacaine and reconstructive surgery. 2012; 129 (4):771‑772.
produces significant effect on reducing the time to reach 8. Koh W. U, Min H. G, Park H. S. et al.Department of:
complete sensory and motor block and therefore shortens Hyaluronidase for axillary block. Anesthesiology
the total anesthetic time before operation, increases and Pain. 2015, 70, 282–289.|
the duration of motor and sensory block, increases 9. Keeler JF, Simpson KH, Ellis FR, et al.,Effect of
the analgesic duration and reduces the postoperative addition of hyaluronidase to bupivacaine during
analgesic consumption. axillary brachial plexus block. British Journal of
Anaesthesia 1992; 68: 68 –71.
The Institutional Ethics Committee approved this
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 475
10. Vastani N, Seifert B, Spahn DR, et al., Sensitivities sensory axillary plexus blockade. Anesth Pain
of rat primary sensory afferent nerves to Med. 2015; 5(1).
magnesium: implications for differential nerve 12. Rao LN, Jeyalakshmi V, Nagaraju M, Anitha S.
blocks. Eur J Anaesthesiology. 2013; 30(1):21–8. The effect of magnesium sulfate as an adjuvant
P mid: 23138572. to 0.5% bupivacaine on motor and sensory
11. Haghighi M, Soleymanha M, Sedighinejad A, et supraclavicular brachial plexus blockade. Int J
al.The effect of magnesium sulfate on motor and Basic Clin Pharmacol. 2015; 4(2):317–21.
476 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Influence of Social Cultural Capital and Marketing on Skin

Whitening Products Use among Higher Education Female
Students in the Northeast of Thailand

Anawat Phutongnak1, Wongsa Laohasiriwong2, Kittipong Sornlorm3

1Doctor of Public Health Program, Faculty of Public Health, Khon Kaen University, Thailand, 2Faculty of Public
Health, Khon Kaen University, Thailand, 3Thakhantho District Public Health Office, Kalasin Province, Thailand

Abstract
Introduction: There have been increasing trends of skin whitening products use globally. Social cultural
capital has been identified as one of a significant determinants of skin whitening products use. However,
there was no study on these issues in Thailand. Therefore, this study aimed to identify skin whitening
products use situation and the association between social cultural capital, marketing, and skin whitening
products use among female higher education students in the Northeast of Thailand.

Method and Materials: This cross‑sectional study was conducted in the Northeast of Thailand among 1,143
female higher education students. Data was collected using a self‑administered structured questionnaire.
The Generalized Linear Mixed Model (GLMM) was used to identify the associations between social cultural
capital, marketing and skin whitening products use when controlling other covariates.

Results: Most of the respondents ever used skin whitening products (84.95% : 95% CI: 82.88–87.03),
of which 52.66% (95% CI: 49.77–55.57) were current users, and 17.41% (95% CI: 15.21–19.61) were
inappropriate use. The social cultural capital factor that were associated with skin whitening products use
were those who were not satisfied with skin colors (Adj. OR=3.48; 95% CI=2.18–5.55; p<0.001), had friends
using skin whitening products (Adj. OR=2.63; 95% CI=1.71–4.04; p<0.001, had thin to normal figures (Adj.
OR=2.53; 95% CI=1.54–4.15; p<0.001), and had family members using skin whitening products (Adj.
OR=1.86; 95% CI=1.10–3.15; p=0.020), studied in humanities and social sciences (Adj. OR=2.07; 95%
CI=1.25–3.45; p=0.005) and product marketing (Adj. OR=1.92; 95% CI=1.15–3.20; p=0.012). Moreover,
other factors that were also associated with skin whitening products use were family monthly income.

Conclusion: Majority of the higher education female students were current skin whitening products users
of which about one‑sixth was inappropriate users. Both social cultural capital, marketing had influence on
skin whitening products use.

Keywords: Skin whitening, Social cultural capital, Marketing, Female students.

Introduction the most popular products of the global beauty industry,

particularly in Asia. Marketing forecasters predict
Skin whitening products use is an ancient and
the business will be worth about USD 31.2 billion
widespread practice in many cultures(1), and is one of
by 2024(2). In several Asian countries, particularly
India, Japan, Korea, China, and Thailand, women face
pressure to lighten their skin due to the social perception
Corresponding Author: that light skin is considered to be a cultural marker
Wongsa Laohasiriwong, Ph.D. of beauty, class, and wealth, and has been reflective
Faculty of Public Health, Khon Kaen University, of high social status for many decades(3‑4). The social
Thailand cultural capital refers to social, political, economic,
e‑mail: [email protected] cultural assets, and imperceptible health resources(5‑6),
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 477
with a growing recognition of the socioeconomic by using a multi‑stage random sampling method. The
status and social determinants of health(7). It has been sampling frame was all 18 universities in the Northeast
described as a feature of trust, norms, networks, skill, of Thailand. The first stage was a random selection of
cultural knowledge, and education that can improve 4 universities, followed by randomly selecting 3 fields
the efficiency of society by facilitating coordinated from each university. Then, one faculty from each field
actions(8). In addition, previous studies reported that the was randomly selected. Therefore, a total of 12 faculties
advertising industry has recently created a market on were included in the study. Simple random sampling
notions of beauty, and enhance social cultural capital was applied to select participants proportional to the size
for the improvement in confidence and career prospects of the estimated total samples. A total number of 1,143
through the use of products advertised to promote white individuals were chosen to participate in this study.
skin(9).
Research Tools: A structured questionnaire was
However, skin whitening products frequently developed based on the research questions and relevant
contain toxic ingredients that are directly associated literatures. The structured questionnaire consisted of 4
with adverse health and skin problems (10). A study on parts including: 1) Demographic and socioeconomic:
the use of skin whitening products among university age, university level, field of study, residence, allowance,
students indicated that 70.7% of females reported using family monthly income, adequacy of expense, and
skin whitening products (11) of which their use was family members. 2) Skin whitening products use
associated with adverse skin effects, lack of personal included; Have you ever used skin whitening products
control, risky sexual behaviors, and low social support in your lifetime? Do you currently use skin whitening
(12). In Thailand, as well as the Northeast region, the
products? Inappropriate use was assessed by using
country biggest region both in term of land areas and a list of dangerous cosmetics from the FDA (Food
population, there are still lack of research specifically and Drug Administration, Ministry of Public Health,
concerned with social cultural capital, skin whitening Thailand), defined as those who reported any use of
products use, and their relationship to female higher dangerous cosmetics. 3) Social cultural capital included;
education students. satisfied with skin color, have a friend using skin
whitening products, have any family members using
Hence, this study aimed to describe skin whitening skin whitening products, Figures were assessed by using
products use situation and to identify the association BMI (Body Mass Index). The scores were categorized
between social cultural capital, marketing, and skin into four groups according to the WHO (World Health
whitening products use among female higher education Organization) (14) for Asian‑Pacific cutoff points, as
students in the Northeast of Thailand. The findings of follows: Underweight (<18.5 kg/m2), Normal (18.5–
this study will provide evidence for health, education 22.9 kg/m2), Overweight (23–24.9 kg/m2), and Obese
and relevant sectors to formulate appropriate measures ( ≥25 kg/m2). Finally, the scores were dichotomized
to improve inequalities in health and reduce the use of as thin/normal (<23) and overweight/obesity ( ≥23). 4)
skin whitening products. Marketing: Product, Price, Place, and Promotion. Using
the 5 scores (Very Low, Low, Moderate, High, Very
Method high). After summing up the total marks, according
This cross‑sectional analytical study was conducted to Best’s theory, the scores were categorized into 3
between March to July 2019. The population were female groups (Low, Moderate, High). Finally, the scores were
higher education students in the Northeast of Thailand. dichotomized as low/moderate (<3.68) and high ( ≥3.68)
The inclusion criteria were female higher education by using the mean as the cutoff point.
students aged 18 years old and older, currently studying
for a bachelor’s degree in universities of the Northeast The questionnaire was undergone content validation
of Thailand, able to verbally communicate, and agreed by 5 experts and was revised to improve its validity.
to participate in the study with written informed consent. The Cronbach’s alpha coefficient of social cultural
The sample size was calculated by using the formula to capital was 0.80, marketing was 0.87. A self‑administer
estimate the sample size for a logistic regression analysis questionnaire was used for data collection. The
of Hsieh (13). The estimated sample size was 1,143. We researcher responded to possible questions raised by
recruited students from 18 universities of the Northeast the respondents, and assisted them when necessary. The
completed questionnaires of each student were placed
478 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
into an individual envelope, sealed, and put into a box. level of product marketing.
Confidentiality of all data was fully assured.
Most of the respondents used skin whitening
Data Analysis: The data was analysed using products (84.95%), 52.66% were current use and 17.41%
STATA® (ver. 13; College Station, TX, USA: Stata were inappropriate use.
Corp). Frequency and percentage were presented to
describe the categorical variables. Continuous variables Table 1: Number and percentage of skin whitening
were described as mean and standard deviation, products use among female higher education
median and range. The generalized linear mixed model students in the Northeast of Thailand (n = 1,143)
(GLMM) was performed to model the random effects Characteristics Number Percent 95% CI
and correlations within clusters. In the modelling,
Use of Skin Whitening Products
the universities were set as random effects. Bivariate
Never 172 15.05 13.09 – 17.24
analysis was used to determine the association of each
Ever 971 84.95 82.76 – 86.91
independent variable with skin whitening products use.
Current Use
The variable that had p‑value<0.25 were proceeded
No 541 47.34 44.44 – 50.24
to multivariable analysis, of which the backward
Yes 602 52.66 49.76 – 55.56
elimination method was used for model fitting. The final
Inappropriate Use
model results were presented as adjusted Odds Ratio
(Adj. OR), 95% CI, with the levels of significance of No 944 82.59 80.28 – 84.68
0.05. Yes 199 17.41 15.32 – 19.72

The bivariate analysis indicated that social cultural

Results
capital factor including satisfied with skin colors, had
The average age of female higher education students friends using skin whitening products, figures, had
was 20.67 ± 1.25 years old. Almost equal proportion of family members using skin whitening products, and field
students were form each 4 universities (about 25%) and of study, product marketing and marketing on place, age,
were from freshman (24.06%), sophomore (24.41%), family members, family monthly income, and allowance
junior (27.91) and senior: 23.62%. Majority of the might associated with skin whitening products use
student lived in private accommodation. Their median (p‑value <0.25). These variable were proceeded to the
family monthly income was USD 940 with the ranged of multiple variable analysis using GLMM. The results
USD 163 to USD 6,528. Nearly half of the respondents indicated that satisfied with skin colors (adj. OR=3.48:
had adequate financial support but were unable to save 95% CI; 2.18‑5.55), had friends using skin whitening
any money. Most of respondents (84.51%) had thin products (adj. OR= 2.63: 95% CI; 1.71‑ 4.04), were
and normal figure, and had friends (71.22%) using thin‑normal (adj. OR= 2.53: 95% CI; 1.54‑ 4.15), studied
skin whitening products. Almost one‑third had family in the field of humanities and social sciences (adj. OR=
members using skin whitening products and were not 2.07: 95% CI; 1.25‑ 3.45), had product marketing level
satisfied with their skin colors. Majority of respondents (adj. OR= 1.92: 95% CI; 1.15‑ 3.20), and had monthly
(53.81%) perceived a moderate level of overall family income ≥ 980 USD (adj. OR= 2.13: 95% CI;
marketing strategies and about 60% perceived a high 1.41‑ 3.20)

Table 2. Factors Associated with Skin Whitening Produce Use among Female Higher Education Students:
A multivariable analysis (n = 1,143)

Characteristics N % of Use OR AdjOR 95% CI p‑value

Satisfied with skin colors <0.001
Yes 618 81.42 1 1
No 353 91.93 2.60 3.48 2.18 –5.55
Had friends using skin whitening products <0.001
No 226 68.69 1 1
Yes 745 91.52 4.92 2.63 1.71 – 4.04
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 479

Characteristics N % of Use OR AdjOR 95% CI p‑value

Had family members using skin whitening products 0.020
No 591 80.19 1 1
Yes 380 93.60 3.61 1.86 1.10 – 3.15
Figures <0.001
Overweight‑obesity 136 76.84 1 1
Thin‑normal 835 86.44 1.92 2.53 1.54 – 4.15
Field of study 0.005
Sciences and Technology/Health
Sciences 278 82.74 1 1
Humanities and Social
Sciences 693 85.87 1.27 2.07 1.25 – 3.45
Product marketing 0.012
Low‑moderate 380 81.02 1 1
High 591 87.69 1.67 1.92 1.15 – 3.20
Family monthly income <0.001
< 980 USD 464 80.70 1 1
≥ 980 USD 507 89.26 1.99 2.13 1.41 – 3.20

Discussion use skin whitening products as well as having family

members using skin whitening products were 1.86 times
Skin whitening products use among female higher
more likely to use them. It might be that both peers
education students was 84.95%. This finding is consistent
and families could have direct communication with the
with previous studies reporting a high prevalence
students that could have influence on their behaviors.
of skin whitening products use (1,15). However, this
These findings were consistent with another study (20).
was inconsistent with a study among African women,
Students with thin to normal figures were 2.53 times
observed only 60% the respondents using skin whitening
more likely to use skin whitening products compared
products (16). Our study observed that 52.66% of students
to those in the overweight and obese group. This was
were current users, which was higher than the 37.60%
in similar with the study in India (17), but inconsistent
found in India. It probably due to the greater range of
with the study in Sudan (15). This might be due to the
ages (16‑60 years) as well as the cultural setting of
body image and beauty concerns of female students
the study (17). About one sixth were using the products
engaged in weight control. Students who studied in
inappropriately, a little lower than 46.7% of teenage
humanities and social sciences were 2.07 times more
females reported using harmful cosmetics (18).
likely to use skin whitening products than students who
The multivariable analysis of this study confirmed studied science and technology. The finding was also
that social cultural capital was significantly associated consistent with another study (21). Students with a high
with skin whitening products use. Regarding social level of product marketing were 1.92 times more likely
cultural capital and satisfaction with skin colors, students to use skin whitening products, which was similar with a
who were dissatisfied with their skin colors were 3.48 study in United Arab Emirates (22). Students with family
times more likely to use skin whitening products. This monthly income ≥ USD 980 were 2.13 times more likely
finding was consistent with a previous study (15). Social to use skin whitening products. This was also similar
and cultural notions connected females using skin with a study conducted in Southeast Asia (19). It might
whitening products(15). The presence of social cultural be that they had money to spend on nonessential items.
capital among university students was associated with
their entire health and individual life (19). Shroff, H et al Conclusion
suggested enhanced social cultural capital for prevention As high as 84.95% of the higher education female
of use among women(17). Students who had friends using students ever used skin whitening products of which
skin whitening products were 2.63 times more likely to more than half were current skin whitening products
480 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
users. About one‑sixth was inappropriate users. Both 9. Kavita K. Obsessions with Fair Skin: Color
social cultural capital, marketing had influence on skin Discourses in Indian Advertising. Adv Soc Rev.
whitening products use. 2008;9(2):1–19.
10. Ladizinski B, Mistry N, Kundu RV. Widespread
Limitation of the Study: Since this is a
use of toxic skin lightening compounds: medical
cross‑sectional study, it could not identify the causal
and psychosocial aspects. Dermatol Clin.
relationship between independent variables with skin
2011;29(1):111–23.
whitening products use.
11. Ofili A, Eze E, Onunu A. Prevalence of use of skin
Conflicts of Interest: The authors declare no lightening agents amongst University of Benin
conflicts of interest. undergraduates in Benin City, Nigeria. Niger Med
Pract. 2006; 49(1).
Ethics Clearance: After explaining the study
objective, written informed consent was taken from all 12. Adbi A, Chatterjee C, Kinias Z, Singh J. Women’s
the participated in the study. Confidentiality of the data Disempowerment and the Market for Skin
was fully assured. The Khon Kaen University Ethics Whitening Products: Experimental Evidence
Committee in Human Research approved the exemption from India [Internet]. 2016 [cited 2019 Sep 13].
for ethical approval of this study (reference no. HE Available from: https://ssrn.com/abstract=2866
612343). 336
13. Hsieh FY, Bloch DA, Larsen MD. A simple method
Source of Funding: Self of sample size calculation for linear and logistic
regression. Stat Med. 1998;17(14):1623–34.
References
14. Pan WH, Yeh WT. How to define obesity?
1. Olumide YM. Use of skin lightening creams. BMJ. Evidence‑based multiple action points for public
2010;341:c6102. awareness, screening, and treatment: an extension
2. Global Industry Analysts I. Skin Lighteners: A of Asian‑Pacific recommendations. Asia Pac J Clin
Research Brief [Internet]. 2018. Available from: Nutr. 2008;17(3):370–4.
https://www.strategyr.com/MarketResearch/Skin_ 15. Anwar EA, Mohamed EH. Use of skin‑whitening
Lighteners_Market_Trends.asp products by sudanese undergraduate females:
3. Chaudhri SK, Jain NK. History of cosmetics. Asian A survey. J Racial Ethn Heal Disparities.
J Pharm. 2009;3(3):164–7. 2017;4(2):149–55.
4. Alghamdi KM. The use of topical bleaching 16. Dlova N, Hamed SH, Tsoka‑Gwegweni J, Grobler
agents among women: A cross‑sectional study A, Hift R. Women’s perceptions of the benefits and
of knowledge, attitude and practices. J Eur Acad risks of skin‑lightening creams in two South African
Dermatology Venereol. 2010;24(10):1214–9. communities. J Cosmet Dermatol. 2014;13(3):236–
5. Bourdieu P. The forms of capital. In: Richardson 41.
J, editor. Handbook of Theory and research for the 17. Shroff H, Diedrichs PC, Craddock N. Skin
society of Education. Greenwood: Westport, CT; Color, Cultural Capital, and Beauty Products: An
1986. Investigation of the Use of Skin Fairness Products
6. Pillai TR, Ahamat A. Social‑cultural capital in in Mumbai, India. Front Public Heal. 2018;5.
youth entrepreneurship ecosystem: Southeast Asia. 18. Kongwong R, Wattananamkul V. A Study of
J Enterprising Communities. 2018;12(2):232–55. “Harmful Cosmetics” Usage Behavior Among
7. Story WT. Social capital and health in the least Female Teenagers in Ubon Ratchathani Province.
developed countries: A critical review of the IJPS. 2011;7(1):76–87.
literature and implications for a future research 19. Peltzer K, Pengpid S, James C. The globalization
agenda. GPH. 2013;8(9):983–99. of whitening: prevalence of skin lighteners (or
8. Putnam R, Leonadri R, Nanetti R. Making bleachers) use and its social correlates among
Democracy Work: Civic Traditions in Modern university students in 26 countries. Int J Dermatol.
Italy. Princeton: Princeton University Press; 1993. 2016;55(2):165–72.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 481
20. Mojdeh K, Fariba M. Socio‑economic factors agents in Khartoum Sudan 2016. J Clin Exp
influencing cosmetic products use by females Dermatol Res. 2017;8(6):74.
under 20 years old in Yazdanshahr NajafAbad. 22. Salim KH. The Influence of Brand Loyalty on
Dermatology Cosmet. 2013;4(1):1–9. Cosmetics Buying Behavior of UAE Female
21. Alshima SA. Knowledge, attitude and practice of Consumers. Int J Mark Stud. 2011;3(2):123–33.
female university students towards skin lightening
482 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Knowledge Management Based Performance Improvement on

Certified Health Workers in Health Center of South Sulawesi

Andi Mansur Sulolipu1, Ridwan Amiruddin2, Sukri Palutturi3, Ridwan M. Thaha4, Arsunan A.A.2
1DoctoralProgram Student, 2Professor, Department of Epidemiology, 3Professor, Department of Health Policy
and Administration, 4Senior Lecturer, Department of Health Education and Behavioral Sciences, Faculty of Public
Health Hasanuddin University, Makassar, Indonesia

Abstract
Introduction: The aim of this research was to determine the effect of Knowledge Management on improving
the performance of health workers force at Primary Health Center of South Sulawesi.

Material and Method: The research used qualitative method. The informants were 12 health workers. Data
collection used was in‑depth interviews. The tools used were tape recorders and camcorders.

Finding and Discussion: This study found that the Knowledge Management method was relevant to be
used in increasing the performance of health workers force in a group of health workers (Doctors, Nurses,
Midwives, and SKM (Bachelor of Public Health) who come from different functional health positions) at the
South Sulawesi Community Health Center.

Conclusion: Performance of health work force could be done using one method which was knowledge
management.

Keywords: Health workers force, Knowledge management, Performance.

Introduction goals. Health workers contribute up to 80% in the

success of health development. In 2006, WHO reported
Global Health Workforce Alliance (GHWA)
that Indonesia was one of 57 countries that faced a health
Conference reported that the quality of Human Resources
HR crisis, both in number and distribution.
Health is still a problem at the global level. In Indonesia,
various efforts to improve the quality of health human Competence is an ability possessed by someone in
resources to achieve sustainable competitive advantage carrying out a task or a job based on skills and knowledge.
and increase profitability were carried out through The development of human resource competencies
education and training. However, the education and in the health sector is a strategic component of health
training system have been criticized for years. The development in order to accelerate the distribution
quality of the results of education and training of health of health services and the achievement of health
workers in general is still inadequate1. According to development goals. The performance of an organization
various studies showed that health workers are the main will be determined by one of the main elements, which
key in the success of achieving health development is the quality of human resources2.

The implementation of non‑quality training will

have an impact on the low competency of graduates
Corresponding Author: which ultimately affects the performance of institutions/
Andi Mansur Sulolipu organizations. According to Hendry, the practice of
Doctoral Program Student in Faculty of Public Health, improving the quality of human resources (training,
Hasanuddin University, Makassar, Indonesia job design, employee skills, employee attitudes, work
e-mail: [email protected] motivation, etc.) has an impact on the performance
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 483
of various business units3. Likewise, Sule findings research is to improve the performance of the health
showed a significant positive relationship between work force at the Primary Health Center of South
competency‑based training and development and Sulawesi. In the era of knowledge‑based society in the
employee performance4. Knowledge management is 21st century, the way people learn has changed. New
a concern of what is called Knowledge Management knowledge is gained by learning from training, work and
(KM). According to Qwaider, Knowledge Management exchange of experiences. The US Department of Labor
helps manage knowledge individually or in group within estimated that more than 70% of knowledge occurs from
organizations or between organizations that can affect experience and 30% from education and training9.
the quality and benefits of knowledge5.
Knowledge of each individual in the organization
Several studies were conducted on knowledge or the company is certainly different so it causes
management related to variables such as performance, the knowledge does not develop evenly within the
competence, training, learning, and others. Research environment. Knowledge Management is one solution
conducted by Tongsamsi discovered the effect of to assist knowledge processing, so that individuals
knowledge management and training on manager in training or learning classes can have the same
competencies6. Knowledge management positively knowledge9, then with the same knowledge it can help
influences organizational performance. Another to develop an organization or company. Knowledge
study was conducted by Chandavimol, which isthe management is formed from a knowledge, where
development of a mixed training model by applying knowledge is divided into two types, those are Tacit
the principles of knowledge management and learning Knowledge and Explicit Knowledge. This knowledge
actions, in order to develop the design competency can be in the form of: books, journals, scientific works,
of health human resource development staff training references or others. This knowledge is obtained and
programs in the government sector7. Furthermore, developed from the content and information contained
the working team will form collaboration between in it.
participants in education and training 8 . The aim of this

Figure 1. SECI Model

Figure 1 is known as the SECI Model10, in the improvement of curriculum, teaching and learning
figure where there are two types of knowledge, processes usingtechnology, as well asimproving
those aretacit knowledge and explicit knowledge. In response by monitoring and combining lessons from
university education activities, knowledge management student experience and evaluation11. Nawaz and Gomez,
can improve administrative services related to the presented two Knowledge Management Model Concepts.
484 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
The first model concentrates on how knowledge sources knowledge and choose strategic knowledge. This
are transformed into strategic knowledge, where the enhances procedural knowledge owned by the students,
process of converting tacit and explicit knowledge into generates core subject skills and algorithms, core subject
knowledge diffusion converts it again as the application techniques and method as well as formula knowledge to
of knowledge. Participants develop their knowledge determine when and how to use appropriate procedures
by understanding the concept of subject matter and to solve problems. The Strategic Knowledge Model can
converting it into strategic knowledge. The second be implemented in universities, then for Knowledge
model strategic knowledge is a source of knowledge Models can be implemented in advanced training
for students, while learning knowledge learners diffuse institutions.

Figure 2. The Victorian council and social services

Knowledge Management strategy is very much Heath Center, since knowledge management is very
needed to cooperate or collaborate, namely Cooperation, helpful in understanding the management of the health
Coordination and Collaboration. Simple horizontal center. In addition it is also able to be directly held.
integration between cooperation, coordination and
collaboration is shown in Figure 2. Knowledge management can improve organizational
performance12 even though not all knowledge resources
Material and Method affect organizational performance directly. However, it
cannot be ignored because they work in combination
Based on the conceptual framework, the variables with other supporting sources, including knowledge
in this study consisted of: Knowledge Management acquisition and application knowledge that can
Strategy as an independent variable, and Enhancing contribute directly to the organizational success.
Performance and competency as the dependent variable.
This study used qualitative research method to obtain Based on the results of research at the Primary Health
comprehensive, valid and objective data. Center that have implemented knowledge management,
it shows that it indirectly affects the performance of
Finding and Discussion health workers so that it can encourage the management
The results of in‑depth interviews showed that the of the health center to improve the function of health
application of knowledge management in the form of services. The following are the results of the interview:
face‑to‑face socialization had a positive impact and ..........Socialization of training results improved
benefits for the health workers in the Primary Health performance, seen from the document management of
Center. Thus, it was very well implemented for every the health center that had been produced.....
training attended by the health workers in the Primary
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 485
Performance is a work achievement that can be 2. Harper K, Armelagos G. The changing disease‑scape
measured based on the standards or criteria set by the in the third epidemiological transition. Int J Environ
Primary Health Center. The completion of basic tasks Res Public Health. 2010;7(2):675–97.
and functions is the performance of a health worker who 3. Hendry C, Pettigrew A. The Practice of Strategic
is physically and mentally attached. Human Resource Management. Pers Rev.
1986;15(5):3–8.
..........At our place (Primary Health Center),every
employee who participated inthe training must be 4. Sule BA. Assessment of implementation of
trained to conduct socialization of training in meeting competence based: Effect of Competence Based
each patient in the Primary Health Center..... Management Approache on employee performance
in UNHCR Kenya. 2015; Available from: erepo.
Knowledge Management focuses on the usiu.ac.ke/bitstream/handle/11732/627/BSULE
identification, acquisition, distribution and maintenance PROJECT.pdf?sequence...
of substantial and relevant knowledge. Rush (2005) 5. Qwaider WQ. Integrated of Blended Learning
described the term of Knowledge Management related System (BLs) and Knowledge Management
to the exploitation and development of knowledge assets System. Int J e‑Learning Secur. 2011;1(2):89–95.
of an organization with the intention of improving the
6. Tongsamsi K, Tongsamsi I. Influence of training
organizational goals. Knowledge management has been
and knowledge management on competency
implemented in many organizations with the expectation
among quality managers at Rajabhat Universities in
that they will have a positive effect on performance 11.
Thailand. J Psychol Educ Res. 2015;23(2):54–72.
Conclusion 7. Chandavimol P, Natakuatoong O, Tantrarungroj
P. Blended Training Model with Knowledge
The results showed that knowledge management had
Management and Action Learning Principles to
an effect on performance, and it could be concluded that
Develop Training Program Design Competencies.
health workers in the Primary Health Center who were
Int J Inf Educ Technol. 2013;3(6):619–23.
committed to organizing had an impact on completing
their main tasks and functions as health workers. 8. Trivellas P, Akrivouli Z, Tsifora E, Tsoutsa
Knowledge management provides development and the P. The Impact of Knowledge Sharing Culture
ability to think, work and manage work well so as to on Job Satisfaction in Accounting Firms. The
produce performance that affects the health services. Mediating Effect of General Competencies.
Furthermore, research on learning strategies and Procedia Econ Financ [Internet]. 2015;19(15):238–
knowledge management are suggested to be combined 47. Available from: http://dx.doi.org/10.1016/
because they can facilitate the learning well. S2212‑5671(15)00025‑8
9. Chandavimol P, Natakuatoong O, Tantrarungroj
Conflict of Interest: There is no conflict of interest P. Knowledge Management and Action Learning
to be declared. in Blended Training Activities. Creat Educ.
2013;04(09):51–5.
Source of Funding: self or other source: The
source of funding for this research came from private 10. Gourlay S, Hill K. shortcomings. 1995;(Figure
funds. 1):1–10.
11. Ramakrishnan K, Norizan MY. Knowledge
Ethical Clearance: The ethical approval of Management System and Higher Education
this research was based on the letter Number: 3598/ Institutions. Int Conf Inf Netw Technol.
UN4.14.8/TP.02.02/2019), Faculty of Public Health, 2012;37(Icint):67–71.
Hasanuddin University, Makassar, Indonesia.
12. Nonaka I. The knowledge‑creating firm. Harv Bus
References Rev. 1991;69(6):96–104.

1. Report M. Global Health Workforce Alliance.

2006;(April).
486 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Determinants that Influence Relationship between Motivation

and Job Satisfaction of Health Workers at Primary Health
Care in Indonesia

Armedy Ronny Hasugian1,3, Jaslis Ilyas1, Besral2, Adang Bachtiar1

1Administrative
Policy and Health Department, 2Biostatistics Department, Faculty of Public Health,
Depok, Indonesia, University of Indonesia, Depok, Indonesia, 3National Institutes of Research and Development,
Ministry of Health Republic of Indonesia

Abstract
Background: The result from first National Study in Indonesia showed motivation and job satisfaction
of health worker was low. The objective of this study was to identify determinants factor that influence
relationship between motivation and job satisfaction of health worker at PHC in Indonesia.

Method: This was an advance analysis of RISNAKES 2017, a crossed sectional study which conducted
at PHC in Indonesia. The respondents were physician, dentist, nurse, and midwife. Structural Equation
Modelling (SEM) was used for analysis the relationship.

Result: Total 402 health workers recruited from 302 at PHC in Indonesia and the model association was fit
(Critical Ratio=8.057, p<0.000). Motivation was responsible for 51% variance of job satisfaction. “Length
working at current PHC” was the only determinant relate significantly, but there were some significance on
parts of observed variable which associated with construct variable.

Conclusion: “Length working life at current facility” was determinant that influenced the relationship
between motivation and job satisfaction.

Keywords: Human Resource, Health Worker, Job Satisfaction, Motivation, Indonesia.

Introduction achieve that is optimizing motivation and job satisfaction

of health worker.1 National study showed motivation
Primary Health Care/PHC (PUSKESMAS) is a
and job satisfaction of Indonesia’s health workers were
first line of community health service in Indonesia,
only 43% and 23%.2
located in every sub district in Indonesia, and their
duties are to promote, prevent, curative and rehabilitate World Health Organization (WHO) already
of health communities based on National Health. The recommended the policy to improve motivation and
best performance and productivity of health worker is job satisfaction of health worker at health facility.3–5
important to manifest it. The most common approach to The strategies were incentive, learn new skill 6,
supportive supervision 7, strategy for future carrier 8,
work atmosphere 9, and etc. All of the strategies are
depend to the basic characteristics of health worker
Correspondence Author:
and their working environment or determinant factor.
Armedy Ronny Hasugian
Understanding determinants of motivation and job
Determinants that Influence Relationship between satisfaction and their relationships is a basic to choose
Motivation and Job Satisfaction of Health Workers at the best strategy, including at Primary Health care/PHC
Primary Health Care in Indonesia (PUSKESMAS) in Indonesia.
e‑mail: [email protected]
Hp.+6281214068314 The objective of this article was identified the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 487
determinants that influence relationship between Questionnaire (MSQ) that already using in many field
motivation and job satisfaction at PHC in Indonesia. study to measure the satisfaction. The determinants
Structural Equation Modelling (SEM) is a tool of statistic factor were “Job suitability” (suitable of health services
and one approach that can be used to understand and activity at PHC11,<80% vs ≥80%), “Regional”(Jawa
identified the determinant. Through this approach would vs Non‑Jawa‑Bali, “Occupational”(Physician vs Not
help policy maker to develop design policy option on Physician), “Adequate income” (adequacy of one month
health worker responses. salary for their live activity; Yes vs No), “Saving money”
(capability of health worker to saving his income from
Material and Method 1 month salary; Yes vs No), “Length of working life at
This is an advance analysis from the first study of health facility(<8 years vs ≥ 8 years), and “Length of
National Human Resource of Health Study (RISNAKES) working life at current PHC”(<5 years vs ≥ 5 years).
2017 for health worker at government health facility Univariate analysis used to identify characteristic
including PHC 2.This was a cross sectional study, the of respondent, and analysis of reliability indicator of
respondent was a physician, dentist, nurse and midwife motivation and job satisfaction questionnaire used
at PHC and observed at “time study” by independent Cronbach Alpha test with cut off > 0.7.12 Structural
enumerator from open until closed time of PHC. They Equation Modelling (SEM) assessed association
were also answer “motivation and job satisfaction between motivation and job satisfaction with model fit
questionnaire” themselves (self‑administered were CMIN/df<2, RMSEA <0.08, GFI >0.90, CFI>0.90,
questionnaire) too. Entry and cleaning of this data TLI>0.90 and SRMR nearest <0.08.13The reliability and
were already doing by laboratory Management Data on validity of construct variableof model was analysed
National Institutes of Health Research and Development, by Average Varian Extracted (AVE) and Construct
Ministry of Health Republic Indonesia. The respondents Reliability (CR). Invariant measurement was done to
signed inform consent voluntary before start the study identify determinants influence association between
and they had opportunity to understand the questioner motivation and job satisfaction, only p value ≥0.05 can
before start answer. All of the initial names or place be compared. SEM analysis used AMOS 24.
during recruitment and publication were confidential.
Results
Measurement of motivation was using indicators
from instrument in Kenya by Muntale at all, with 23 Total 402 respondents analysed at 302 PHC from
questionnaires.10 Meanwhile, the of job satisfaction 1430 respondents at 425 PHC in “time study”, the entire
was using short questionnaire Minnesota Satisfaction characteristic was showed at table 1.

Table 1: Characteristic respondent of the study (n=402)

Characteristic Group Frequency Percentage

Man 79 19.7
Sex
Woman 323 80.3
Physician 166 41.3
Dentist 46 11.4
Occupational
Midwife 97 24.1
Nurse 93 23.1
≥80% 137 34.1
Job suitability
<80% 265 65.9
Jawa Bali 140 34.8
Regional
Non Jawa Bali 262 65.2
Yes 191 47.5
Adequacy Income
No 211 52.5
488 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Characteristic Group Frequency Percentage

Yes 170 42.3
Saving Money
No 232 57.7
≤8 years 208 51.7
Length of working life at health facility
>8 years 194 48.3
≤5 years 224 55.7
Length of working life at current PHC
>6 years 178 44.3
Median (SD) Minimum Maximum
Age (Years) 34(8.18) 22 60
Length of working life at health facility (Years) 8 (7.99) 0.5 37
Length of working at life current PHC (Years) 5 (6.09) 0.5 31

Source: Own research

Mean of 23 indicator of motivation was range of job satisfaction were selected. The model was fit with
(SD) 1.85(0.89) ‑ 4.19(0.56) and 20 indicator of job CMIN/df=1.696, GFI=0.971, TLI=0.969, CFI=0.976,
satisfaction was 2.86(1.04) – 3.89(0.62). The indicators RAMSEA=0.042, SRMR=0.036, all the path diagram
reliable to analyse as a motivation and job satisfaction was differently significant (p<0.000) (figure 1). The AVE
construct variable with Cronbach Alpha 0.75 and 0.90. for construct motivation was 0.48 and job satisfaction
was 0.36, meanwhile CR of construct motivation was
The model based on 23 indicators motivation 0.73 and job satisfaction was 0.83. This result can be
and 20 indicators job satisfaction were developed and accepted and indicating the variable were reliable and
showed only 3 indicator of constructs motivation and 8 valid14.

Note: X4=“The chance to be “somebody” in the community”, X5=“The way my boss handles his/her workers”, X8=“The way my
job provides for steady employment”, X10=”The chance to tell people what to do”, X14=“The chances for advancement on this job”,
X16=“The chance to try my own method of doing the job”, X17=“The working conditions”, X19=“The praise I get for doing a good
job”, X32=”I am proud to be working for this hospital”,X33= “I find that my values and this hospital’s values are very similar”, X34=“I
am glad that I work for this facility rather than other facilities in the country”. Source. Own research

Figure 1: Model fit of relationship between motivation and job satisfaction (standardized regression weight).
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 489
The result of invariant measurement for that were the working condition and happiness. This
determinants showed only factor “Job suitability” (P situation consistent with other studies and showed
value of measuring weights=0.122, P value of structural “working condition” such as quality team collaboration,
weight 0.167), “Regional” (0.231, 0.283), “Length of positive work environment, moral distress, interaction
working life at health facility “(0.189, 0.091), “Length with management and health worker, length of working,
of working life at current PHC (0.288, 0.070)” can would influence the motivation and job satisfaction.20‑22
be compared and the model was fit. The comparative Moreover, the management of human resource,
analysis showed only “Length of working life at current leadership, job description, infrastructure, environment,
PHC” influences association between motivation and job “being important” might relate with the situation of
satisfaction (regression weight estimate <5 years vs ≥5 health facility/PHC that influence the happiness of
years; 0.81 vs 0.47, p<0,05) with significantly different health worker.23 However, the relationship was same
indicator “glad work at current PHC”< 5 years higher after 8 years working at PHC.
than ≥5 years. There were still significances different on
some parts of observed variable at “Regional” construct; Praise/appreciation, job stability and job advancement
i.e. job stability (X8) and job advancement (X14); and were important indicators that differently significance in
“Job suitability”construct; i.e. praise/appreciation for determinant “Job suitability” and “Regional” even both
good job(X19);although no significant influenced to of them were not influencing the relationship between
relationship between motivation and job satisfaction. motivation and job satisfaction. Praise/appreciationis
Meanwhile, there were dominantly different indicator important in order get high job suitability and study on
for determinants “Occupational”, “Adequate income” Chinese Nurses showed that psychological reward as
and “Saving money”, i.e indicator the way of X5, job a praise/appreciation would increase job satisfaction
stability (X8), job advancement (X14), chance used own beside a psychological payment.24 Meanwhile, many
method (X17), praise/appreciation for good job(X19), health workers had hesitation about their job stability
and glad work at current PHC (X34), though they were and advancement if their work at remote area or with
no invariant. the low economic is. This is consistent with study at
Pakistan, that building carrier progression was needed
Discussion for motivation and retention of health worker.25

There was a significantly association between Determinants “Adequate income”, “saving money”
motivation and job satisfaction of physician, dentist, and “Occupational” were not influence the relationship
nurse, and midwife (health worker) at PHC in Indonesia. between motivation and job satisfaction, buttheir
The 11 indicators depicted the working environment dominant indicator showed working condition was
(extrinsic motivation) of organization and showed crucial for health worker. How organizational factor
the harmonization between environment and health such as reward from leader, manage the job description,
worker and this confirmed the “work motivation” incentive and etc. are important. This is consistent that
theory and “work adjustment theory”.15,16 In this study, the health worker need good environment to make sure
the motivation has related with 51% variance of job they get what their need and achieve the target.6,25,26
satisfaction, this condition showed motivation of health
worker play an important role for job satisfaction of There were limitations of this article, first, the total
health worker at PHC in Indonesia. Someone with sample size only a part of total sample of National
higher motivation had a power from inside and makes Human Resource of Health Study (RISNAKES)
the person do important better for themselves and make 2017, but this was enough to show the association
them satisfy. 6,17–19 with Structural Equation Modelling (S’EM). Second,
RISNAKES conducted only one day activity observed
The association between motivation and job of health worker, but based on their job description, one
satisfaction was significantly different in “Length of daily activity in one PHC similar with others, so the
working life at current PHC” group, which working measurement enough to show the activity. Third, when
life ≤ 5 years had higher association than > 5 years. measure the motivation and job satisfaction, the study
It showed that manage “length time of working “was used self‑determined questionnaire, so the potential bias
important to improve relationship between motivation could happen, to reduce the possibility, the enumerators
and job satisfaction. The important indicators to manage trained to explain answer the question.
490 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Conclusion 4. Dieleman M, Harnmeijer JW. Improving

health worker performance: in search of
“Length of working life at current facility” influences
promising practices. Hum Resour Health.
the relationship motivation and job satisfaction of
2006;(September):77.
physician, dentist, nurse, midwife and pharmacist at
PHC in Indonesia. Working condition/environment 5. van de Pas R, Veenstra A, Gulati D, Van Damme
is important to optimize the relationship between W, Cometto G. Tracing the policy implementation
motivation and job satisfaction. of commitments made by national governments and
other entities at the Third Global Forum on Human
Policy Option: The policy option based the result Resources for Health. BMJ Glob Heal [Internet].
of this study are: 2017;2(4):e000456. Available from: http://gh.bmj.
com/lookup/doi/10.1136/bmjgh‑2017‑000456
1. Develop and optimize working condition to
manage length of working before and after 5 years 6. Hotchkiss DR, Banteyerga H, Tharaney M.
working at PHC. The health worker should be given Job satisfaction and motivation among public
opportunity to move or stay to other facility with sector health workers: Evidence from Ethiopia.
their intention periodically (after 5 years) based Hum Resour Health [Internet]. 2015;13(1):1–
result of evaluation and monitoring. 12. Available from: http://dx.doi.org/10.1186/
s12960‑015‑0083‑6
2. Make motivation and satisfaction survey for health
7. Kok MC, Vallières F, Tulloch O, Kumar MB,
worker periodically to ensure their intention working
Kea AZ, Karuga R, et al. Does supportive
at PHC
supervision enhance community health worker
Acknowledgment: The author wants to thank the motivation? A mixed‑method study in four
entire individuals who have helped the process of writing African countries. Health Policy Plan [Internet].
this article and the respondent of National Human 2018;(September):988‑98. Available from:
Resource of Health Study (RISNAKES) 2017. We like https://academic.oup.com/heapol/advance‑article/
to thank the NIHRD data management laboratory for doi/10.1093/heapol/czy082/5105818
helping manage the data process for this article 8. Ojakaa D, Olango S, Jarvis J. Factors affecting
motivation and retention of primary health care
Conflict of Interest: Authors declare that there is
workers in three disparate regions in Kenya. Hum
no conflict of interest.
Resour Health. 2014;12(1):1–13.
Funding: This study was no grant from any 9. Goetz K, Marx M, Marx I, Brodowski M, Nafula
institution. M, Prytherch H, et al. Working atmosphere and
job satisfaction of health care staff in Kenya: An
Ethical Clearance: Ethical commission National
exploratory study. Biomed Res Int. 2015;2015.
Institutes of Health Research and Development approved
the ethic of this study. 10. Mutale W, Ayles H, Bond V, Mwanamwenge
MT, Balabanova D. Measuring health workers’
Reference motivation in rural health facilities: baseline results
from three study districts in Zambia. Hum Resour
1. Aduo‑Adjei K, Emmanuel O, Forster OM. The Health. 2013;11(1):8.
Impact of Motivation on the Work Performance
11. Ilyas Y. Perencanaan SDM Rumah Sakit, Teori,
of Health Workers (Korle Bu Teaching
Metoda dan Formula. Depok: Pusat Kajian Ilmu
Hospital): Evidence from Ghana. Hosp Pract Res.
Keseshatan FKM‑UI. CV Usaha Prima; 2011.
2016;1(2):45–50.
12. Bland M, Altman DG. Statistics Notes: Cronbach’
2. NIHRD Ministry of Health Indonesia. Report
s Alpha. Br Med J. 2011;314(7080):1996–7.
of Human Reource of Health Study 2017
Puskesmas (Laporan Riset Ketenagaan di Bidang 13. Hu LT, Bentler PM. Cutoff criteria for fit indexes
Kesehatan(Risnakes) 2017 Puskesmas). 2017. in covariance structure analysis: Conventional
criteria versus new alternatives. Struct Equ Model.
3. World Health Organization. Global strategy on
1999;6(1):1–55.
human resources for health: Workforce 2030. 2016.
14. Claes Fornell, Larcker DF. Evaluating
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 491
Structural Equation Models with Unobservable 22. Makames RA, Alkoot EM, Al‑Mazidi BM,
Variables and Measurement Error. J Mark Res El‑Shazly MK, Kamel MI. Sources and expressions
[Internet]. 1981;18(1):39–50. Available from: of stress among physicians in a general hospital.
http://www.dt.co.kr/contents.html?article_ Alexandria J Med [Internet]. 2012;48(4):361–6.
no=2012071302010531749001 Available from: http://linkinghub.elsevier.com/
15. Franco LM, Bennett S, Kanfer R, Stubblebine P. retrieve/pii/S2090506812000218
Determinants and consequences of health worker 23. Sato M, Maufi D, Mwingira UJ, Leshabari
motivation in hospitals in Jordan and Georgia. Soc MT, Ohnishi M, Honda S. Measuring three
Sci Med. 2004;58(2):343–55. aspects of motivation among health workers at
16. Dawis R V. Work adjustment theory. Encycl primary level health facilities in rural Tanzania.
Psychol Vol 8. 2007;(1984):268–9. PLoS One [Internet]. 2017;12(5):e0176973.
Available from: http://journals.plos.org/plosone/
17. Armstrong M, Taylor S. A handbook of human
article/file?id=10.1371/journal.pone.0176973
resource management practice. Thirteenth. Human
& type=printable% 0Ahttp://ovidsp.ovid.com/
Resource Management. Philadephia: Kogan Page;
ovidweb.cgi?T=JS & PAGE=reference & D=emexa
2014.
& NEWS=N & AN=615956497% 0Ahttp://dx.plos.
18. Aamodt Michael G. Industrial/Organizational org/10.1371/journal.pone.0176973% 0Ahttp://
Psychology: An Applied Approach. Sixth. Hague search.ebscohost.c
J‑D, editor. Belmont: Wadsworth Cengage
24. Chen F, Yang M, Gao W, Liu Y, De Gieter S.
Learning; 2010.
Impact of satisfactions with psychological reward
19. Octaviannand R, Pandjaitan NK, Kuswanto S. and pay on Chinese nurses’ work attitudes. Appl
Effect of Job Satisfaction and Motivation towards Nurs Res [Internet]. 2015;28(4):e29–34. Available
Employee’s Performance in XYZ Shipping from: http://dx.doi.org/10.1016/j.apnr.2015.03.002
Company. J Educ Pract. 2017;8(8):72–9.
25. Shah SM, Zaidi S, Ahmed J, Rehman SU.
20. Galletta M, Portoghese I, Carta MG, D’Aloja Motivation and Retention of Physicians in Primary
E, Campagna M. The Effect of Nurse‑Physician Healthcare Facilities: A Qualitative Study From
Collaboration on Job Satisfaction, Team Abbottabad, Pakistan. Int J Heal Policy Manag
Commitment, and Turnover Intention in Nurses. [Internet]. 2016;5(8):467–75. Available from:
Res Nurs Heal. 2016;39(5):375–85. http://ijhpm.com/article_3181.html
21. Dodek PM, Wong H, Norena M, Ayas N, Reynolds 26. Dieleman M, Cuong PV, Anh LV, Martineau T.
SC, Keenan SP, et al. Moral distress in intensive Identifying factors for job motivation of rural
care unit professionals is associated with profession, health workers in North Viet Nam. Hum Resour
age, and years of experience. J Crit Care [Internet]. Health. 2003;1:1–10.
2016;31(1):178–82. Available from: http://dx.doi.
org/10.1016/j.jcrc.2015.10.011
492 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Risk Factors for Obesity in Patients with Hypertension

Aylinda Wahyuni Putri1, Ratu Ayu Dewi Sartika2

1Student of Magister Program of Nutrition Department, 2Professor of Nutrition Department,
Faculty of Public Health, Universitas Indonesia, Depok, Indonesia

Abstract
Background: Non‑communicable diseases (NCDs) are a leading cause of death worldwide. In 2018, NCDs’
prevalence had reportedly increased since 2013. Hypertension was the biggest cause of NCDs diagnosed
in health facilities, from 25.8% to 34.1%. Patients with hypertension and obesity are at increased risk of
complications from diabetes mellitus and kidney disease.

Objective: The present study aimed to determine risk factors for obesity in patients aged 25–69 years with
hypertension.

Materials and Method: This was an observational study with a cross‑sectional design, using secondary
data from the ‘Cohort Study of Risk Factors of Non‑communicable Diseases’, conducted in Bogor City,
Kebon Kelapa Village in 2017. The population in this study included adult patients with hypertension aged
25–69 years.

Results: The prevalence of obesity in patients with hypertension was 47.4%.Risk factors that were
significantly related to obesity in patients with hypertension included age groups 25–44 and 45–59, female
gender and excessive energy intake (p = 0.009, 0.050, 0.025 and 0.039, respectively and odds ratio = 2.43,
1.73, 1.85 and 1.85, respectively).

Conclusions: Risk factors associated with obesity in patients aged 25–69 years with hypertension included
age, gender and energy intake.

Keywords: Obesity, hypertension, adult, elderly.

Introduction kidney failure and premature death.3–6 It is estimated to

cause 12.8% of deaths worlwide.7 In 2018, hypertension
Non‑communicable diseases (NCDs) are the leading
was the main cause of NCDs diagnosed in health
cause of death worldwide. Around 15 million people
facilities. Hypertension’s prevalence increased from
aged 30–69 years die each year from NCDs, with 85%
25.8% in 2013 to 34.1% in 2018.2
occurring in low and middle‑income countries.1 NCDs’
prevalence increased in Indonesia between 2013 and Studies have reported that the prevalence of obesity
2018.2 among patients with hypertension is increasing. A study
by Ford et al. using data from the National Health and
Hypertension is a leading cause of cardiovascular
Nutrition Examination Survey showed that obesity’s
disease that can lead to strokes, coronary heart disease,
prevalence increased from 25.7% from 1976–1980 to
50.8% from 1999–2004 in adults with hypertension.8
Qin et al. also reported an increase in the prevalence
Corresponding Author: of obesity and central obesity in hypertensive adults in
Ratu Ayu Dewi Sartika China.9 A study by Sartika et al. showed that obesity’s
Professor, Nutrition Department, Faculty of Public prevalence in Indonesian patients with hypertension was
Health, Universitas Indonesia, Depok 40.7% in urban areas and 18.9% in rural areas.10
e‑mail: [email protected]
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 493
Patients with hypertension and obesity are at conducted in 2017. This research sample was selected
increased risk of complications of type 2 diabetes mellitus using total population sampling. Respondents with heart
and kidney disease.11, 12 Obesity status in patients with disease (n = 50), stroke (n = 44), diabetes mellitus (n
hypertension is associated with a significant difference = 118) and pregnancy (n = 1) were excluded from the
in the average onset age of type 2 diabetes mellitus.12 In study sample. Thus, 318 respondents were included in
patients with hypertension, obesity and insulin resistance the study.
also play major roles in the genesis of kidney failure,
which is known as ‘nephrosclerotic hypertension’.11 The dependent variable in this study was obesity
status, with a body mass index (BMI) parameter >27
Risk factors such as age, gender, education, income, kg/m². BMI was calculated as body weight in kilograms
diet, physical activity, hypertension treatment, smoking divided by the height in metres squared and categorised
and stress contribute to the incidence of obesity in as: underweight (<18.5 kg/m2), normal weight (18.5–
patients with hypertension. Risk factors for obesity 25.0 kg/m2), overweight (25.1–27.0 kg/m2) and obese
complications in patients with hypertension vary greatly (> 27 kg/m2).13 Independent variables were age, gender,
among regions. education, conversation, nutrition intake, physical
activity, hypertension treatment, smoking and stress.
The present study aimed to determine the risk factors Nutrient intake was measured as the amount of energy,
for obesity complications in patients with hypertension carbohydrate, protein, fat and sodium consumed daily
aged 25–69 years in Bogor City in 2017. This study’s compared with dietary recommendations for people
results are expected to provide an evidence base for with hypertension (DASH).14 Intake of nutrients was
appropriate health programmes to prevent obesity in categorised as low (<90%), moderate (90% –119%) and
patients with hypertension. high ( ≥120%).15

Materials and Method Data processing involved cleaning and transforming

The present study was cross‑sectional in design data and was performed by univariate and bivariate using
and analysed secondary data from the ‘Cohort Study chi Square test with a 95% confidence interval (CI) (α =
of Non‑communicable Diseases’, conducted by the 0.05) and odds ratios (ORs).
National Institute of Health Research and Development,
Results
Republic of Indonesia, in Bogor City, Kebon Kelapa
Village, in 2017. This study’s population were all Characteristics of patients with hypertension:
patients with hypertension aged 25–69 years who were Analysis of nutritional status in patients hypertensive
respondents in 2017. Hypertension was defined as aged 25–69 years showed malnutrition in 1.6%, normal
systolic blood pressure >140 mmHg and/or diastolic nutrition in 35.3%, with 15.7% overweight and 47.4%
blood pressure >90 mmHg, doubling of blood pressure obese. The prevalence of hypertension was greatest
within 5 min under appropriate conditions, diagnosis (53%) among those aged 45–59 years (pre‑elderly). The
of hypertension by a health professional or undergoing incidence of hypertension was highest (72.6%) among
treatment for hypertension. A population of 489 patients females compared with males. Most (65.1%) patients
with hypertension aged 25–69 years was selected from with hypertension were of low education status. The
the ‘Cohort Study of Non‑communicable Diseases’, patients’ characteristics are presented in Table 1.

Table 1. Characteristics of patients with hypertension aged 25–69 years

Variables Category N %
Nutritional Status Underweight 5 1.6
(n = 312) Normal 110 35.3
Overweight 49 15.7
Obese 148 47.4
Missing 6
494 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Variables Category N %
Obesity No 164 52.6
(n = 312) Yes 148 47.4
Missing 6
Age (Years) 25–44 (adult) 67 21.1
(n = 318) 45–59 (pre‑elderly) 168 53.0
60–69 (elderly) 82 25.9
Gender Male 87 27.4
(n = 318) Female 231 72.6
Education status High 111 34.9
(n = 318) Low 207 65.1
Income Low 159 50.0
(n = 318) High 159 50.0

Source: Secondary data processed

Prevalence and risk factors for obesity in significantly related (p <0.05) and the risk factors for
patients with hypertension: The prevalence of obesity obesity in patients with hypertension were age, gender
in patients with hypertension was quite high (47.4%) and energy intake. Adult patients with hypertension
and was higher in females compared with males (51.5% aged 25–44 years showed a 2.43‑fold higher risk of
vs. 36.5%). Obesity in patients with hypertension mostly obesity compared with that of elderly patients (aged 60–
occurs in adulthood, from age 25 to 44 years. The 69 years), and pre‑elderly patients (aged 45–59 years)
prevalence of obesity was higher in patients with a low showed a 1.73‑fold higher risk of obesity compared
education status compared with those who were highly with that of elderly patients (aged 60–69 years). There
educated (50.2% vs. 42.3%). Nutrient intake in obese were 1.85 times more female than male patients with
hypertensive patients showed high energy (58.2%), hypertension. High energy intake in patients with
high carbohydrate (54.8%), adequate protein (61.4%), hypertension was 1.85 times higher than low energy
moderate fat (52.4%) and low sodium (50.3%) intake. intake. The results of the bivariate analysis of risk factors
for obesity in patients with hypertension are presented in
The bivariate analysis showed that factors were Table 2.

Table 2. Risk factors for obesity in patients with hypertension aged 25–69 years

Obesity
Total
Variables No Yes OR P‑value
N % N % N %
Age (years)
25–44 (adult) 28 42.4 38 57.6 66 100.0 2.433 0.009*
45–59 (pre‑elderly) 84 50.9 81 49.1 165 100.0 1.729 0.050*
60–69 (elderly) 52 64.2 29 35.8 81 100.0
Gender
Male 54 63.5 31 36.5 85 100.0
Female 110 48.5 117 51.5 227 100.0 1.853 0.025*
Education
High 64 57.7 47 42.3 111 100.0
Low 100 49.8 101 50.2 201 100.0 0.792 1.375
Income
Low 83 53.9 71 46.1 154 100.0
High 81 51.3 77 48.7 158 100.0 1.111 0.725
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 495

Obesity
Total
Variables No Yes OR P‑value
N % N % N %
Energy intake
Low 85 57.0 64 43.0 149 100.0
Moderate 40 50.0 40 50.0 80 100.0 1.328 0.308
High 28 41.8 39 58.2 67 100.0 1.850 0.039*
Carbohydrate intake
Low 91 54.2 77 45.8 168 100.0
Moderate 34 51.5 32 48.5 66 100.0 1.112 0.714
High 28 45.2 34 54.8 62 100.0 1.435 0.226
Protein intake
Low 129 54.2 109 45.8 238 100.0
Moderate 17 38.6 27 61.4 44 100.0 1.880 0.060
High 7 50.0 7 50.0 14 100.0 1.183 0.759
Fat intake
Low 51 55.4 41 44.6 92 100.0
Moderate 30 47.6 33 52.4 63 100.0 1.368 0.339
High 72 51.1 69 48.9 141 100.0 1.192 0.514
Natrium intake
Low 71 49.7 72 50.3 143 100.0
Moderate 33 55.0 27 45.0 60 100.0 0.807 0.487
High 49 52.7 44 47.3 93 100.0 0.885 0.648
Hypertensive medication
No 60 37.3 101 62.7 161 100.0
Yes 48 34.0 93 66.0 141 100.0 1.151 0.643
Type of hypertensive medication
Captopril 6 33.3 12 66.7 18 100.0
Amlodipine 35 32.1 74 67.9 109 100.0 1.057
Nifedipine 6 46.2 7 53.8 13 100.0 0.583
Bisoprolol 1 100.0 0 0.0 1 100.0 0.000 0.396
Low physical activity
Yes 50 32.7 103 67.3 153 100.0
No 59 40.4 87 59.6 146 100.0 0.718 0.205
Moderate physical activity
Yes 105 36.1 186 63.9 291 100.0
No 4 57.1 3 42.9 7 100.0 0.423 0.456
High physical activity
Yes 9 47.4 10 52.6 19 100.0
No 100 35.8 179 64.2 279 100.0 1.611 0.445
Smoking
No 121 51.7 113 48.3 234 100.0
Yes 43 55.1 35 44.9 78 100.0 0.872 0.695
Stress
No 144 52.0 133 48.0 277 100.0
Yes 11 52.4 10 47.6 21 100.0 0.984 1.000
* p < 0.05
Source: secondary data processed
496 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Discussion Excessive energy intake is related to obesity in

patients with hypertension and is associated with a
Our results indicate that the prevalence of obesity in
1.85‑fold increased risk of obesity compared with those
patients with hypertension aged 25–69 years in Bogor
with low energy intake. When energy intake exceeds
City in 2017 was high (47.4%). This high prevalence is
energy expenditure, a positive energy balance occurs,
in line with findings from previous studies by Ford et al.
leading to an increase in body mass. A 60% –80%
(2008), Qin et al. (2013) and Sartika (2015).8,9.10 The
increase in body mass is associated with an increase in
cause of obesity among patients with hypertension is
body fat.17 An imbalance between excess energy intake
multifactorial. The level of hypertension, socioeconomic
and output results in weight gain, both under normal
status, residential area, consumption of red meat,
conditions and in patients with hypertension.
physical activity, hypertension treatment, family
history of diabetes, hypertension and heart disease,
Conclusion
which is associated with obesity among people with
hypertension.9 The prevalence of obesity in patients with
hypertension aged 25–69 years in Bogor City in 2017
In the present study, risk factors for obesity was 47.4%. Risk factors that were significantly related to
complications in patients with hypertension were found obesity in patients with hypertension included age (adults
to be age, gender and energy intake. Residential area, aged 25–44 and pre‑elderly aged 45–59 years), female
consumption of red meat, family history of diabetes, gender and excessive energy intake (p = 0.009, 0.050,
family history of hypertension and family history of 0.025 and 0.039, respectively and OR = 2.43, 1.73, 1.85
heart disease could not be analysed due to limited and 1.85, respectively). The high prevalence of obesity in
secondary data. patients with hypertension is a health problem requiring
appropriate treatment since controlling weight gain is
The prevalence of obesity in patients with
fundamental to improving quality of life in patients with
hypertension was higher in adults aged 25–44 years than
hypertension. Our results are expected to be used to plan
in pre‑elderly (45–59 years) and elderly (60–69 years)
appropriate health programmes and prevent obesity in
patients. Under normal conditions, age is associated
patients with hypertension.
with obesity as metabolism decreases with age, which
increases the risk of obesity. However, in the present Conflict of interest statement: The authors declare
study with a population of patients with hypertension, that there is no conflict of interest.
adults (25–44 years) showed a higher risk of
complications of obesity that was 2.43‑fold higher than Ethical Clearance: The present study obtained
elderly (60–69 years) patients, whereas this value was approval from ‘The Research and community engagement
1.73‑fold higher in pre‑elderly (45–59 years) compared Ethical Committee Faculty of Public Health Universitas
with elderly patients. Indonesia’, Ket‑593/UN2.F10/PPM.00.02/2019.

The prevalence of obesity in female patients with Source of Funding: This study and publication were
hypertension was higher than that of males. These supported by Directorate of Research and Community
findings reveal a significant relationship between gender Service (Hibah PITTA), Universitas Indonesia, Depok,
and incidence of obesity in patients with hypertension. Indonesia.
Females with hypertension showed a 1.85‑fold higher
Acknowledgements: We would like to show our
risk of obesity compared with males with hypertension.
appreciation to the National Institute of Health Research
This study’s results are in line with those reported by Qin
and Development, Ministry of Health for giving us
et al. (2013).9 They conducted a study in Lianyuangang,
the opportunity to use datafrom the ‘Cohort Study
China from October 2008 to September 2009 and
of Non‑communicable Diseases’ and Directorate of
showed that the prevalence of obesity in females with
Research and Community Service, Universitas Indonesia
hypertension was higher than that of males.9 Females
for support funding.
are at greater risk of obesity since they generally have
more fat than males, including a higher amount of
References
subcutaneous fat and more fat deposits in the glutaeal–
femoral area or peripherals that determine the typical 1. World Health Organization. Noncommunicable
pear‑shaped female (peripheral or gynoid type obesity).16 disease. 2018.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 497
2. National Institute of Health Research and 10. Sartika RAD, Wulandari RA, Ompusunggu
Development. Indonesia basicHealth Research2018. IJ, Sutrisna B. Risk factors of dyslipidemia
Jakarta: Indonesian Ministry of Health; 2018. in hypertensive patients in selectedurban and
3. Staessen JA, WangJ, Bianchi G, Birkenhäger ruralareas in Indonesia. J Food Nutr Disord.
WH. Essential hypertension. Lancet. 2003; 2015;4(2).doi:10.4172/2324‑9323. PMID
361(9369):1629‑41. doi: 10.1016/S0140‑6736 1000168.11. Kincaid‑Smith P. Hypothesis: obesity
(03)13302‑8. PMID 12747893. and theinsulinresistancesyndromeplay a majorrole
in end‑stage renalfailureattributed to hypertension
4. FieldsLE, BurtVL, CutlerJA, HughesJ, RoccellaEJ,
and labelled‘hypertensivenephrosclerosis’. J
SorlieP. The burden of adulthypertension
Hypertens.2004;22(6):1051‑5. doi: 10.1097/00004
in the United States1999‑2000: Arisingtide.
872‑200406000‑00001. PMID 15167435.
Hypertension. 2004;44(4):398‑404. doi:
10.1161/01.HYP.0000142248.54761.56. PMID 12. ChannanathAM, FarranB, BehbehaniK,
15326093. ThanarajTA. Impact of hypertension on the
Association of BMI with Risk and Age at
5. KearneyPM, WheltonM, ReynoldsK,
Onset of Type 2 diabetesmellitus: age‑ and
MuntnerP, WheltonPK, HeJ. Global burden
gender‑mediatedmodifications. PLOSONE.
of hypertension: analysis of worldwidedata.
2014;9(4):e95308. doi: 10.1371/journal.
Lancet. 2005;365(9455):217‑23. doi: 10.1016/
pone.0095308. PMID 24743162.
S0140‑6736(05)17741‑1. PMID 15652604.
13. Indonesian Health Ministry. Pedoman Praktis
6. NCD RiskFactor Collaboration(NCD‑RisC).
Memantau Status Gizi Orang Dewasa; 2011.
Worldwide trends in blood pressure from 1975 to
2015: a pooled analysis of 1479 population‑based 14. United States Department of Health and Human
measurement studies with 19·1 million participants. Services. Your guide to lowering your blood
Lancet 2017; 389: 37–55. doi: 10.1016/ pressure with DASH. DAS Heating plan; 2006.
S0140‑6736(16)31919‑5.7. World Health 15. GibsonSR. Principal of nutritional assessment. UK:
Organization. Raised blood pressure. 2018. Oxford University Press; 2005.
8. FordES, ZhaoG, LiC, Pearson WS, MokdadAH. 16. Karastergiou K, Smith SR, Greenberg AS, Fried
Trends in obesity and abdominalobesity among SK. Sex Differences in Human Adipose Tissues–
hypertensive and nonhypertensiveadults in the the Biology of Pear Shape. Biol Sex Differ.
United States. AmJ Hypertens. 2008;21(10):1124‑8. 2012;3(1):13. doi: 10.1186/2042‑6410‑3‑13. PMID
doi: 10.1038/ajh.2008.246. PMID 18772861. 22651247.
9. QinX, ZhangY, CaiY, HeM, SunL, FuJ, LiJ, 17. HillJO, WyattHR, PetersJC. Energy balance and
WangB, XingH, TangG, WangX, XuX, XuX, obesity. Circulation. 2012;126(1):126‑32. doi:
HuoY. Prevalence of obesity, abdominalobesity 10.1161/CIRCULATIONAHA.111.087213. PMID
and associated factors in hypertensiveadultsaged 22753534.
45‑75 years. ClinNutr. 2013;32(3):361‑7. doi:
10.1016/j.clnu.2012.08.005. PMID 23084742.
498 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

The Role of Social Support on Coping Stress in Type‑2

Diabetes Mellitus Patients with Gangrene Complications

Ayu Aisah Zuraidah1, Arif Nur Muhammad Ansori2, Suhailah Hayaza3,

Ilham Nur Alfian1, Suryanto1, Nurul Hartini1
1Facultyof Psychology, Universitas Airlangga, Kampus B Universitas Airlangga, 60286, 2Faculty of Veterinary
Medicine, Universitas Airlangga, Kampus C Universitas Airlangga, 60115, 3Faculty of Science and Technology,
Universitas Airlangga, Kampus C Universitas Airlangga, 60115

Abstract
This study aims to identify how the type of coping stress strategy for the type‑2 diabetes mellitus patients,
who experienced gangrene complication. Coping stress strategy is an efforts strategy to overcome feelings
of stress due to illness. Coping stress strategy in this study is divided into two types, namely problem‑solving
effort, and emotion‑focused coping. The method used in this study was a qualitative approach by taking
three people with type‑2 diabetes mellitus and complications of gangrene as participants. The method used
for selecting the participants was a purposive approach. The data were collected using structured interviews
and field notes. The data was analyzed by using thematic analysis with a theory‑driven approach. The
result shows that the three participants had a coping stress strategy to heal their stress while experiencing
diabetes and gangrene complication. Patients were able to cope well with stress control routine, change
their eating patterns, look for information on diabetes mellitus, and exercise regularly. Patients also got
supports from professionals, family, and friends. Coping stress strategy techniques for each different subject
depend on their surroundings. This study found that there is three dominant coping stress strategy chosen
by the patients which are the planful problem solving and the seeking social support that belongs to the
problem‑solving effort section, and the positive appraisal section that belongs to the emotion‑focused coping
section. However, three patients also performed stress diversion, called escape/avoidance, to cope with their
stress.

Keywords: coping stress strategies, type‑2 diabetes mellitus patients, gangrene complication.

Introduction that they had diabetes mellitus, there would be concern

inside his/her mind about what they will face later. This
Diabetes mellitus is one of the chronic diseases
will lead them to stress stage. The emotions of denying,
that have an increased number of patients and become a
obsessed, anger, and frustration become the main reasons
major public health problem worldwide[1]. According to
that eventually can cause stressfulness. This condition
the World Health Organization, in 2010 the number of
will give a negative impact on his/her body[4].
people with diabetes mellitus in the world has reached
271 million[2]. In 2010, Indonesia was at the 4th rank Rustini describes that diabetes mellitus type 2
globally with 8 million diabetes patients[3]. Diabetes patient that experience gangrene complication has go
mellitus is differentiated into type 1 and type 2[4]. through changes in his/her life behaviour, start from
dietary habit, physical exercise, blood sugar control,
Type‑2 diabetes mellitus causes helpless feeling to
gangrenous wounds treatment, etc that will happen
its patient, a feeling that appears because he/she cannot
throughout life with patience and in order to make his/
change his/her future anymore. This feeling arises based
her condition stable. Furthermore, patient will suffer
on many causes, such as uncertain health condition,
physical regression. Gangrenous wounds condition will
added with recovery and recurrence and also physical
get worse and rot[6].
regression[5]. Psychologically, when the patient knew
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 499
Anggraeni and Cahyanti stated that one way to cope was used to fully understand the case without making
with psychological stress that diabetes mellitus patient new concepts or theories or any generalizations[11].
had is by using a management strategy done by the
patient. With this stress management strategy, people The participants were appointed purposively, which
with diabetes mellitus, especially those who experience means the selection of participants was based on meeting
gangrenous complications, will be able to develop their certain criteria. The participants were typed 2 diabetes
own experiences about their disease including emotional mellitus patients who have gangrene complication.
and cognitive aspects which will ultimately help them to Participants were gone through a screening test using an
decide which stress management strategy is suitable for instrument by Sarafino. This instrument would help to
him/her to handle the stress[7]. find which participants have the lowest stress level, that
later would be interviewed on how they use their stress
Stress management strategy is a process to management strategies that make them survive until
resolve many demands both internally and externally, now. The participant criteria in this study were type‑2
which exceed capacity from the patient. The stress diabetes mellitus patients who experience gangrenous
management strategy refers to various efforts, both complications, 40‑60 years old, have diabetes mellitus
mental and behavioral, to master, tolerate, reduce, and gangrenous complications for more than 5 years,
or minimize a stressful situation or event[8]. A study and passed the screening test. The data was collected
conducted by Vázquez et al. about stress management using interview and field notes. The interview was
strategy showed that optimistic individuals performed guided by general guidelines. These general guidelines
problem‑solving effort directly in dealing with stressful were used to remind the interviewer about the questions,
events and problems associated with their health which and as a checklist for whether the aspects discussed and
in the end will affect their self‑care and healing process asked was relevant or not. This research used thematic
in the future[9]. Rohmah et al. on her research on coping analysis. Thematic analysis is an information coding
mechanisms said that a good combination of both stress process which produces topic lists, topic models and
management strategies, namely problem‑solving effort, related qualification[12].
and emotion‑focused coping, would provide good
results in improving the life quality of people with Results
diabetes mellitus. Understanding of how to regulate In this research, there were various reactions from
diet, treatment, and self‑acceptance, as well as the social diabetes mellitus patient with gangrene complication, for
support from family and surrounding is a strategy of the example; shocked, disappointed, and depressed because
diabetics which makes their life better[10]. his/her incomplete feet, pulling themselves from society
Until today, research about psychological stress and becoming helpless. We also found that this disease
condition of a diabetic patient who suffers gangrene not only caused patients to lose physically but also
complication is still rarely found. Whereas, the data psychologically. A patient who has stress experience
compiled by Rustini shows that the percentage of diabetic because of this disease can also be found in this research.
patients with gangrene complication has reached 50% of Initially, after suffering from gangrene complications
the total number of people with diabetes[6]. Therefore, it and having to be amputated, diabetics could not accept
is important to make a research to find what type from the condition and often felt anxious about their current
the stress management strategy that the type‑2 diabetes physical limitations. On their attempts to accept the
mellitus patients with gangrene complication use. reality they used stress management strategy in the form
of confrontative coping. They did a lot of confrontative
Materials and Method coping efforts such as not wanting to be taken to the
hospital, lying to cover up their actual foot and physical
This study is a qualitative research with an intrinsic condition to the doctor, and also not wanting to be
case study. Through a case study approach, the researcher amputated. Because of that, one of the patients had to
could get a bold and integrated understanding of a special go through longer treatment because he/she refused to
case. The special case was related to the individual. get amputated.
The type of case study used for stress management
strategy research on type 2 diabetes mellitus patient with Diabetics also need support from people around
gangrene complication was intrinsic case stud. This type them. Social support is one of the indicators of the
500 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
stress management strategy from the problem‑solving up. Patients also tried to get closer to God by increasing
dimension, called seeking social support. Social support worship and pray. They felt relieved after poured out
from the surroundings is very much needed to motivate all his heart during their prayers. It helped him/her to
the patients in order to recover. Without it, they might be calmer and less stressful in living his/her life. These
not survive until now. The types of social support that positive appraisals helped the patients to relax and get
are received and needed by each person with diabetes optimal treatment. These patients have also done stress
are actually the same, but they also depend on the coping strategies in the form of accepting responsibility.
individual character and the environment. Patients with In this study, the action of accepting responsibility was
diabetes mellitus who have a supportive family would shown by acknowledging their diet mistakes which have
tend to ask help from their children and their partners, led them to experience diabetes mellitus and gangrenous
while patients who are closer to their friends would tend complications.
to ask support from friends. Patients admitted that social
support from people around them has enhanced their Discussion
spirits during their treatment. Diabetics with gangrene Even though they have good planning to maintain
complication also have long‑term plans to maintain their condition, diabetics with gangrene complication
their condition, focusing on how to heal the wound, to have also been in a condition where he/she is truly
prevent stress, and to stay healthy. This step is included saturated with all the medical routines he/she has been
in a stress management strategy, specifically belongs to doing. This is a stress diversion called escape/avoidance.
the problem‑solving effort dimension, and called planful In this study, it was found that the patients tried to divert
problem‑solving. The action of planful problem solving stress by imagining a condition where he/she was not a
performed by the patient, in this case, was shown by person with diabetes mellitus. As explained above the
doing treatment and taking medication regularly. The patient was an active person, with the current situation
other actions were shown by running diabetic diets to sometimes they really wanted to feel normal like before.
maintain blood sugar levels, fasting, consulting to a The patient also forgot to eat the diet that was suggested,
doctor, and treating the wounds regularly. These patients even though he/she knew that the food was not good
also learned about their disease in order to understand for his/her health. The stress management strategy in
what to do with it. this study used the basic strategy described by Taylor.
In this study, diabetics with gangrenous Stress management strategies are divided into 2 types,
complications also had a stress management strategy in namely problem‑solving effort, and emotion‑focused
the form of self‑control to deal with stress due to their coping that will be done by everyone when experiencing
illness. It was found that self‑control performed by the a stressful experience. In this study, diabetics with
patients by not telling their problem if they could solve gangrene condition used both stress management
it themselves. They tried to sort out what things need strategies to manage their stress. Problem‑solving effort
to be told and what to be handled by their own. The is an attempt to do something constructive to overcome a
next stress management strategy that these patients used situation that creates social stress, including an adverse,
was distancing. It was found that the distancing was dangerous or challenging event faced by an individual.
performed by not to overly think about their illness and Meanwhile, emotion‑focused coping is an attempt to
not to mourn about it. Patients tried to prevent stress by regulate the emotions felt by individuals while facing
assuming that everything has its time. social stressful event. In this study, we found that
there were three biggest stress management strategies
In this study, it was found that diabetics with performed by the three patients. In the problem‑solving
gangrene also carried out stress management strategies effort section, there were the planful problem‑solving
in the form of positive appraisal. The positive appraisal actions and the seeking social support actions. While
done by the patients was by being grateful to be able to in the emotion‑focused coping section, there were
survive until now and trying to find a positive meaning positive appraisal actions. These means that the three
behind their situation. Patients also had an inspiration patients focused on their plans to solve the problem,
that makes them optimistic to be recovered. They had their steps to overcome the wound condition so that
goals and had known what was important in their lives, they could prevent stress condition. After that, the three
for example, patients were eager to be healthy because patients surrendered entirely to God. All of them agreed
they wanted to see their children succeeded and grew to surrender themselves and looked for the positive
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 501
meaning behind their current situation. They were aware References
of their priorities at the moment and not focusing on their
1. Husen SA, Khaleyla F, Kalqutny SH, Ansori ANM,
sadness. The third is a stress management strategy that
Susilo RJK, Alymahdy AD, Winarni D. Antioxidant
will not succeed without the support of people around
and antidiabetic activity of Garcinia mangostana L.
the patient[8]. This support makes the patient strong and
pericarp extract in streptozotocin‑induced diabetic
eager to go through the day as well as motivates them to
mice. Bioscience Research. 2017;14(4): 1238‑1245.
be healthy and healed. This support comes from family,
neighbors, friends, and people closest to the patients, 2. World Health Organization. Diabetes. Available
including medical personnel. from: https://www.who.int/diabetes/en/[Accessed
28th February 2019].
Conclusion 3. Arisman. Textbook on Nutrition Obesity, Diabetes
Mellitus, and Dyslipidemia. Jakarta: Penerbit EGC;
Diabetes mellitus is not only caused by genetic
2017.
factors. All the three patients in this study, despite
having the genetic factors, they also did not maintain 4. Evans JL, Goldfine ID, Maddux BA, Grodsky GM.
their diet well. It was this diet that eventually led them to Are oxidative stress‑activated signaling pathways
have diabetes mellitus and gangrene complications. The mediators of insulin resistance and beta‑cell
three patients showed different performance on handling dysfunction?. Diabetes. 2003;52(1): 1‑8.
stress using stress management strategies. There were 5. Satiadarma MP. Hostility and chronic diseases.
three biggest stress management strategies performed in Jurnal Psikologi Ilmiah. 2003;8(1): 1‑14.
this study: the planful problem solving and the seeking 6. Rustini SA. Effect of Coping Strategy and
social support which belongs to the problem‑solving Complications of Gangrene on Stress Levels in
effort section, and the positive appraisal section which Diabetes Mellitus Patients (Case Study: Adi Husada
belongs to the emotion‑focused coping section. The Hospital Kapasari Surabaya). Master Thesis.
strategies focused on how they plan to solve the problem, Surakarta: Universitas Sebelas Maret; 2014.
what steps they must take to overcome the wound
7. Anggraeni T, Cahyanti IY. Difference of
condition, and then surrender entirely to God. All three
psychological well‑being on middle age adult with
patients looked for the positive meaning behind their
type 2 diabetes based on coping strategy. Jurnal
current situation and were aware of their priorities at
Psikologi Klinis dan Kesehatan Mental. 2012;1(2):
that moment. Then, those strategies would not succeed
86‑93.
without the support of people around the patient. This
support made the patient strong and motivate them to 8. Taylor SE. Health Psychology. 4th Ed. New York:
heal. The support came from family, neighbors, friends, McGraw‑Hill Higher Education; 2017.
and people closest to the patients, including medical 9. Vázquez C, Hervás G, Rahona JJ, Gómez D.
personnel. There was a difference regarding which was Psychological well‑being and health. Contributions
the most dominant stress management strategy used of positive psychology. Annuary of Clinical and
by each patient. The difference is caused by how the Health Psychology. 2009;5: 15‑27.
environmental conditions where the patient live. 10. Rohmah DH, Bakar A, Wahyuni ED. The coping
mechanism in diabetic patients in internal division
Conflict of Interest: The authors declare that they
RSUD dr. Soegiri Lamongan. Critical, Medical &
have no conflict of interest.
Surgical Nursing Journal. 2012;1(1).
Source of Funding: No source of funding for this 11. Poerwandari EK. Qualitative Approach to Human
study. Behavior Research. Jakarta: LPSP3 Universitas
Indonesia; 2017.
Ethical Approval: No ethical approval is needed.
12. Sarafino EP. Health Psychology: Biopsychosocial
Interactions. 6th Ed. USA: John Wiley & Sons;
2017.
502 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

The Relationship of Work Instructions Compliance with

Safe Behavior of Production Part Workers in PT X

Ayu Prima Kartika1, Windi Wulandari2, Noeroel Widajati1, Abdul Rohim Tualeka1
1Department of Occupational Health and Safety, Faculty of Public Health, Airlangga University,
2Department of Public Health, Faculty of Health Sciences, Muhammadiyah Surakarta University, Indonesia

Abstract
Metal casting industry which is having high risk to work accidents and have applied work instructions (IK)
to all unit working parts. Based on preliminary survey in PT X the level of work instructions compliance
is 70% and 80% of workers safe behavior. The majority of workers work instructions compliance and safe
behavior, but there are still workers did not compliance with work instructions and safe behavior. This
study aimed to analyze the relation of work instructions compliance with safe behavior of production part
workers in PT X. The kind of research is quantitative observational with cross sectional analytic approach
that studies the relationship independent variabel with dependent variabel. The research population is all
labor production section in PT X many as 74 people with the sample many as 48 people has been present
working on the research day. The results of the fisher’s exact test showed (p=0,03) < 0,05 which means
Ho rejected so that there was a correlation between work instructions compliance with safe behavior at
production line workers in PT X. Conclusions of the study, that there is a significant relation exsist between
work instructions compliance with safe behavior. Advice for the company are to be able to establish P2K3,
hold an inspection formal and informal.

Keywords: Work instructions compliance, safe behavior.

Introduction accidents compared to 2014 which amounted to 2,549

work accidents3.
The development of industrialization and
modernization is increasingly rapid resulting in Accident events based on data, facts and experience
increased operational work intensity, so that there are are a series of events because of the potential for
various impacts such as fatigue, loss of balance, lack interrelated hazards, workplace accidents can be
of skills, lack of knowledge about sources of danger caused by work or unsafe actions such as those related
are the causes of accidents and work‑related diseases to protective machinery, can be moved or modified
that can affect company performance8. Manpower, sequences, work indoors withbad lighting and so on.In
Transmigration, and Population offices of the Central various studies of workplace accidents dangerous
Java Provincial Government noted an increase in work behavior is an important indicator7,10.
accident data in 2015 which amounted to 3,083 work
There is a significant relationship between
compliance with work instructions and safe behavior
obtained p value of 0.01 <0.05 which indicates the
Correspondence Author:
relationship of compliance with work instructions and
Abdul RohimTualeka
safe behavior is being at the mechanical part employees
Department of Occupational Health and Safety, of PT Y1.
Faculty of Public Health, Airlangga University, 60115
Surabaya, East Java, Indonesia PT X has applied Work Instruction (IK) to all work
e‑mail: [email protected] or units. All work process activities and actions are carried
abdul‑r‑[email protected] out daily based on abbreviated work instructions (IK)
Handphone: +6281333519732 which are supervised by each section head. Based on the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 503
results of the preliminary survey in the production section workers. age is directly proportional to one’s
of PT X the level of compliance with work instructions physical capacity and reaches its peak at the age of 25
was 70% and as much as 80% of workers behaved years, increasing age will be followed by a decrease
safely. Most workers obey work instructions and work in physical capacity such as sharpness of vision,
safely, but there are still workers who do not comply hearing, speed of distinguishing things, making
with work instructions and behave unsafe. Based on this decisions and the ability to remember. Production
background, researchers are interested in knowing the workers at PT X are almost all productive and can
relationship of work instructions compliance with safe work well8.
behavior of production part workers in PT X.
2. Work Period of Respondents: The number
of workers with the highest working period of
Material and Method
production at PT X for a very long working period
This type of research is an observational quantitative is 37.5% and the number of workers with the least
study using an analytical cross sectional approach that working period during the long service period is
studies the relationship of independent variables, namely 10.4%. a long working period can have an influence
work instructions compliance with dependent variables, on the experience of workers so that the longer the
namely safe behavior that is assessed and measured working period, the experience they have will be
simultaneously in one time5. more and more mature and vice versa2,4. Most of the
workers in the production of PT X have very long
The population of this study is that all the production
working hours so that they have good experience
workforce in PT X numbered 74 people with a minimum
and skills that can support the smooth running of
sample size of 43 people and at the time of the study a
the work and can complete their tasks quickly and
total of 48 workers were present and were willing to be
precisely.
studied. The independent variable is work instructions
compliance using the obedient category ≥ mean and
<mean for the non‑compliant category and the dependent
variable for safe behavior using the safe category ≥ mean
and<mean for the unsafe category. Using univariate and
bivariate analysis with the provisions of the chi‑square
test, namely the null hypothesis (Ho). If p value <0.05,
then Ho is rejected and if p value is ≥ 0.05 then Ho is
accepted.

Findings:
1. Age of Respondents:

Figure 2. Work Period

3. Education of Respondents: From the table

known that the majority of workers with high
school education or equal to 70.8%, and only 2.1%
of workers who did not go to school or did not
complete elementary school. education is important
in dealing with technological developments, so
workers can use and maintain it if damage occurs.
Based on research, production department workers
at PT X have mastered the work they are doing,
Figure 1. Age of Respondents
skillfully and skillfully using equipment, and
Most of the production workers at PT X were in processing materials such as printing sand without
the early age, 33.3% and only 2.1% were elderly mold, pouring steel liquid in the production process,
where education is needed in this case because of
504 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
the accuracy in calculations when pouring hot steel Behavior
liquid, it must be measured correctly8. Work Period Total
Safe Unsafe
Table 1. Education of Respondents 8 3 11
Long enough
16,65% 6,25% 22,9%
Behavior 4 1 5
Age Total Long
Safe Unsafe 8,32% 2,08% 10,4%
Late teens 2 0 2 13 5 18
Very long
Early adult 10 4 14 27,08% 10,42% 37,5%
Late adult 9 3 12 35 13 48
Total
72,91% 27,09% 100%
Early elderly 12 4 16
Late elderly 2 1 3 6. Education with Safe Behavior: The biggest
Seniors 1 0 1 workers with high school education were 52.06%
Total 36 12 48 who behaved safely but still had workers who did
not behave safely with a high school education of
4. Age with Behavior: Most of the workers who 18.74%.
behave safely are in the early age, which is 25%, with
early aged workers who behave unsafe at 8.3%. age Table 4. Education with Safe Behavior
is directly proportional to one’s physical capacity Behavior
and reaches a peak at the age of 25 years, increasing Education Total
Safe Unsafe
age will be followed by a decrease in physical
1 0 1
capacity such as sharpness of vision, hearing, speed No school
2,1% 0,0% 2,1%
of distinguishing things, making decisions and the
Graduated from 7 2 9
ability to remember8. elementary school 14,6% 4,2% 18,8%
Table 2. Age with Behavior Graduated from junior 3 1 4
high school 6,2% 2,08% 8,3%
Education Frequency Percent (%) Graduated from high 25 9 34
No school 1 2,1 school 52,06% 18,7% 70,8%
Graduated from elementary 36 12 48
9 18,8 Total
school 74,98% 25,02% 100%
Graduated from junior high
4 8,3
school 7. Working Conditions: Working conditions in the
Graduated from high school 34 70,8 production section of X can be seen that 100%
Total 48 100 of respondents observed work in safe working
conditions.
5. Work Period with Behavior: Most workers who
behave safely enter a very long working period of Table 5. Working Conditions
27.08%, but there are still those who behave unsafe
Working Condition Frequency Percent (%)
at 10.42% even though they have entered a very
Safe 48 100
long working period.the longer a person’s working
Unsafe 0 0
period, the more experience he has and the more
Total 48 100
mature he has, but there are still those who do not
behave safely because they already feel experienced 8. Work Instructions Compliance: Work instructions
and skilled in doing work4. compliance for the production workforce of PT
Table 3. Work Period with Behavior X amounting to 71% of respondents obeying
work instructions while 29% of respondents did
Behavior not comply with work instructions given by the
Work Period Total
Safe Unsafe company.
10 4 14
New Most workers have complied with the work
20,86% 8,34% 29,2%
instructions well even though there are no officers
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 505
who supervise, such as checking equipment before
use, writing work reports that have been completed,
using personal protective equipment arranged in
work instructions such as glasses, earplugs, masks,
clothes protectors, gloves, shoes. They follow work
instructions correctly because they understand that
they work with considerable danger, namely the risk
of being exposed to melt and hot steel splashes, but
there are still workers who are not obedient such
as not checking the equipment to be used first, not
using personal protective equipment when work
because workers reason that when using personal
protective equipment they will feel uncomfortable
Figure 4. Safe Behavior
and disrupt their activities, that is, they are not free.
10. Relationship between Work Instructions
compliance with Safe Behavior: The results of
the chi‑square statistic test showed that the use of
the chi‑square test was not fulfilled because there
was an expeted value <5 so that using the value of
fisher’s exact test, the results of fisher’s exact test
showed p value of 0.03 <0.05 which means that Ho
was rejected between compliance with safe conduct
of work instructions for production workers at PT
X. Statistical test results, the correlation between
work instructions compliance with safe behavior
produces a number of 0.29, the figure shows a low
correlation level6.
Based on the results of statistical tests, it was found
that production workers at PT X were observed,
Figure 3. Work Instruction Compliance
workers who obeyed work instructions and behaved
9. Safe Behavior: The safe behavior of production safely were 52.08%, workers who did not comply
workers at PT X at 73% of workers behave safely with work instructions but behaved safely were
while 27% of workers who do not behave safely 20.83%, obedient workers work instructions but
when working. not as safe as 18.75%, workers who do not comply
with work instructions and do not behave safely are
Workers behave safely such as using personal 8.34%.
protective equipment even though they are not
supervised, use equipment according to their This research is in line with previous research
functions, do not joke while working, but based that there is a relationship of work instructions
on research there are still workers who behave compliance with safe behavior on employees of
unsafe such as smoking in the work area, black sand the mechanical part of PT Y with a p value of 0.01
workers who do not use protective equipment self <0.051. and there is a relationship between the
at all, do not use personal protective equipment that practice of applying the SOP with the incidence of
is complete using earplugs, gloves but do not use workplace accidents and the practice of nurses with
glasses when welding, unsafe work positions such a p value of 0.0029.
as working positions for too long squatting and It is known from statistical tests that the more
bending when forming sand resulting in back pain, obedient to work instructions, the workers tend
exposed to sparks during the induction process and to behave safely in the workplace. Workers at PT
when pouring steel liquid into the mold. X who are obedient to work instructions realize
that the importance of work instructions to be
506 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
understood and adhered to because they know they There is a significant relationship between work
work in a place that is at high risk for accidents and instructions compliance and safe behavior of production
by behaving safely such as using personal protective part workers in PT X.
equipment that is using glasses, earplugs, masks,
Conflicts of Interest: All authors have no conflict
protective clothing, shoe gloves so that they can
interest to declare.
protect them while working.
Source of Funding: The source of the research cost
But there are still workers who do not comply with
from self.
work instructions because they feel familiar with
the work done such as not checking equipment to Ethical Clearance: The study was approved by
be used, not using personal protective equipment, the institutional Ethical Bord of the Muhammadiyah
then behaving unsafe such as smoking in work Surakarta University, Faculty of Health Sciences, Public
areas because there are no sanctions directly given, Health Study Program.
no using personal protective equipment based on All subjects were fully informed about the
research workers reasoned uncomfortable and procedures and objectives of this study each subject
felt complicated when they had to use personal prior to the study signed an informed consent form.
protective equipment and they used personal
protective equipment completely only when there References
was a visit.
1. Aisha. Compliance relations with Behaviors Safe
Table 6. Relationship between Work Instructions Work Instructions in Section Mechanics Employees
compliance with Safe Behavior PT. X. [Thesis Scientific]. Surakarta: Faculty of
Health Sciences, University of Muhammadiyah
Behavior Surakarta; 2016.
Compliance Total P/r
Safe Unsafe
2. Badeni. Leadership and Organizational Behavior.
25 9 34
Compliance Bandung: Alfabeta; 2013.
52,08% 18,75% 70,83%
10 4 14 3. Transmigration and Manpower Office. Monitoring
Uncompliance 0,03/0,29 Labor. Transmigration and Manpower Office of
20,83% 8,34% 29,17%
35 13 48 Central Java Province; 2016.
Total
72,91% 27,09% 100% 4. Fahmi. Organizational Behavior (Theory,
Applications, and Case). Bandung: Alfabeta; 2016.
Conclusion 5. Notoatmodjo. Health Research Method. Jakarta:
Base on the result of the study it can be concluded Rineka Copyright: 2012.
that the Most of the production workers at PT X are in 6. Sugiyono. Research Method Combined (Mixed
the early age, which is 33.3% and those who behave Method). Bandung: Alfabeta; 2014.
safely for the early elderly are 25%. The working 7. Tarwaka. Basics Safety And Prevention of
period of most production workers has entered a very Accidents in the Workplace. Surakarta: Hope
long working period of 37.5% and workers who enter Press; 2012.
very long work periods behave safely at 27.08%. Most
8. Tarwaka. Occupational Health and Safety
of the workers have high school education or equal to
Management and Implementation K3 at Work
70.8% with workers with high school education who
(Issue 2). Surakarta: Hope Press; 2014.
behave safely at 52.06%. 100% safe working conditions,
namely the work area free from garbage, there are no 9. Wijayanti. Relations Practice Implementation of
water spills on the floor, there are label items, equipment the Standard Operating Procedure (SOP) and the
used in good condition, personal protective equipment is use of Personal Protective Equipment (PPE) by
available in good condition, there are hygiene facilities, Genesis Accidents In Perinatology Unit Nurses in
and there is a first aid kit in each part of the work. hospitals Tugurejo Semarang. [Thesis Scientific].
Workers who adhere to work instructions based on the Semarang: Medical Faculty of the University of
results of the study are 71%.Workers who behave safely Dian Nuswantoro Semarang; 2014.
are based on the results of research, which is 73%. 10. Winarsunu. Psychology Safety. Malang: UMM
Press; 2008.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 507

The Relationship of Age and Work Period with Hearing

Disorders on Workers Which are Exposed to Noise Above
Threshold Limit Value of Loom Part Weaving Ajl Department
in Pt Bintang Asahi Tekstil Industry

Bella Oktavia1, Rezania Asyfiradayati2, Abdul Rohim Tualeka1

1Department of Occupational Health and Safety, Faculty of Public Health, Airlangga University,
2Department of Public Health, Faculty of Health Sciences, Muhammadiyah Surakarta University, Indonesia

Abstract
The production process at Loom part Weaving AJL Department PT Bintang Asahi Textile Industry using
machines with loud noise can cause noise and the risk of causing hearing loss for workers. PT Bintang Asahi
Textile Industry been providing a blob ear protective devices threads to protect workers from exposure
to noise. But the level of awareness of workers are still lacking in the use of PPE compliance. This study
aimed to analyze the relationship between length of service and age with hearing loss of workers exposed
to noise> Threshold Limit Value on the Loom Weaving Department AJL PT Bintang Asahi Textile Industry.
This research uses a quantitative research design with cross sectional analytic. The population in this study
were working Loom part Weaving AJL Department with a sample of 71 respondents taken by simple random
sampling. Data analysis used Product Person. The results showed no relationship between age and hearing
loss of workers part Loom Weaving Department AJL (p = 0.0001), there is a correlation between working
period with a hearing loss of workers Loom part Weaving AJL Department (p = 0.0001).

Keywords: Age, years of service, hearing loss, noise.

Introduction A person’s hearing power in capturing sound is

influenced by internal and external factors. Of the
Occupational hazards are classified into several
various factors that can affect the hearing threshold, the
types, one of which physical hazards such as noise.
most prominent in internal factors are age and external
Noise that exceeds the threshold value >85 dBA can
factors, namely the length of exposure to noise2. Based
cause hearing loss. Hearing loss is directly proportional
on research, results showed no correlation with age and
to age, and reaches its peak at the age of 25 years, with
years of hearing threshold value of workers exposed to
increasing age it is followed by a decrease in physical
noise in the Steel Melting Shop production unit of PT.
capacity such as decreased hearing1.
X Sidoarjo3.

PT Bintang Asahi Textile Industry or in short with

PT BATI is a company that is in the area of Sragen and
engaged in the textile field. The production process
Correspondence Author:
at PT BATI using machines that could potentially
Abdul Rohim Tualeka
cause noise, one of its engines on the Loom Weaving
Department of Occupational Health and Safety,
AJL Department. Workers in the Loom Weaving AJL
Faculty of Public Health, Airlangga University, 60115 Department work for 8 hours in a day.
Surabaya, East Java, Indonesia
e‑mail: [email protected] or Based on the preliminary survey to measure the
abdul‑r‑[email protected] noise level at the Loom at two points, the result of
Handphone: +6281333519732 measurement exceeds the threshold limit value (85 dBA).
508 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
At a noise level of >85 dBA after a 10‑year work period Measuring Point Noise Measurement Result (dBA)
workers will experience hearing loss4. While the results Point IV 87.77
of interviews with 15 workers Loom part Weaving AJL Point V 87.88
department in PT Bintang Asahi Textile Industry with Average 87,45
tenure below 10 years, there were seven workers have
a hearing loss. The purpose of this study was to analyze Based on Table 1, results in the lowest measurement
the relationship between age and years of service to the point 1 to the value of 86.93 dBA. While the results of
hearing impaired workers exposed to noise exceeding the highest measurement at the point to 5 with a value of
the threshold limit value at the Loom part Weaving AJL 87.88 dBA. With an average overall measurement result
Department in PT Bintang Asahi Textile Industry. is 87.4 + 0.325. The results of measurements of noise at
the Loom part Weaving AJL department Textile Industry
Research Method PT Bintang Asahi show all >85 dBA, these results do
This type of research is quantitative analytic using not match or exceed the Threshold Limit Value has been
cross sectional design. The population in this study determined.
were all employees of section Loom part Weaving AJL Table 2. Age of Respondents
department in PT Bintang Asahi Textile Industry with
the number of 156 workers and obtained a sample with Respondents Age Frequency Percent
the number of 71 respondents. The sampling technique 28 4 5.6
in this study is simple random sampling where each 29 1 1.4
population has the same chance to be selected as a 30 3 4.2
sample. 31 1 1.4
32 6 8.5
The variables in this study consisted of two
35 1 1.4
variables, namely the independent and dependent
variables. The independent variables in this study were 36 1 1.4
age and years of service workers Loom part Weaving 37 1 1.4
AJL department, and the dependent variable in this 38 1 1.4
study is hearing impaired workers Loom part Weaving 39 2 2.8
AJL department. While confounding variables were 41 2 2.8
measured in this study is the intensity of the noise at the 42 9 12.7
Loom part Weaving AJL department. 43 1 1.4
44 7 9.9
Collecting data on age and years of using a
45 4 5.6
questionnaire, hearing loss using audiometric tool and
46 1 1.4
noise using a sound level meter. The research was
47 2 2.8
conducted during the hours after work in accordance
48 7 9.9
with the work shift respondents. For the morning shift it
49 2 2.8
takes place at 14.00, for the afternoon shift at 22.00, and
50 1 1.4
the night shift at 06.00. while the noise measurement was
51 2 2.8
carried out at 10:00. Data analysis using computerized
statistical programs included univariate analysis and 52 5 7.0
bivariate analysis. 54 1 1.4
62 1 1.4
Findings: Total 71 100

Table 1. Measurement Method Based on Table 2, the oldest age is 62 years only one
person with a percentage of 1.4%, while the youngest
Measuring Point Noise Measurement Result (dBA)
age is 28 years and as much as 4 respondents with a
Point I 86.93
percentage of 5.6%. The average age of respondents
Point II 87.25
overall was 41.80 + 7.5 years.
Point III 87.46
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 509
Table 3. Respondents Work Period Listen Threshold (dB) Frequency Percent
28.12 2 2.8
Years of Service Respondents Frequency Percent
28,50 1 1.4
3 6 8.5
28.75 2 2.8
4 3 4.2
28.87 1 1.4
5 1 1.4
30.00 1 1.4
6 3 4.2
30.62 1 1.4
7 5 7.0
30.87 1 1.4
8 7 9.9
31.25 1 1.4
9 3 4.2
32.30 1 1.4
10 5 7.0
32,50 2 2.8
11 6 8.5 33.12 2 2.8
12 5 7.0 33.75 2 2.8
15 5 7.0 34.37 2 2.8
16 5 7.0 35.00 2 2.8
17 3 4.2 35.62 1 1.4
18 10 14.1 36.87 1 1.4
19 1 1.4 37.50 1 1.4
20 1 1.4 38,12 1 1.4
23 1 1.4 38.75 1 1.4
27 1 1.4 39.37 2 2.8
Total 71 100 40.62 1 1.4
41.12 1 1.4
Based on Table 3, the longest tenure at 27 years
41.25 1 1.4
only 1 respondent with a percentage of 1.4%, while the
41.87 1 1.4
most recent period of employment is 3 years as many as
43.12 2 2.8
6 respondents with a percentage of 8.5%. The average
tenure is 11.58 + 5,518 years. 43.75 1 1.4
44.75 1 1.4
Table 4. Hearing loss respondents 45.00 1 1.4
46.87 1 1.4
Listen Threshold (dB) Frequency Percent
47.50 1 1.4
7.50 2 2.8
49.37 3 4.2
8.75 3 4.2
52,50 1 1.4
9.37 1 1.4
54.37 1 1.4
10,00 1 1.4
54.95 1 1.4
10.62 4 5.6
56.25 1 1.4
11.00 1 1.4
68.12 1 1.4
11.25 1 1.4
Total 71 100
14.37 2 2.8
15,00 1 1.4 Based on Table 4. The results of the hearing level
20.00 1 1.4 measurement section worker Loom Weaving AJL
21.25 1 1.4 Department highest value of 68.12 dB measurement
22.00 1 1.4 only 1 respondent with a percentage of 1.4%, while
23.12 1 1.4 the lowest is the measurement results are 7.50 dB 2
26.87 2 2.8 respondents with a percentage of 2.8%. The average
28.00 2 2.8
yield of the overall measurement of hearing that is 31.09
+ 14.16 dB.
510 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 5. Test Results Minimum Relations with there is a relationship between length of service with
Hearing Loss NIHL events at home exhaust industry workers in Sub
Purbalingga Lor6.
Variables Average Significance
Age 41.80 Based on the results of interviews with workers
0.0001
Hearing disorders 31.09 in the Loom section of the AJL Weaving Department,
many workers complained about the effects of engine
Based on Table 5, the results of the Person Product noise such as the disruption of communication with other
statistical test show a significance of 0,0001 <0,05, workers, the feeling of always wanting to get angry,
which means that Ho is rejected so there is a social and decreased hearing. The main effect of working
relationship with hearing loss in the Loom part Weaving continuously on a noisy environment will be uplifted to
AJL Department at PT Bintang Asahi Industrial Textiles. health, namely damage to the auditory senses caused by
The strength value of the relationship between age and loud sounds such as the sounds of production machines.
hearing loss was 0.574 (strong relationship strength).
Other factors that can affect hearing loss is the use
There are studies that suggest that there is a significant of ear protection device. PT Bintang Asahi provide ear
relationship between age and hearing threshold value of protective devices such as earplugs in the form of lumps
respondents surveyed. These results indicate a p‑value of of fabric, wherein the fabric blob should be used during
0.000, which means there is a relationship or correlation the job. The control efforts that can be made with the
between age and the Threshold Limit Value3. In another conditions at PT Bintang Asahi Textile Industry on noise
study states that there is a relationship between age and levels include engineering through good maintenance
degree of hearing loss right ear (p = 0.046), left ear (p = of equipment such as checking machines every day,
0.042), and the degree of deafness double ear (p = 0.006) giving lubricants on the moving parts so that lubricant
in residents around highways exposed to noise5. can function to muffle the noise of the machine being
move, and put a damper with rubber pads so that noise
Table 6. Test Results Work Period Relations with
caused by vibration and machined metal parts, rubber
Hearing Loss
pads mounted on moving machine parts fall so that the
Variables Average Significance noise can be controlled with the rubber pads. PT Bintang
Years of service 11.58 Asahi Industrial Textiles has not provided ear protectors
0.0001 that comply with the standards of health and safety of its
Hearing disorders 31.09
workers, making efforts to provide protective equipment
Based on Table 6, the results of statistical test such as ear earplug and earmuff is required by PT
showed Person Product Significance value of 0.0001 Bintang Asahi Textile Industry to maintain the health of
<0.05, which means that Ho is rejected so that no future their workers. Efforts to control the rotation of workers
relationship with a hearing loss of workers working who enter the category of elderly age early and exposed
Loom part Weaving AJL Department in PT Bintang to noisy exceeds the threshold limit value, can be moved
Asahi Textile Industry. Rated strength of the relationship on a part that has a low noise level.
between working life with a hearing loss is 0.493 (the
strength of the relationship is strong enough). The Conclusion
correlation is in line with the results of the correlation
The average age of the respondents, 41.80 ±7.593
between working period with a hearing loss of 0,455,
years, with the difference in age is 28‑62 years. The
the correlation results are also included in the category
average tenure of respondents ie 11.85 + 5,518 years,
strong enough4.
with the difference in working period is 3‑27 years. The
The results are consistent with the theories and hearing threshold measurement results with the average
studies that have been done, including the theory that respondent is 31.09 ± 14.16 dB, the difference in hearing
suggests that the tenure effect on hearing threshold value threshold respondents are from 7.50 to 6.18 dB. The
of labor. increase in hearing threshold on the working average results of measurements of noise intensity
life group> 10 years higher than the working age group is 87.45, the value is> 85 dBA exceed the Threshold
<10 years1. While the research results are consistent Limit Value (TLV), by a margin of 86.93 to 87.88 dBA.
with research that has been done the results show that Statistical test results in getting the relationship between
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 511
age with hearing loss of workers with significant value of 2. Sudiajeng THBL. Ergonomics for Safety,
0.0001 and a correlation value of 0.574 (strong) statistical Occupational Health and Productivity. Surakarta:
test results in getting the relationship between working UNISBA Press; 2004.
life with a hearing loss of workers with significant value 3. Putri WW, Martiana T. Relationship between Age
of 0.0001, and the results a correlation of 0.493 (strong and Work Period with Threshold Value Listen
enough). to Workers Exposed to Noise at Pt. X Sidoarjo.
Indonesian Journal Occupational Safety and
Conflicts of Interest: All authors have no conflict
Health. 2018; 5: 173.
interest to declare.
4. Khakim U. Relationship between Work Period and
Source of Funding: The source of the research cost Threshold Value of Noise Exposed Workers in
from self. Weaving Section in PT Triangga Dewi Surakarta.
Sebelas Maret University; 2011
Ethical Clearance: The study was approved by
the institutional Ethical Bord of the Muhammadiyah 5. Siti YRSU. Old And Long‑Term Relationships
Surakarta University, Faculty of Health Sciences, with Hearing Impairment on Publicly Exposed
Publict Health, Study Program. People Noise in Surakarta. A Criterion and Service
Provider. 2015;
All subjects were fully informed about the 6. Diah PDLBAK. The Relationship between the
procedures and objectives of this study each subject Duration of Work Period and Noise Induced
prior to the study signed an informed consent form. Hearing Loss in Home Industry Exhaust Workers
in Purbalingga Lor Village. J Mandala Kesehatan.
References 2011;
1. Tarwaka. Occupational Safety and Health (Issue 2).
Surakarta: Harapan Press; 2014.
512 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Health Literacyon Weighing Control and Use of

Weight Loss Products among Working‑age Women in the
Northeast of Thailand

Chalee Yaworn1, Wongsa Laohasiriwong2, Kittipong Sornlorm1

1Doctor of Public Health Program. Faculty of Public Health, 2Faculty of Public Health,
KhonKaen University, KhonKaen, Thailand

Abstract
This cross‑sectional study aimed to describe weight loss products’ use patterns and identify the association of
health literacy on weight control and weight loss products use among working‑age women in the Northeast of
Thailand. The study was conducted among 1,190 respondents who were multistage randomly selected from
4 provinces of the Northeast region. Data were collected using a self‑administered structured questionnaire.
The generalized linear mixed model (GLMM) was used to identify the association between health literacy
and weight loss products use when controlling the effects of other covariate presenting adjusted OR and 95%
confidence interval. The results indicated that 23.19% (95% CI = 20.79‑25.59) of the respondents ever used
weight loss products, of which 11.60% (95% CI = 9.77‑13.41) were current users. Levels of health literacy
on weight control was statistically significant with weight loss products use including having; sufficient
level of health literacy (adj. OR = 2.62: 95% CI=1.59‑4.31, p‑value <0.001), problematic level of health
literacy (adj. OR = 4.71: 95% CI=2.87‑7.72, p‑value <0.001) and inadequate level of health literacy (adj. OR
= 10.97: 95% CI=6.17‑19.51, p‑value <0.001) when compared with having excellence level. The significant
covariate was had waist circumference ≥ 80 cm. (Adj. OR = 4.12: 95% CI = 2.79‑6.11, p‑value =0.025),
finished lower than bachelor degree (adj. OR = 2.11, 95% CI = 1.78‑3.70, p‑value <0.001), had average
monthly income ≥ 15,000 THB =(adj. OR = 3.08: 95% CI = 2.20‑4.31, p‑value <0.001), About twenty three
percent of working‑age womenever used weight loss products. Health literacy was highly associated with
used weight loss products.

Keywords: Weight loss products, Health literacy, working‑age women.

Introduction control, however, with a long term effort 4. Therefore,

many people use various weight loss products because
Overweight and obesity cause various health
they are quicker and easier than exercising or dieting5.
problems all over the world1, obesity particular is one of
Although this method is dangerous or has many side
the main causes of morbidity and mortality2 especially
effects6, as well as being unable to confirm the weight
cardiovascular disease (CVD). Awareness of the serious
loss results as to whether or not effective7. The main
health consequences, people turn their attention to weight
target groups of these products are working women8.
control to be within the standard3. It is wildly accepted
Because he or she is a person with financial readiness,
that lifestyle modification, such as healthy dietary habits
able to make independent purchase decisions and pay
and regular physical activity is necessary for weight
attention to the shape9.

Health literacy is linked to the ability of individuals

Corresponding Author: to understand and apply health information to practice
Wongsa Laohasiriwong for disease prevention and health promotion10. People
Ph.D., Faculty of Public Health, KhonKaen University, with an excellent level of health literacy should be less
KhonKaen, Thailand. likely to use weight loss products since they are well
e‑mail: [email protected] aware of their complications than those with inadequate
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 513
health literacy. Social‑cognitive factors also play an was presented as adjusted odds ratio (Adj. OR), 95%
important role in behavioral determination11. confidence interval (CI) and p‑value <0.05 as statistical
significant level.
Although different health behavior theories have
been used to explain weight management, roles of Result
social‑cognitive factors on weight loss remain poorly
understood12. Also, there is limited evidence concerning Socio‑demographic: The average age of the
the influence of socio‑demographic gradients on dieting respondents was 39.46 ±10.71 years old, 58.74 were
and attempts at weight loss13 such as women are more married, 67.15 percent had education lower than a
likely to concern about their shape. bachelor’s degree. the occupation was employee 25.04
percent, an average monthly income 10,000‑19,999
The Northeastern region of Thailand is the biggest baht, average monthly expenditures less than 10,000
region both in terms of areas and population. Most of baht, normal body mass index 40 percent, waist
the labor forces of the country are from this region. With circumference exceeds the standard threshold 50.25
the long term continuously economic expansion, there percent without chronic disease 86.47 and healthy status
has been an increasing trend of overweight and obesity of 81.26 percent.
among northeasterner women. Therefore it is essential
to the determinants of weight loss products use among Almost a quarter of the respondents ever used
them. weight loss products (23.19% : 95% CI = 20.79‑25.59)
of which 11.60% (95% CI = 9.77‑13.41) were current
Objective: To describe the weight loss products users. The most common type of weight loss product use
use and identify the association between health literacy were diet pills which were consumed by 7.84% of the
on weight control and weight loss products use among respondents, followed by diet coffee (6.68%) and fiber
working‑age women in the Northeast of Thailand. products (4.50%), see table 1.

Materials and Method Table 1: Number and percentage of weight loss

products use pattern (n = 1,190 people)
This cross‑sectional study was conducted in 2019.
The population was working‑age women aged 20 to Weight loss products use pattern Number Percent
59 years old in the Northeast of Thailand. The sample 1. Weight loss products use
size was calculated by using the sample size estimation Currently, use 138 11.60
formula for the logistic regression analysis of Hsieh14. Used for less than 6 months and stop
39 3.28
The estimated sample size was 1,190. The respondent using
was recruited from 4 provinces of the Northeast of Used for more than 6 months and stop
99 8.32
Thailand by using multi‑stage random sampling method using
to respond to a structured questionnaire. Never used but would like to use in the
90 7.56
future
Data Analysis: All analyses were performed Never used and want to use 824 69.24
using Stata version 10.0 (Stata Corp, College Station, 2. Type of weight loss product use
TX). Descriptive statistics including frequency and (Can answer more than 1 question)
percentage to describe categorical data whereas mean, Diet pills 101 7.84
standard deviation, median, and maximum‑minimum Diet coffee for weight loss 86 6.68
for continuous data. A simple logistic regression was Fiber products 58 4.50
used to identify individual the association between Konjac Extract 55 4.27
each independent variable and weight loss products Wearable products for weight loss 12 0.93
use. The independent factors that had p‑value <0.25 15 Tea products 11 0.85
were processed to the multivariable analysis using the A traditional procedure such as massage 10 0.78
generalized linear mixed model (GLMM) to identify Chitosan 9 0.70
the association between health literacy and weight Weight loss program 8 0.62
loss products use when controlling the effect of other Equipment 7 0.54
covariates, of which 4 provinces were selected to Garcinia extract 5 0.39
include as random effects. The magnitude of association
514 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Weight loss products use pattern Number Percent OR = 2.62 :95% CI=1.59‑4.31, p‑value <0.001), had
Increased metabolism products 4 0.31 problematic level of health literacy (adj. OR = 4.71:95%
Other weight loss products 8 0.62 CI=2.87‑7.72, p‑value <0.001) and had inadequate
Do not use weight loss products 914 70.96
level health literacy 10.97 times the use of weight loss
products for those with excellent health literacy (adj.
Association between health literacy and weight OR = 10.97: 95% CI=6.17‑19.51, p‑value <0.001) when
loss products use among northeastern working women compared with those with excellent level of health
when controlling other covariates: A multivariable literacy. The other significant covariates were, those with
analysis: Association between health literacy and weight waist circumference ≥ 80 cm. (adj. OR = 4.12: 95% CI
loss products use among northeastern working women = 2.79‑6.11, p‑value =0.025), graduated bachelor degree
were identified by using the Generalized Linear Mixed or higher (adj. OR = 2.11,95% CI = 1.78‑3.70, p‑value
Model (GLMM) to control the clustering effect in each <0.001), had average monthly income ≥15,000 THB
health zone. The results indicated that levels health (adj. OR = 3.08:95% CI = 2.20‑4.31, p‑value <0.001),
literacy were associated with weight loss products use see Table 2.
including had sufficient level of health literacy (adj.

Table 2: Association between health literacy and weight loss products use among northeastern working
women when controlling other covariates: a multivariable analysis using GLMM

Factors Number Percent Crude OR Adj. OR 95% CI P‑value

Health literacy
Excellent 320 9.69 1 1 1.60‑4.24 <0.001
Sufficient 407 18.92 2.17 2.61 2.88‑7.61 <0.001
Problematic 331 30.32 4.15 4.68 6.04‑18.62 <0.001
Inadequate 132 50 9.32 10.6
Education Level
≥ Bachelor Degree 391 18.41 1 1 1.78‑3.70 <0.001
<Bachelor Degree 799 25.53 1.52 2.57
Income per month (THB)
<15,000 667 15.59 1 1 2.20‑4.31 <0.001
≥15,000 523 32.89 2.65 3.08
Waist circumference(cm.)
<80 588 10.54 1 1 4.48‑8.98 <0.001
≥80 602 35.55 4.68 6.31

Discussion northeasterners. Ratchaburi, on the other hand, had a

lower income. The multivariable analysis of this study
This present study observed that about 23% of
also indicated that higher income had a high influence
working‑age women ever used weight loss products.
on weight loss products use (adj. OR = 3.08) which was
This proportion was a little lower than those found in
similar to a study in Sweden 13.
a study in 2015 in Bangkok, Thailand indicated that
27.7% of the respondents used weight loss products16. Health literacy (HL) played an important role in
However, it was higher than those found in a study in weight loss products use. Our finding indicated that those
2017 in Ratchaburi Province, Thailand that observed that who had excellence level of health literacy on weight
19.6% of the participants used weight loss products17. A control were less likely to use weight loss products when
possible explanation was that there was a higher level of compared to those who had sufficient, problematic, and
economic development in Bangkok, people have higher inadequate levels of HL (adj. OR= 2.61, 4.68, and 10.60
income and might concern about shape more than the respectively). A study of Cheong et all. Indicated that
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 515
HL had a positive impact on weight loss behaviors. References
There was also evidence that interventions focusing on
1. Organization WH. Obesity and Overweight [Fact
improving knowledge and HL skills could effectively
Sheet No 311], 2012. Geneva: World Health
control the weight18. HL influences reach and moderates
Organization. 2015.
weight effects. These findings underscore the need to
integrate recruitment strategies and further evaluate 2. Lopez‑Gomez JJ, Izaola‑Jauregui O, Primo‑Martin
programmatic approaches that attend to the needs of D, Torres‑Torres B, Gomez‑Hoyos E,
low‑HL audiences. HL is necessary and an important Ortola‑Buigues A, et al. Effect of weight loss
indicator when making decisions about weight loss on bone metabolism in postmenopausal obese
products. Having HL can influence the choice and women with osteoarthritis. Obes Res Clin Pract.
decision not to use weight loss products. Therefore, 2019;13(4):378‑84.
encouraging the public to have good HL will help people 3. Unick JL, Ross KM, Wing RR. Factors associated
to avoid using weight loss products and choose to use with early non‑response within an Internet‑based
the right weight control19.Our finding also observed that behavioural weight loss program. Obes Sci Pract.
there were socioeconomic gradients to overall health 2019;5(4):324‑32.
and showed that those with lower levels of education 4. Rao G. Office‑based strategies for the management
had poorer health and higher mortality. A previous study of obesity. American family physician.
of Barbering et.all13 also indicated that proper dietary 2010;81(12):1449.
regimen and overweight were associated with higher 5. Burns RD. Energy balance‑related factors
education levels. Similarly a studied of Ball observed that associating with adolescent weight loss intent:
males who were married, living in households with shared evidence from the 2017 National Youth
income and who had less education were more likely to Risk Behavior Survey. BMC Public Health.
use weight loss products20. Waist circumference(WC) 2019;19(1):1206.
is one of the conditions of metabolic syndrome, which
6. Yang N, Chung D, Liu C, Liang B, Li XM. Weight
is an important risk factor of cardiovascular disease21.
loss herbal intervention therapy (W‑LHIT) a
Women with higher WC have a bigger belly which made
non‑appetite suppressing natural product controls
them looked fat. This might lead to more concern about
weight and lowers cholesterol and glucose levels
weight loss. They might try to reduce the WC as quick
in a murine model. BMC Complement Altern Med.
as possible by using weight loss products22. Therefore,
2014;14:261.
it requires effective measures to improve health literacy
on appropriate weight control especially among those 7. Manore MM. Dietary supplements for improving
with lower education having a big belly and had a higher body composition and reducing body weight:
income that has more purchasing power. where is the evidence? International journal
of sport nutrition and exercise metabolism.
Conclusion 2012;22(2):139‑54.
The study indicated that about 23 percent of 8. Vitalone A, Menniti‑Ippolito F, Moro PA,
working‑age women ever used weight loss products. Firenzuoli F, Raschetti R, Mazzanti G. Suspected
Health literacy was highly associated with used weight adverse reactions associated with herbal products
loss products when considering the influenced of waist used for weight loss: a case series reported to the
circumference, educational level, and income. Italian National Institute of Health. Eur J Clin
Pharmacol. 2011;67(3):215‑24.
Source of Funding: Nil 9. Grogan S. Body image: Understanding body
dissatisfaction in men, women and children:
Conflict of Interest Statement: The authors declare
Routledge; 2016.
that there is no conflict of interest.
10. Sørensen K, Van den Broucke S, Fullam J, Doyle
Ethical Clearance: The written informed consent G, Pelikan J, Slonska Z, et al. Health literacy and
was taken from all the individuals after explaining the public health: a systematic review and integration
study objectives. The Ethical Committee of KhonKaen of definitions and models. BMC public health.
University approved this study (reference no. HE 2012;12(1):80.
622008).
516 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
11. Hansen S, Huttunen‑Lenz M, Sluik D, Brand‑Miller 18. Faruqi N, Spooner C, Joshi C, Lloyd J, Dennis
J, Drummen M, Fogelholm M, et al. Demographic S, Stocks N, et al. Primary health care‑level
and Social‑Cognitive Factors Associated with interventions targeting health literacy and their
Weight Loss in Overweight, Pre‑diabetic effect on weight loss: a systematic review. BMC
Participants of the PREVIEW Study. Int J Behav Obes. 2015;2:6.
Med. 2018;25(6):682‑92. 19. Zoellner J, You W, Almeida F, Blackman KC,
12. Byrne S, Barry D, Petry NM. Predictors of weight Harden S, Glasgow RE, et al. The Influence of
loss success. Exercise vs. dietary self‑efficacy and Health Literacy on Reach, Retention, and Success
treatment attendance. Appetite. 2012;58(2):695‑8. in a Worksite Weight Loss Program. Am J Health
13. Barebring L, Winkvist A, Augustin H. Promot. 2016;30(4):279‑82.
Sociodemographic factors associated with reported 20. Zhu S, Wang Z, Heshka S, Heo M, Faith MS,
attempts at weight loss and specific dietary regimens Heymsfield SB. Waist circumference and
in Sweden: The SWEDIET‑2017 study. PLoS One. obesity‑associated risk factors among whites in the
2018;13(5):e0197099. third National Health and Nutrition Examination
14. Hsieh FY, Bloch DA, Larsen MD. A simple Survey: clinical action thresholds. The American
method of sample size calculation for linear journal of clinical nutrition. 2002;76(4):743‑.
and logistic regression. Statistics in medicine. 21. Hou X, Lu J, Weng J, Ji L, Shan Z, Liu J, et al.
1998;17(14):1623‑34. Impact of waist circumference and body mass
15. Hosmer David W, Stanley L. Applied logistic index on risk of cardiometabolic disorder and
regression. New York: Wiley0‑471‑61553‑6. 2000. cardiovascular disease in Chinese adults: a national
diabetes and metabolic disorders survey. PLoS one.
16. Vinijchaiyanun C. Factors Affecting Weight
2013;8(3):e57319.
Control Dietary Supplements Consumption of
People in Bangkok. WMS Journal of Management 22. Klein S, Allison DB, Heymsfield SB, Kelley DE,
Walailak University. 2017;Vol.6(No.1 (Jan – Apr Leibel RL, Nonas C, et al. Waist circumference and
2017)): 84‑90. cardiometabolic risk: a consensus statement from
shaping America’s health: Association for Weight
17. Kanogporn Maneemas PM. Factors Associated
Management and Obesity Prevention; NAASO,
with Consumption of Food Products with the
the Obesity Society; the American Society for
Claim of Weight Control among Female Students
Nutrition; and the American Diabetes Association.
in Vocational Certificate Level: Case Study of
Obesity. 2007;15(5):1061‑7.
Ratchaburi Technical College. Thai Journal of
Pharmacy Practice. 2019;11 (1(Sep – Nov 2019)):
775‑86.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 517

Awareness Regarding Heart Diseases among

Middle Aged Adults in a Rural Area of Rupandehi District

Chanda Sah1, Priyanka Gyawali2

1Lecturer, Department of Medical‑Surgical Nursing, Universal College of Nursing Sciences,
2Clinical Instructor, Department of Medical‑Surgical Nursing, Devdaha Medical College, Rupandehi, Nepal

Abstract
Cardiovascular diseases (CVDs) are the number one cause of death globally. Lack of awareness about CVDs
risk can lead to delays in seeking treatment and increased risk for sudden death. This study was conducted
to assess the awareness on heart diseases among middle‑aged adults in a rural area of Rupandehi district,
Nepal. Descriptive cross‑sectional study was conducted among 107 middle‑aged adults of Shudhodhan
rural municipality, Rupandehi district. The samples were selected by non‑probability purposive sampling
technique. Pretested and pre validated semi‑structured questionnaire was used for data collection. The data
was analyzed using SPSS 16.0 version. More than half of the respondents (55.14%) had high level awareness
on heart disease. About 71.03% had family history of heart diseases. Regarding risk factors of heart diseases
cent percent respondents were aware of alcoholism,98.13% were aware of smoking, 47.66% were aware of
family history and 14.02% were aware of menopause. 99.07% respondents were aware of elevated blood
pressure and chest pain as cardinal symptoms of heart diseases. The study reveals that respondents had
low awareness on family history as risk factor of heart diseases whereas there is statistically significant
association between family history of respondents and level of awareness regarding heart disease (p=0.002).
Respondents (14.02%) also had low awareness on lifestyle changes with medicines as management of heart
disease. Hence it is necessary to educate people about heart diseases risk factors and lifestyle changes for
management and prevention of heart diseases.

Keywords: Awareness, heart disease, middle‑aged adults.

Introduction heart attacks and strokes. Over three quarters of deaths

take place in low‑ and middle‑income countries.1
Cardiovascular diseases (CVDs) are disorders of
the heart and blood vessels and they include coronary In Nepal from 2005 to 2015, the ischemic heart
heart disease, rheumatic heart disease, congenital heart disease increased around 25.3% and Coronary heart
disease and other conditions. Triggering these diseases‑ disease reached 10.79% of total deaths.2 About 40% of
which manifest primarily as heart attacks and strokes‑ non‑communicable admissions are due to CVDs.3 These
are tobacco use, unhealthy diet, physical inactivity and facts create as enormous social burden reducing labour
harmful use of alcohol. An estimated 17.9 people died productivity and creating an overcharge of public fees,
from CVDs globally in 2016, representing 31% of all in a country with a poor healthcare system and a feeble
global deaths and 85% of all CVD deaths are due to economy. The earthquakes of 2015 also imposed critical
social and epidemiological effects to the population
resulting in lifestyle changes.4

Corresponding Author: A government data has shown that 99.6% of

Chanda Sah the Nepali population is at the risk of contracting
Lecturer, Universal College of Nursing Sciences, cardiovascular diseases. The national survey carried
Bhairahwa, Rupandehi, Nepal out by the Health Research Council has recently found
e‑mail: [email protected] that a majority of people has one or more risk‑factors
518 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
including tobacco use, alcohol consumption, low fruit Variables Frequency Percentage
and vegetable consumption and physical inactivity that Gender
pose a threat for disease. Biological factors such as Male 47 43.93
obesity, high blood pressure, high blood glucose level Female 60 56.07
and abnormal lipids also contribute to the risk of the Educational Status
disease.5
Literate 54 50.47
The aim of the study was to assess the awareness on Illiterate 53 49.53
heart diseases among middle‑aged adults in a rural area Occupation
of Rupandehi district, Nepal. Business 18 16.82
Farmer 34 31.78
Material and Method Service holder 10 9.35
Homemaker 45 42.06
Descriptive cross‑sectional design was used for
the study to find out awareness regarding heart disease Family History
in middle‑aged adults.The study was conducted in Yes 76 71.03
Shudhodhan rural municipality, ward number 2, No 31 28.97
Rupandehi district, Nepal.The total population residing
From the table 2 below, more than half of the
in thisrural municipality is 8,865. Total 107 samples
respondents 59 (55.14%) had high awareness and others
were selected using purposive sampling technique.
48 (44.86%) had low awareness regarding heart diseases.
Interview schedule was used for data collection with
use of pretested and prevalidated semi‑structured Table 2: Respondents’ Overall Awareness
questionnaire, developed by researchers. There were 22 Regarding Heart Disease n = 107
questions regarding heart diseases. Data was collected in
between April to September, 2017. Administrative and Level of Awareness Frequency Percentage
ethical approval was obtained from concerned authorities High 59 55.14
prior to data collection. The researchers contacted each Average ‑ ‑
respondents, written informed consent for the study was Low 48 44.86
obtained and interviewed. Descriptive statistical method Mean awareness score=14.35, Total score=20
was used with SPSS 16 version to analyze data using
frequency, percentage and mean. Out of 107 respondents, cent percent answered
alcoholism, 98.13% answered smoking and minority
Resuits answered family history (47.66%) and menopause
(14.02%) as risk factors of heart diseases as shown in
As shown in table 1,out of 107 respondents, 40.19% graph 1 below.
of respondents belong to 40‑46 years and 21.50% belong
to 54‑60 years of age. Similarly 56.07% respondents
belong to female gender. Regarding educational
status, 50.47% respondents are literate. As regard to
occupation, 40.19% of respondents are homemakers.
Majority of respondents (71.03%) had family history of
heart diseases.

Table 1: Respondents’ Socio‑demographic Variables

n=107
Graph 1: Respondents’ Awareness Regarding Risk
Variables Frequency Percentage Factors of Heart Disease
Age
40‑46years 43 40.19 Regarding to cardinal symptoms awareness,
47‑53 years 41 38.32 majority of respondents (99.07%) answered elevated
54‑60 years 23 21.5 blood pressure and chest pain and minority (44.86)
answered extreme fatigue as shown in table 3.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 519
Table 3: Respondents’ Awareness Regarding with the findings of study conducted by Tecla et al.
Cardinal Symptoms of Heart Diseases n = 107 (2015) in Western Kenya which showed that 58% of the
respondents had knowledge regarding heart disease.6
Cardinal Symptoms** Frequency Percentage
Elevated blood pressure* 106 99.07 The findings of the study showed that 68.22% of
Chest pain* 106 99.07 respondents had awareness about sex, 87.85% were
Palpitation* 56 52.34 aware about age as non‑modifiable risk factors of heart
Back pain 10 9.35 disease which is not consistent with the findings of study
Muscle rigidity 9 8.41 conducted by Acharya et al. (2012) in Kathmandu which
Extreme fatigue* 48 44.86 showed 13.8% knew about sex and 46.9% knew age as
*Correct response, **Multiple responses risk factors of heart disease.7

As regard of management of heart diseases shown in The findings of the study showed that 47.66% of
graph 2 below, out of 107 respondents, 85.98% answered respondents had awareness about family history as risk
only medicine and minority (14.02%) of respondents factors of heart disease which is consistent with the
answered medicine with change in life style. 17.6% of findings of study conducted by Aharyaet al. (2012) in
respondents answered there is free treatment of heart Kathmandu which showed 46.9% respondents knew
disease from Government. about family history as risk factor of heart disease.7

The findings of the study showed that 98.13%

respondents are aware about smoking, 66.36% are aware
about obesity and 72.9% knew stress as risk factors of
heart disease which is not consistent with the findings of
study conducted by Acharya et al. (2012) in Kathmandu
which showed that 70.4% respondents are aware of
smoking, 58.8% knew obesity and 63.7% knew stress as
risk factors of heart disease.7
Graph 2: Respondents’ Awareness Regarding The findings of the study showed that 99.07%
Treatment of Heart Disease of respondents had awareness regarding chest pain
as cardinal symptoms of heart disease which is not
Table 4 below shows the association between family
consistent with the findings of study conducted by
history and awareness level on heart diseases. It shows
Aharya et al. (2012) in Kathmandu which showed 24%
that there is statistically significant association between
knew about chest pain as cardinal symptoms of heart
family history of respondents level of awareness
disease.7
regarding heart disease.
The findings of the study showed that 24.30% of
Table 4: Association between Family History of
respondents had awareness regarding medicine with
Respondents and Level of Awareness Regarding
change in lifestyle as treatment of heart disease which
Heart Disease
is not consistent with the findings of study conducted
Level of Awareness by Ingvar et al. (2007) in Sweden which showed 48%
Variables Χ2 p‑value knew medicine with change in lifestyle as treatment of
High (%) Low (%)
Family History heart disease.8
Yes 36 (47.37) 40(52.63)
No 23(74.19) 8(25.81)
6.47 0.002 Conclusion

Significance level at 0.05 More than half of the respondents had high level
awareness on heart disease. The study reveals that
Discussion respondents had low awareness on family history,
menopause as risk factor of heart diseases whereas
The findings of the present study reveal that more
there is statistically significant association between
than half of the respondents that is 55.14% had high
family history of respondents and level of awareness
level of awareness on heart disease which is consistent
520 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
regarding heart disease (p=0.002). Respondents also 4. Abegunde DO, Mathers CD, Adam T, Ortegon
had low awareness on lifestyle changes with medicines M and Strong K. The burden an costs of chronic
as management of heart disease. Hence it is necessary diseases in low‑income and middle‑income
to educate people about heart diseases risk factors and countries. Lancet. 2007; 370: 1929‑38. https://doi.
lifestyle changes for management and prevention of org/10.1016/S0140‑6736(07)61696‑1
heart diseases. 5. Gautam, M. Cardiovascular disease survey to be
held in Nepal. The kathmandu post. 2014 http://
Conflict of Interest: Authors of this manuscript
kathmandupost.ekantipur.com/news/2014‑09‑11/
declare that there is no conflict of interest.
cardiovascular‑disease‑survey‑to‑be‑held‑in‑nepal.
Source of Funding: Self. html
6. Tecla, M., et al. Knowledge regarding
Ethical Clearance: It was taken from concerned
cardiovascular disease among middle adult in
authority that is Institutional Review Committee,
Kenya. Biology Medical Center. 2015; 15:421.
Universal College of Medical Sciences and Teaching
https://bmcinfectdis.biomedcentral.com/articles/
Hospital, Tribhuvan University.
10.1186/s12879‑015‑1157‑8
References 7. Acharya, R., & Khadka, I. Knowledge regarding
heart disease among the adult population in
1. WHO. Cardiovascular diseases (CVDs) media Kathmandu. Biomedical and Sciences. 2012;4(9),
centre. http://www.who.int/cardiovascular_ 601‑606. http://www.scirp.org/JOURNAL/Paper
diseases/global‑hearts/Global_hearts_initiative/en/ Information.aspx?PaperID=23053
2. Institute for Health Metrics and Evaluation. Nepal, 8. Ingvar, O., Odeberg, H., Troein, M. & Lennart,
2015. www.healthdata.org R. Awareness and management of cardiovascular
3. Bhandari GP, Angdembe MR, Dhimal M, Neupane disease risk factors among middle‑aged
S and Bhusal C. State of non‑communicable Swedish men and women. Scandinavian
diseases in Nepal. BMC public health. 2014; 14:23. Journal of Primary Health Care. 2007; 16(3),
https://doi.org/10.1186/1471‑2458‑14‑23 165‑170. http://www.tandfonline.com/doi/
pdf/10.1080/028134398750003124
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 521

Correlation of Osteocalcin Urine Levels with Bone Mass

Density in Menopause Women in H. Adam Malik General
Hospital Medan

Cherry Kumalasari1, M. Fidel Ganis Siregar2, Deri Edianto3,

Christoffel L. Tobing4, M. Fahdhy4, Cut Adeya Adella3
1Department of Obstetric and Gynecology, Medical Faculty, Universitas Sumatera Utara, H. Adam Malik General
Hospital Medan, 2Professor of Fertility Endocrinology and Reproduction Division, Department of Obstetric
and Gynecology, Medical Faculty of Universitas Sumatera Utara/President of Indonesian Menopause Society,
Perkumpulan Menopause Indonesia, 3Staff of Oncology and Gynecology, Department of Obstetric and Gynecology
Division, Medical Faculty of Universitas Sumatera Utara, 4Staff of Feto Maternal Division, Department of
Obstetric and Gynecology Divison, Medical Faculty of Universitas Sumatera Utara

Abstract
Aim: This research is expected to revealed the correlation between urinary osteocalcin and bone density in
menopausal women.

Method: Descriptive study with case series design, conducted at Department of Obstetrics and Gynecology
H. Adam Malik General Hospital Medan and Integrated Laboratory of Medical Faculty, University of North
Sumatra and Setia Budi Hospital for DEXA Scan measurements in January 2019. The research sample was
taken by 21 menopausal women using non‑probability sampling with consecutive sampling techniques.
Analysis of the correlation of urinary osteocalcin with bone mass density using Pearson correlation.

Results: The mean value of urinary osteocalcin in women with normal bone mass density was 6.67 ± 0,53
and the mean value for the osteopenia group was 9.05± 1.30. The results of the Pearson correlation showed
a r score ‑0.803 and p <0.001. In this research shows that the higher level of urinary osteocalcin, the lower
the T score.

Conclusion: This research shows a significant negative correlation of urinary osteocalcin levels with bone
mass density (T score) in menopausal women.

Keywords: Osteocalcin, Bone Mass Density, Menopause, DEXA, Osteoporosis.

Introduction menstruation occur after 12 months forward. Average

age of menopause is 51,5 years old.1
Menopause is cessation of menstruation in 12
months. Post menopause is time after menopause. Estrogen deficiency will cause a disruption of
Menopausal transition is time when irregularity of bone remodeling that will cause osteoporosis in
postmenopausal women. This will cause loss of
bone mass and bone quality. Increased secretion of
osteoclastogenic cytokines such as interleukin‑1 (IL‑1),
Corresponding Author:
interleukin‑6 (IL‑6), and tumor necrosis factor (TNF‑α),
Cherry Kumalasari
imbalance in RANKL/OPG gene expression, and
Department of Obstetric and Gynecology, Medical
inhibition of osteoclast apoptosis are several mechanisms
Faculty, Universitas Sumatera Utara, H. Adam Malik
in osteoporosis.2,3,4
General Hospital Medan
e-mail: [email protected] Bone Mass Density (BMD) is a standard for
522 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
measuring bone mass and is assessed using Dual Energy Work Arrangement: After obtaining approval
X‑ray Absorptiometry (DEXA) in the lumbar, radius, and from the ethics commission to conduct research, research
femur. According to WHO, to diagnose osteoporosis, a begins with collecting samples. Body Mass Index (BMI)
T score can be used which osteoporosis is defined by was measured, then measurement of L2‑L4 lumbar bone
BMD> ‑2.5.1 mass density using Dual Energy X‑Ray Absorptiometry
(DEXA). For measurement of urinary osteocalcin levels,
Osteocalcin also has several properties, namely in the N‑MID Osteocalcin (N‑MID‑OT) ELISA kit is used.
the normal state of kidney function, osteocalcin and Urine Osteocalcin (U‑OC) levels were measured by
fragments will be cleared quickly by the kidneys and quantitative ELISA using the manufacturer’s instructions
contribute to free Gla in the urine. However, in the case and using a central portion of urine taken in a 24‑hour
of kidney failure, these fragments accumulate and can period. 100 µl of reagent and urine osteocalcin are
be detected. Problems related to circulating osteocalcin mixed, covered with adhesive, incubated for 2 hours at
instability (S‑OC) after sampling tend to be less severe 37 oC. Pipette layouts are prepared to measure standard
than urinary osteocalcin (U‑OC), which is thought to be solutions and samples. The liquid in each pipette is
the final product of fragmentation.5 removed, but not washed.
Serum OC levels can be detected by various tests, Statistical Analyzed: Data were analyzed
such as tests using monoclonal antibodies to OC N‑mid descriptively to see the frequency distribution of
and OC N‑terminals fragments. Lack of calcium and research subjects based on characteristics. To analyze
phosphorus in women with osteoporosis decreases the relationship of urine osteocalcin with bone mass
the formation of hydroxyapatite crystals, which make density, the data were analyzed by Pearson correlation.
osteocalcin free circulating in the blood. This explains The results of the analysis are said to be significant if p
the increasement of concentration of serum OC levels in <0.05 with a 95% confidence level. Data analysis using
postmenopausal women who have osteoporosis.6 SPSS version 20.
From the research of Rusda M in 2016, there was
a positive correlation between serum estradiol and T
Results
score with r = 0.53. This shows that BMD is reduced in The description of the research subjects
postmenopausal women who have osteoporosis compared characteristics based on age, bone mass density, and
with nonosteoporosis due to decreasement of estrogen body mass index can be seen in the table below.
levels as the main etiology in postmenopausal women.
Calcium and phosphate deficiency in osteoporosis Table 1: Frequency Distribution Based on Sample
women decreases the formation of hydroxyapatite Characteristics
crystals, which causes osteocalcin to circulate freely
Variable n (21 person) Persentage (%)
in the blood. This explains the high concentration of
Age
osteocalcin in menopausal women. This can be taken
50‑55 years old 3 14,3
into consideration that osteacalcin can be used to detect
56‑60 years old 10 47,6
low Bone Mass Density (BMD) conditions.7,8,9,10
61‑65 years old 8 38,1

Material and Method Body Mass Index

Underweight 1 4,8
This is a descriptive study with a case series design Normoweight 7 33,3
to examined the correlation of urinary osteocalcin Overweight 5 23,8
levels with bone mass density in 21 menopausal women
Obesity 8 38,1
which is conducted at Department of Obstetrics and
Menopause Duration
Gynecology H. Adam Malik General Hospital in Medan
1‑2 years old 4 19,0
which takein using non‑consecutive sampling, while
2‑4 years old 7 33,3
for urine osteocalcin examination performed at the
≥ 5 years old 10 47,6
Integrated Laboratory of Medical Faculty, University of
Total 21 100
North Sumatra and Setia Budi Hospital for DEXA Scan
measurements. This research was conducted in January Characteristics of research subjects based on
2019. majority which is age56‑60 years as many as 10 subjects
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 523
(47.6%),normoweight as many as 7 subjects (33.3%) Table 3. Mean Value of Urine Ostocalocalcin based
and menopausal duration ≥ 5 years as many as 10 people on Bone Mass Density in Menopausal Women
(47.6%).
Osteocalcin Mean SD
Table 2. Frequency Distribution of Characteristics Normal 6,67 ± 0,53
and Average Bone Mass Density in Menopausal Osteopenia 9,05 ± 1,30
Women
Mean value of urinary osteocalcin in women with
Bone Mass Density n Per. (%) Mean SD normal bone mass density was 6.67 ± 0.53, the mean
Normal 10 47,6 ‑0,47 ± 0,56 value for the osteopenia group of women was 9.05 ±
Osteopenia 11 52,4 ‑1,51 ± 0,29 1.30.
Total 21 100
Table 4. Correlation of Urine Osteocalcin with Bone
The characteristics of the subjects are based on Density in Menopausal Women
Bone Mass Density, osteopenia group as many as 11
Parameter R P
people (52.4%). While the mean bone mass density in
the normal group was ‑0.47 ± 0.56 and the osteopenia Urine Osteocalcin Levels
‑0,803 <0,001
group was ‑1.51 ± 0.29. T Score
* Pearson Correlations

Figure 1. Osteocalcin Correlation Chart and T Score

From table 4., it was found that there was a significant age was 61 years old. In general, the age of menopause
negative correlation between urinary osteocalcin levels throughout the world is 50 years. Then, from studies in
and T scores with r ‑0.803 and p <0.001. This shows that Thailand on postmenopausal women aged 50‑54 years
the higher the level of urinary osteocalcin, the lower the and 55‑59 years, the prevalence of osteoporosis was
T score in this research. 9.4% and 22.6%. The type of osteoporosis that occurs
in postmenopausal women is the primary type. Where
Age: From the research of Hachul et al 2016, the this is due to estrogen deficiency. Estrogen plays a role
mean age of menopause was 58.9 ± 0.8. From the study in osteoblast and bone mineral homeostasis. The older a
of Bjelland et al 2018, it was found that the average age woman is, the more she will lose bone mass density of
was 56.7 years, and the study of Shadyab et al 2017 about 50% of trabecular bone mass and 30% of cortical
found an average of 74.7 years old research subjects, bone mass due to estrogen deficiency. 11,12,13,14,15
while the Banack et al study, 2018, found that the average
524 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Body Mass Index: This is in line with Bjelland et al mass loss, increased RANKL, inhibition of OPG, and
2018 study found that the average BMI was overweight increased production of cytokines such as IL‑1, IL‑6,
with 25.8 kg/m2, research Banack et al., 2018 found that and TNF‑α. Estrogen deficiency will increase the
the highest BMI data was in the overweight category with production of TNF‑α. by T. TNF‑α cells will increase
26.7 kg/m2. Weight gain during old age is associated the production of RANKL and Macrophage Colony
with a decrease in energy expenditure (EE), due to a Stimulating Factor (M‑CSF). Other cytokines that
decrease in physical activity, loss of body mass. Adipose play a role are Inerleukin‑7 (IL‑7) which increases
tissue and weight will affect bone mass density as osteoclastogenesis. This will cause imbalance of
individuals with overweight and obesity BMI will have resorption and bone formation, which will increase bone
a greater body weight, weight will also affect bone peak loss. Thus, an increase in RANKL after menopause will
mass, and adipocyte tissue in menopausal women will cause an increase in bone resorption and osteoporosis in
be converted to estron, so that postmenopausal women menopause.1,4,22,23,24,25,26
obesity will have more endogenous estrogen.16,17,18,19,
20,21 Mean Value of Urinary Ostocalocalcin to Bone
Mass Density: In the study of Singh et al, 2015, the mean
Menopause Duration: From Sarabi’s research, serum osteocalcin level was 19.25 ± 5.1 ng/m. From the
2018, it was found that the average menopause was 2.8 ± research of Zahrany et al 2014, there was a significant
1.5. Siregar Research, MFG, 2014, found that the average increase in osteocalcin levels in the osteopenia group of
duration of menopausal women was 1‑2 years from 50 women compared to the control group, but there was no
samples (100%). From the study of Najmutdinova, 2016, significant difference in osteocalcin levels between the
the menopause duration of 0‑3 years had a percentage osteopenia and osteoporosis groups. From these data it
of osteopenia of 36.2%, 4‑7 years menopause duration was also found that serum osteocalcin was 10% higher
has a percentage of osteopenia of 43.3%, and a duration in the postmenopausal osteoporosis group. However,
of> 7 years has a percentage of osteopenia of 41.6%. there are no data on the mean value of osteocalcin in
Menopausal women with a menopausal duration of> 7 urine with T scores.19, 27
years have an increased risk of osteoporosis. Peak bone
mass was achieved at the age of decade 30. In addition, the Correlation of Urinary Osteocalcin with T Score:
duration of menopause also has an impact on decreasing This shows that there is a significant relationship between
bone mass density, especially in the lumbar and distal urinary osteocalcin levels with T scores, namely the
radius. Menopausal women will experience a loss of higher the level of osteocalcin, the T score will decrease
bone mass 1‑2% each year in a period of 5‑10 years. further with a correlation value of 0.822. This is in line
Loss of bone mass is more common in the trabecular with the research of Singh et al, 2015 which obtained
bone with a fracture of the vertebrae or distal radius. At a negative correlation between osteocalcin and bone
the onset of menopause, there will be a loss of trabecular mass density with r = ‑0.527. From these research it was
bone mass density of 1.8% and 2.3% in the vertebrae. also found that osteocalcin can distinguish the normal
After 5 years postmenopause, there will be a 7‑10% bone density of postmenopausal women with low bone
decrease in bone mass density in the vertebrae.4,18,24,26 density in postmenopausal women. From the research
of Zahrany et al 2014, it was found that there was a
Bone Mass Density: From the Sarabi study, significant negative correlation between osteocalcin and
2017, data was obtained that 35% of respondents were bone mass density in postmenopausal women with r = ‑,
osteopenia. From the Montazerifar study, in 2014, there 909. This shows that the higher bone turnover, the more
were 36.2% of subjects experiencing osteopenia, and loss of bone mass in osteoporotic women. Calcium and
Sahu’s study, 2018, found that 72 research subjects phosphorus deficiency in osteoporosis women will cause
(36%) were osteopenia groups The effect of estrogen a decrease in the formation of hydroxyapatite crystals,
will directly and indirectly suppress bone resorption. which will cause osteocalcin to circulate freely in the
Where the dominant effect of estrogen is suppression of blood. This can explain why osteocalcin levels increase
new osteoclast formations. modulates the Activator of in postmenopausal osteoporosis women.19,6,27
Nuclear Factor kB (RANK) Receptor in osteoclasts and
stimulates osteoclast apoptosis where RANKL plays a Conclusion
role in increasing osteoclast activity. But in menopausal The mean value for urinary osteocalcin for bone
women who experience a decrease in estrogen, bone mass density status in this research was the osteopenia
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 525
group with a mean of 9.05 ± 1.30. There is a significant Serum Osteocalcin as a Diagnostic Biomarker
negative correlation between urinary osteocalcin for Primary Osteoporosis in Women. Journal of
and bone mass density status in this research with r = Clinical and Diagnosis Research.2015; 9(8).
‑0.803 and p <0.001. This shows the higher the level of 9. Chidre, YV., & Shaikh, AB. Association of Vitamin
osteocalcin in the urine, the lower the bone mass density. D and Osteocalcin Levels in Postmenopausal
Women with Osteoporosis. IJRCOG. 2017.
Conflict of Interest: The researcher ensures that
6(4):1244‑1248.
there is no conflict of interest in this research.
10. Rusda M. Correlation between 25‑Hydroxyvitamin
Source of Funding: Self. There is no source of D and Estradiol Serum Level in Determining Bone
funding in this research. Density in Menopausal Women. Atlantis Press.
2017.
Ethical Clearance: Research permission and
approval were obtained from the Ethics Committee 11. Hachul H, Polesel DN, Nozoe KT, Sanchez ZM,
of the Medical Faculty, University of North Sumatra. Prado MCO, et al. The Age of Menopause and
Every research subject has the right to know the results Their Associated Factors : A Cross Sectional
of the examination conducted on him. Population‑Based Study. Journal of Women’s
Health Care. 2016; (5):5.
References 12. Bjelland EK, Hofvind S, Byberg L, Eskild A. The
Relation of Age at Menarche with Age at Natural
1. Hoffman, L.B, John, O Schorge, Karen, D
Menopause : a Population Study of 336788 Women
Bradshaw, Lisa M. Halvorson, et al. Williams
in Norway
Gynecology 3rd Edition. McGraw Hill
13. Banack HR, Wactawski‑Wende J, Hovey KM,
2. Atapattu, PiyushaMilani., Fernando, Dinithi.,
Stokes A. Is BMI a Valid Measure of Obesity in
Wasalanthanthri S., & de Silva, Angela. Menopause
Postmenopausal Women ? Menopause. 2018; 25(3)
and Exercise : Linking Pathophysioloy to Effects.
: 307‑313.
iMedPub Journals. 2015.
14. Dunneram Y, Greenwood DC, Burley VJ, Cade
3. Lobo, Roger A., Gershenson, David M., Lentz,
JE. Dietary Intake and Age at Natural Menopause :
Gretchen M., & Valea, Fidel A.Comprehensive
Results from the UK Women’s Cohort Study. BMJ.
Gynecology 7th Edition in Chapter 14 : Menopause
2018; 0 :1‑8.
and Care of the Mature Woman. Elsevier. 2017;
p:258‑270. 15. Meiyanti. Epidemiology of Osteoporosis in
Postmenopausa Women Aged 47 to 60 years.
4. Siregar, M Fidel G. Perimenopausal and
Universa Medicina. 2016; 29(3).
Postmenopausal Complaints in Pramedics Assessed
by Menopause Rating Scale in Indonesia. 2014.IOS 16. Franic, Damir., & Verdenik, Ivan. Risk
Journal. 13(12). Factor for Osteoporosis in Postmenopausal
Women‑from Thep Oint of View of Primary Care
5. Kumar, Hari.,Muthukurishnan, J., & Verma A.
Gynecologist. Slovenian Journal of Public Health.
Correlation Between Bone Markers and Bone
2018.57(1):33‑38.
Mineral Density in Postmenopausal Women with
Osteoporosis. Endocrine Practice. 2008. 14(9). 17. Doroudinia, Abtin. Bone Mineral Measurements.
2015. SAM‑CME; 40(8).
6. Ratore, Brijesh., Singh, Manisha,. Kumar, Vishnu.,
& Misra, Aparna. Osteocalcin : an Emerging 18. Harahap, Erwin ES., Siregar, M F Ganis., Aboet,
Biomarker for Bone Turnover. Int J Res Med Sci. Aswar., Harahap, M.Rusda., RivanyRiza, et
2016. 4(9):3670‑3674. al. Hubungan Kadar Estradiol Serum dengan
DensitasTulangpada Wanita Menopause. 2015.
7. Kaliaselvi, VS., Prabhu, K., Ramesh, M., &
Venkatesan. The Association of Serum Osteoaclcin 19. Singh, Sudir, Kumar, Dharmendra, & Lal, Atil K.
with the Bone Mineral Density in Post Menopausal Serum Osteocalcin as a Diagnostic Biomarker for
Women. Journal of Clinical and Diagnosis Primary Osteoporosis in Women
Research. 2013;7(5). 20. Al‑Safi Z. Obesity and Menopause. Elsevier. 2015:
8. Singh, Sudhir., Kumar, Dharmendra., & LalAtil. 1‑6.
526 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
21. Goncalves JTT, Silveira MF, Campos MCC, 25. Montazerifar F, Karajibani M, Alamian S,
Costa LHR. Overweight and Obesity and Factors Sandoughi M, Zakeri Z et al. Age, Weight, and
Associated with Menopause. 2016. Body Mass Index Effect on Bone Mineral Density
22. Kilic, Tulay O. Estrogen Deficiency and in Postmenopausal Women. 2014: 2(2).
Osteoporosis. Intech. 2015. 26. Sahu, S, Sahu A. Correlation of Age at Menopause
23. Drake, Matthew T., Clarke, Bart L., & Lewiecki with Bone Mineral Density in Postmenopausal
EM. The Pathophysiology and Treatment of Women : A Prospective Study. IJOS.2018: 4(3):
Osteoporosis. Clinical Therapeutics. 2015. 37(8); 530‑533.
1837‑1850. 27. Zahrany AA, Nashar NA, Mohamed HA.
24. Sarabi ZS, Rezaie HE, Milani N, Rezaie FE, Diagnostic and Screening of Biochemical Markers
Rezaie AE. Evaluation of Bone Mineral Density in for Osteoporosis and Osteopenia in Saudi Women.
Perimenopausal Period. The Archives of Bone and The Egyptian Journal of Hospital Medicine. 2013 :
Joint Surgery. 2018 : 6(1): 57‑62. 52; 670‑677.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 527

Benefit of Thai Hermit Exercise on MCI Patients’:

A Randomized Controlled Trial

Chomlak Kongart1, Yuttachai Likitjaroen2, Surasak Taneepanichskul1, PhD

1PhD., College of Public Health Sciences, Chulalongkorn University, Phayathai Road, 2Md, PhD., Department of
Neurology, Faculty of Medicine, Chulalongkorn Hospital, Rama IV Road, Pathumwan, Bangkok, Thailand

Abstract
Background: Mild Cognitive Impairment (MCI) is a recurrent brain disorder with the memory. It is caused
by the degeneration of the brain cells that is different from an individual’s age and that develops to dementia.
One way to help reduce stress is by exercising. Thai hermit exerciseis a wisdom in Thai exercise, which
improves psychological status for this condition.

Method: This study was evaluated for a period of 10 weeks in regards to the Thai hermit exercise on
psychological status among patients with MCI. 84 participants were recruited and randomized into
intervention (n=42) control (n=42). The intervention group practiced Thai hermit exercise for 10 weeks.
Psychological effect was evaluated by measuring the psychological status which was futher determined by
the psychological status indicator questionaire. The control group received standard treatment. Both study
groups were assessed by the test at the baseline then at 6th week, 8th week and 10th week of the study. Results:
At baseline there were no significantly difference statistically between the two groups (p<0.05). After the
intervention there were statistically significantly improvement of psychological status (p<0.05).

Conclusion: The results strongly suggested the capability of Thai hermit exercise to be a psychological
effect for patients with MCI.

Keywords: Mild Cognitive Impairment (MCI), Psychological status,Thai hermit exercise (ruesidatton).

Introduction it is a major predictor of tendency to become dementia

and futheridentified two clusters neuropsychiatric
Mild cognitive impairment (MCI) is defined as
symptoms, namely:
cognitive decline greater than what is expected for an
individual’s age and education level, which does not (1) Cluster frontal (aberrant motor behavior,
interfere with daily life activities(1). For the people disinhibition, agitation and problems of appetite), was
with aged 60 years and above, the reported prevalence found to be associated with functional disability even
of MCI rangedfrom 14 to 18% and the progression after controlling the cognitive status and the mood
rate of dementia is about 5‑15% per year(2). Mental cluster scores.
component ‑ MCI behavior at getting unwitting, where
(2) Cluster mood (including stress, depression,
anxiety, apathy, irritability and sleep problems), is more
common than frontal cluster of symptoms (95% of
subjects had at least 1 symptom mood: 53% of subjects
Corresponding Author:
had at least 1 symptom frontal)
Chomlak Kongart
PhD., College of Public Health Sciences, Stress requires one to use physiological and
Chulalongkorn University, Phayathai Road, psychological energy to respond and adapt to the
Pathumwan, Bangkok, Thailand stressor with increased tolerance to stress reflecting early
e‑mail: [email protected] symptoms of dementia(3). According to(4),(5) and (6)stress
528 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
that takes place within a short time frame will disrupt Materials and Method
the short term memory which is basically the verbal
Design and Instruments: This study is a
memory. Whereas when stress occurs long term and
randomized controlled trial, 84 subjects will be
repeatedly, will result in the exposure to the hormone
elaborated at the multicenter. The target population
cortisol which becomes more frequent maycause
of this study was participants who had been formally
shrinkage in hipoccampus and also trigger a further
diagnosed with Mild Cognitive Impairment (MCI) and
decline in the cognitive function that leads to dementia.
treated in King Chulalongkorn Hospital, Bangpli elderly
Epidemiological research looking at the role of stress in
club, Thai traditional medicine clinic at Ramkhamheang
neurodegenerative disease is still relatively small.
University. The participants were recruited following
MCI risk factor have many causes which includes the eligibility criteria as follows.
increased age, diabetes mellitus, smoking, depression,
Inclusion Criteria:
hypertention, and lack of physical activity(7). The positive
effect of physical activity on brain vascularity includes 1. Patients who were diagnosed withMCI of age60
pressure reduction, improvement of the lipoprotein years and older.
profile, increased perfusion which is direct on the brain 2. Able to read speak and understand Thai with no
through the preservation of the neuronal structure and severe hearing and blinding impairment.
major changes in plasticity in the hippocampus(8). Finally,
it has been reported that an active lifestyle with regular 3. Able to walk
physical exercise may prevent distress and reduce in the 4. Willingness to participate in the study and are able
cortisol levels(9). It is also a known fact that even the to provide the informed consent
slightest amount of physical activity done outside can
improve posture, reduce stress and loneliness, sleeping Exclusion Criteria:
better at night, and even preventing depression(10). 1. Regular practice of Thai hermit exercise (Ruesi dad
ton)
Thai hermit exercise (RuesiDatTon)is a traditional
Thai healing technique that mainly consists of breathing 2. Those that had been diagnosed with severe
exercises, self‑massage, acupressure, dynamic exercises, osteoporosis
poses, mantras, visualization and meditation which is 3. Emergence of a new symptom
similar to the Hathayogic practices. In recent years, the
Thai Ministry of Public Health has published several 4. Does not have any previous cognitive impair by
books on ReusiDat Ton. According to these modern Medical illness
texts, some of the benefits of ReusiDat Ton practices 5. Does not have any sort of injury on the brain, skull,
include; improved agility and muscle coordination, or scalp
increased joint mobility, greater range of motion,
better circulation, improved in respiration, improved in Subject Allocation: The sample size for this study
digestion, assimilation and elimination, detoxification, was calculated that a total sample size, based on a
stronger immunity, reduced stress and anxiety, greater previous study(11), using power to detect 20% of effect
relaxation, improved concentration and meditation, size, with the power 80% and the alpha probability at
oxygen therapy to the cells, pain relief, slowing of 0.05. The G power computer application was applied to
degenerative disease and greater longevity. However, calculate the sample size. Participants were randomly
there are very few studies in people that have compared assigned into one of the two parallel groups, either to
the effects of RuesiDat Ton practice on psychological an intervention group to receive the intervention or to a
status. Since no previous evidences regarding these control group to receive usual care.The randomization
aspects of the exercise that have been investigated, thus, list will be generated by using random number from the
this study aims to measure the effect of stress in the Excel program(12).Participants were provided with an
aspect from practicing Thai hermit exercise among MCI information sheet as well as a consent form.
patients. Ethical Consideration: In regards to the ethical
principle, it has been approved by ethics committee of
King Chulalongkorn Hospital.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 529
Intervention: Thai hermit exercise (Ruesidat functions. Cognitive function used the standard test
ton): This study was selected by some Thai traditional which are Verbal Fluency Test (Letters/categories),
medicine experts for 3 postures from the original 80 Trail making A‑B Test and Digit Span. Each test has
postures that were involve with psychological status. details as follows shown below
For the intervention group about one hour a day and 3
times a week of Thai hermit exercise was arranged for Psychological Indicators Questionnaire: This
10 weeks. These exercises are indicated via Figures 1, questionnaire will show how stress affects different parts
2 and 3. of your life. Circle the response which best indicates
how often you experience each stress indicator during a
Outcome Measurements: The Outcome will typical week, which apply to the international counseling
be assessed at the beginning of the exercise, week 6, team(13).
and week 8 and again at week 10 in term of cognitive

Figure 1: The posture to relieve face muscle, includes 7 postures numbered (a) ‑ (g) and should be performed
in sequential order

Figure 2: The posture to relieve laziness includes 7 postures numbered (a) ‑ (g) and should be performed in
sequential order
530 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Figure 3: The posture to relieve headache, blur vision and general weakness includes 9 postures, numbered
(a) – (i) and should be performed in sequential order.

Data Analyis: The demographic variables and the about 3 people or about 7.1% belonging to this category.
psychological status were analyzed using descriptive The majority of the subjects which was about 29 people
statistics such as: Chi‑square test, frequencies, or 69.1% completed primary schools while about 8
percentages, means, and standard deviations. The subjects or only 19.0% completed their High school and
chi‑squared tests were used to summarize the relationship there were few subjects about 5 people or 11.9% who
of variables. Frequencies and percentages were used to completed their Bachelor degree. All of the 42 subjects
summarize the categorical variables. Means and standard (100%) worshipped Buddhist religion and are of Thai
deviations were used to summarize the continuous race.
variables.
The Intervention group mainly consists of 35 female
Results subjects or about 83.3% and only about 7 male subjects
or about 16.7%. More than half of the subjects were in
Demographics: From Table 1, the Chi‑Square the age group between 66‑70 years old, which consisted
Tests results were not significantly correlated with the of 23 people or about 54.8%.About 17 subjects or 40.5%
control and trial at 0.05 and it can be seen that the control of the subjects were in the age range between 60‑65 years
group mainly consisted of female subjects which was and there were only 2 subjects or 4.7% in the age range
about 36 people or up to 85.7% whereas there were only of 70 years and above. The Martial status of most of the
about 6 male subjects or about 14.3%. The age range subjects were married which consisted of 36 person or
of most participated subject were between 60‑65 years 85.7% and there were about 2 subjects or 4.8% whose
old which consisted of 20 people or about 47.6%.The status is single. Divorce, Widows/Separation subjects
number of subjects between the age of 66‑ 70 years were also included in this research and there were also
were about 18 people or about 42.9% and there were 4 about 4 person or 9.5% of the subjects. More than half
people or about 9.5% in the age group of 70 years and the subjects about 25 people or 59.5% completed their
older. The Marital status of most of the subjects were high school while about 10 subjects or 23.8% completed
married which consisted of 36 people or about 85.8% their Primary school. 7 subjects or 16.7% completed
while the subjects who were single consisted of 3 people their bachelor degree. All of the 42 subjects (100%)
or about 7.1%. Divorce, Widows/Separation subjects worshipped Buddhist religion and are of Thai race.
were also included in this research and there were also
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 531
Table 1: Comparisons of socio‑demographic between the intervention group and the control group at pre‑test

Control group Experimental group

Characteristics x2 P value
N % N %
Sex
male 6 14.3 7 16.7 0.091 0.763
Female 36 85.7 35 83.3
Age
60 ‑ 65 years 20 47.6 17 40.5 8.142 .087
66 – 70 years 18 42.9 23 54.8
More than 70 years 4 9.5 2 4.7
Status
Single 3 7.1 2 4.8 2.657 .617
Marry 36 85.8 36 85.7
Divorce/Widow/Separation 3 7.1 4 9.5
Education
Primary school 29 69.1 10 23.8 4.663 .324
High school 8 19.0 25 59.5
Bachelors degree 5 11.9 7 16.7
(p < 0.05)

According to the result from the Table 2 (in the psychological status (stress) at statistical difference of
pre‑test phase) it can be seen that there is no difference 0.05 (p > 0.05).
between control group and experimental group on

Table 2: Comparison between control group and experimental group on psycological statusin the pre‑test

Control group Experimental group

Variable t P value
x S.D. x S.D.
Psychological Status
Stress 3.76 0.32 3.63 0.34 1.81 0.074
(P< 0.05)

According to the results from the Table 3 on it can also be observed that a difference was found in the
Psychological Status, it can be seen that there were experimental group (for pre‑test,6th week,8th week and
no differences in the control group at pre‑test, after 6 10th week) for the Psychological Status at a statistical
weeks, after 8 weeks and after 10 weeks at statistical significance of 0.05 (p < 0.05).
significance of 0.05 (p > 0.05). However, from Table 4,

Table 3: Comparisons between the control group and experimental group on psychological status (stress) at
pre‑test, after 6 weeks, after 8 weeks and 10 weeks

Control Group Experimental Group

Variable F P value F P value
x S.D. x S.D.
Psychological Status
Pre‑test 3.76 0.32 0.659 0.543 3.63 0.34 306.233 0.00*
6 Weeks 3.66 0.52 2.38 0.37
8 Weeks 3.75 0.51 2.25 0.39
10 Weeks 3.67 0.33 1.84 0.15
(P< 0.05)
532 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 4: Comparison of the differences observed in pre‑test, 6 weeks, 8 weeks, and 10 weeks for
Psychological Status in the experimental group

Variable x pre‑test 6 weeks 8 weeks 10 weeks

Psychological Status
Pre‑test 3.63 ‑ 1.252 * 1.386 * 1.796 *
6 Weeks 2.38 ‑ .134 * .544 *
8 Weeks 2.25 ‑ .410 *
10 Weeks 1.84 ‑
(P< 0.05)

Discussion significant results for the use of Thai hermit exercise as

a tool for the improvement of psychological status in
The present study determined to examine the
individuals with MCI. Future research should seek to
condition of MCI patients by using a verbal influence
identify population traits (such as age at which physical
test, a trail Maker B test and a Digit Span Test before
activity began, intervention duration, and baseline
and after the Thai Hermit exercise. Particularly, the
activity level) and intervention characteristics (such
aim was to examine the influence of psychological
as type, frequency, duration, and intensity) that trend
condition(stress) toward the advance of the Thai hermit
toward positive outcomes among these trials. Studies
exercise. In addition, this research aimed to compare the
then could be designed appropriately to test the identified
effect of Thai hermit exercise between the intervention
characteristics for research and knowledge purposes.
and the control groups along the time period of
In addition, long‑term trials that enroll younger adults
observation. Two studies are in line with these findings,
with interventions sustained for a longer periods would
stating the fact that good physical performance seems
benefit the field and provide important insight on
to play a protective factor against cognitive decline
prevention. Although a physically active lifestyle often
whereby regular exercise promotes reduced risk of
is proposed as a way to reduce stress and that cause of
MCI and dementia(14, 15).Furthermore, the present study
MCI and may be progress or leads to dementia. But some
discovered that the observed psychological status at
studies also indicate that there is not enough evidence
pre‑test differed from that at the 6th, 8th and 10th weeks
to determine whether a single component like physical
with a statistical significance (p <0.05). Additionally, the
activity interventions actually offer or lead to the benefit
results from the 6th week differed from the 8th and 10th
of psychological effect. However, clinical practice
week as well as the results from the 8th week differed
largely encourages physical activity to prevent or
from that of the 10th week at a statistical significance
dilute other chronic conditions, and this practice should
for the psychological status category (p<0.05). This is
continue, because it may offer benefits for improving
similar to results found in a study conducted by Lam et
psychological status as well.
al.(16)whereby the authors reported a significant decrease
in depressive symptoms after a 12‑month group‑based Conflict of Interest: The authors declare that there
multi‑modal exercise program compared with the are no conflicts of interest
pre‑test level.
Source of Funding: Self
Conclusion
References
The psychological status showed that pre‑test results
differed from the 6th, 8th and 10th weeks at a statistical 1. Petersen RC. Mild Cognitive Impairment.
significance of 0.05 (p < 0.05) while the 6th week differed New England Journal of Medicine.
from the 8th and 10th weeks at statistical significance of 2011;364(23):2227‑34.
0.05 (p< 0.05). The 8th week was also seen to differ from 2. Ganguli M, Snitz BE, Saxton JA, et al. Outcomes
the 10th week at a statistical significance of 0.05 (p< of mild cognitive impairment by definition:
0.05). A population study. Archives of Neurology.
2011;68(6):761‑7.
This study was successful in showing statistically
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 533
3. Johansson L, Guo X, Waern M, Ostling S, Gustafson Chaosaowapa M, Choatwongwachira W, Seanglaw
D, Bengtsson C, et al. Midlife psychological stress D, et al. Physical effects and cognitive function
and risk of dementia: A 35‑year longitudinal after exercising “Rue‑si‑dad‑ton” (Exercise using
population study2010. 2217‑24 p. the posture of the hermit doing body contortion): A
4. Domes G, Heinrichs M, Rimmele U, Reichwald U, randomized controlled pilot trial2015. 306‑13 p.
Hautzinger M. Acute Stress Impairs Recognition for 12. Glazerman S, M. Levy D, Myers D. Nonexperimental
Positive Words—Association with Stress‑induced Replications of Social Experiments: A Systematic
Cortisol Secretion. Stress. 2004;7(3):173‑81. Review. Interim Report/Discussion Paper2002.
5. Wolf OT, Kudielka BM. Stress, health and ageing: 13. International TCT. Mental Health 2019 [
a focus on postmenopausal women. Menopause 14. Gallucci M, Antuono P, Ongaro F, Forloni PL,
International. 2008;14(3):129‑33. Albani D, Amici GP, et al. Physical activity,
6. R. D. My Health2014. socialization and reading in the elderly over the
7. Mehta S, P H. Mild Cognitive Impairment2016. age of seventy: what is the relation with cognitive
decline? Evidence from “The Treviso Longeva
8. Foster P, Rosenblatt K, Kuljiš R. Exercise‑Induced
(TRELONG) study”. Arch Gerontol Geriatr.
Cognitive Plasticity, Implications for Mild
2009;48(3):284‑6.
Cognitive Impairment and Alzheimer’s Disease.
Frontiers in Neurology. 2011;2:28. 15. Ahlskog JE, Geda YE, Graff‑Radford NR,
Petersen RC. Physical exercise as a preventive or
9. Kalmijn S, Launer LJ, Stolk RP, de Jong FH,
disease‑modifying treatment of dementia and brain
Pols HAP, Hofman A, et al. A Prospective Study
aging. Mayo Clin Proc. 2011;86(9):876‑84.
on Cortisol, Dehydroepiandrosterone Sulfate,
and Cognitive Function in the Elderly. The 16. Lam LC, Chan WC, Leung T, Fung AW, Leung
Journal of Clinical Endocrinology & Metabolism. EM. Would older adults with mild cognitive
1998;83(10):3487‑92. impairment adhere to and benefit from a structured
lifestyle activity intervention to enhance cognition?:
10. M S. Text book of Nursing Geriati. 2 ed. Jakarta :
a cluster randomized controlled trial. PLoS One.
EGC2006.
2015;10(3):e0118173.
11. Tanasugarn L, Natearpha P, Kongsakon R,
534 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Relationship of Individual Characteristics and Noise Intensity

with Subjective Hearing Loss to Workers at Pt. X

Cut Suci Almadiana T.1, Sumihardi2, Abdul Rohim Tualeka1

1Department of Occupational Health and Safety, Faculty of Public Health, Airlangga University, 2Department of
Public Health, Faculty of Health Sciences, Baiturrahmah University, Indonesia

Abstract
One company that has a risk of hearing loss is PT. X engaged in the supply, processing and distribution of
steel and ready‑mixed materials for construction, electricity, mining, telecommunication and transportation
industries. Location of noise intensity there are 4 parts that is part of iron pole, elbow, pipe and work shop.
The purpose of this study was to determine the relationship of individual characteristics and noise intensity
with subjective hearing loss to workers in PT. X..The type of this research is analytic research with cross
sectional design. Population in this study are all workers in unit production of PT. X as many as 157 people
with a sample of 61 people. The sampling technique is simple random sampling. The study was conducted
in January ‑ October. The data were analyzed univariate using frequency and bivariate distribution using
Chi‑Square statistical test with significance level 95% α = 0,05. The results showed less than half (49.2% of
respondents subjected to subjective hearing loss. Less than half (39.3%) of respondents were at risk. More
than half (68.9%) of respondents have long worked.

More than half (68.9%) had less intensity than NAB (<85 dB). More than half (60.7%) of respondents
did not use ear protective equipment. There is a significant relationship of age, length of service, noise
intensity, ear protection with subjective hearing loss in PT. X .It is expected that the company minimizes
noise intensity by using silencers. The sound‑proofing device can use the barrier wall between the machine
and the worker or the silencer can be mounted on the sound source on the machine and it is expected that the
company provides clear rules with sanctions for workers who do not use ear protection.

Keywords: Age, Working Period, Noise Intensity, Use of PPE and Subjective Hearing Loss.

Introduction Data from the World Health Organization (WHO)

in 2012 there were 250 million people worldwide with
The ear is a very vulnerable organ that although
moderate or severe hearing loss, this figure rises to more
it can accept the imposition of a certain range, finally
than 275 million people. Based on the amount of 80% of
ear will react and stop functioning, how the ear and
them are in developing countries. In America, more than
some action should be taken in the workplace to protect
5.1 million workers exposed to noise with an intensity of
workers’ hearing ability 1.
more than 85 dB2.

A total of 246 workers in the United States for the

Correspondence Author: purposes of hearing checked indemnity insurance, found
Abdul Rohim Tualeka 85% had nerve deafness and of that number 37% the
Department of Occupational Health and Safety, frequency of 4000 Hz and 6000 Hz. Also according to
Faculty of Public Health, Airlangga University, 60115 NIOSH (National Institute for Occupational Safety and
Health) note that 22 million workers have the potential
Surabaya, East Java, Indonesia
for hearing impaired annually and 10 million workers in
e‑mail: [email protected] or
the United States have a hearing loss problem associated
abdul‑r‑[email protected]
with the job3.
Handphone: +6281333519732
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 535
The prevalence of hearing loss increased due to noise complaints worker after working for 5 years
to advances in the field of industrial technology and and it was only realized after the other party as a wife,
environmental noise. Indonesia including emerging children, and friends associate said that people need a
industrial countries, so in an effort to increase the voice loud enough to be able to hear. The increase in
construction of used industrial equipment which can hearing threshold on the group work period> 5 years.
cause noise in the workplace. It is a damaging impact Exposure to noise below 85 dB for a while does not
on workers if it is not prevented by the noise control cause a decrease in auditory function permanently7.
programs include the use of hearing protection for
workers exposed to noise4. Factors associated with hearing loss in the
Production Department of Labor PT. Japfa Comfeed
In Indonesia, the problem of noise included in the Indonesia in Makassar Unit found the results of the risk
major problems in the industrialized world. It is evident of age 23.9%, 45.7% work period risk, risk working long
from the prevalence of hearing loss due to noise exposure 45.7%, 58.7% do not wear APT, high noise intensity of
in the workplace. Noise exposure received by workers 41.3% and complaints of hearing 60, 9% 10, Rahmawati
with a prevalence ranging from 86.1 to 108.2 dB Noice research on factors associated with hearing loss in
Induced Hearing Loss (NIHL) amounted to 31.81% 5. workers in the department of metal forming and heat
treatment of PT. Dirgantara Indonesia (Persero) in 2015
Occupational hearing disability (occupational found no association with the use of ear protectors non
deafness/noise‑induced hearing loss) is the partial or audiotory with subjective complaints (p value = 0.001)5.
complete loss of hearing someone permanent, on one
or both ears caused by the continuous noise in the One company that has the risk of hearing loss is
workplace environment. Hearing loss due to noise can PT. X engaged in business in the supply, processing
be prevented by doing some preventive measures such and distribution of steel and concrete material
as by the use of noise protection devices, limitation of ready for konsruksi industry, electricity, mining,
exposure time and periodic audiometric examinations telecommunications and transportation. The company
for early detection of disturbance. In connection with has a staff of about 485 people with as many as 157
the effort to implement health and safety, the use of production employees. Locations intensity of noise,
personal protective equipment is one attempt to control there are 4 parts, iron pole, elbow, pipe and work shop.
workplace noise. Act 1 of 1970 on Occupational Safety,
in particular Articles 9, 12 and 14, which govern the A preliminary survey of researchers in July through
provision and use of personal protective equipment at interviews with 10 workers on each production PT. X
the workplace6. said there were complaints of hearing in 6 (60%) say
often experience dizziness, impaired communication
factors associated with hearing loss is noise, and concentration at work less hard because the engine
age, years of service, the use of personal protective sound with the sound of pipe cutting machine, grinding
equipment, history of smoking, use of ototoxic drugs, machine iron, zinc plate waves and 4 (66.7%) with an
neighborhood, gender and medical history. The factors average age of workers> 35 years. 5 people (83.3%) had
that most affect the value of hearing threshold is the hearing loss such as ringing in the ears due to work more
age and length of exposure to noise. Someone workers than five years, 10 people have been interviewed four
have a longer service life may be at risk of occupational people no hearing loss because when working with ear
diseases than workers who have shorter working lives7. protection equipment.

Age is a determining factor the increase someone Method

listening threshold value. The level of compensation is
used a correction factor of 0.5 dB per year for workers This type of research is analytic with cross sectional
with more than 40 years of age. Age is a determining approach, in which both the data collection for the
factor the increase someone listening threshold value. independent variables (the noise intensity, age, years
Some of the changes associated with the aging can occur of service, the use of PPE) and the dependent variable
in the ear. Membrane in the middle ear, including the ear (hearing loss subjectively) done together at the same
drum becomes less flexible as we age8. time.11

Clinical symptoms of patients with hearing loss due This research was conducted at PT. X. When the
536 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
study in January‑October. The population in this study Based on Figure 2 above it can be seen that 39.3%
were all workers at the production unit of PT. X as have a lifespan of at risk at PT. X. The results are
many as 157 people with a sample of 61 people. The consistent with research done Ibrahim factors associated
sampling technique using proportional random sampling with complaints of hearing loss in manpower production
technique. PT. Japfa Comfeed Indonesia, Tbk. Makassar unit found
the results of which 40.5% have a lifespan of at risk 9
The statistical test used chi‑square in data processing
with SPSS is as beikut 12:

a. When the table 2 x 2 found value E (expectation) <5

then the test value used is the fisher exact.
b. When the table 2 x 2 and not found the value of
E (expectation) <5 then the test value used is the
continuity correction.
Findings:

Figure 3. Work Period of Respondents

Based on the above Figure it can be seen that more

than half (55.7%) of respondents have long worked. The
results are consistent with research conducted Asriani
Risk Factors Associated with Genesis Hearing on Mine
Employees at PT Aneka Tambang (ANTAM) Southeast
Sulawesi Pomalaa results found that 55.7% of workers
have long worked12.
Figure. 1 Subjective Hearing Loss Table 1: Age relationship with Subjective Hearing
Loss
The results of the study can be seen that less than half
(49.2%) of respondents have a hearing loss subjectively. Subjective Hearing Loss p
It can be seen from the results of the research answers Total
Age Disruption Normal value
as much as 57.4% despite having to leave the workplace f % f % f %
steadily reduced hearing ability, 52.5% work while Risky 19 79.2 5 20.8 24 100
anxious, 47.5% often feel ear buzzing 44.3% others say 0,000
Not Bersiko 11 29.7 26 70.3 37 100
workers face hearing loss, 42.6% worked in the company
Total 30 49.2 31 50.8 61 100
since the health of 41% easily distracted and easily tired
while working. Based on table 1 can be seen the proportion of
workers who are experiencing hearing loss at the age of
subjective higher risk (79.2%) compared to age without
risk (29.7%). Based on test results obtained statistical p
value = 0.000 (p <0.05) there is a significant correlation
between age with hearing loss subjectively PT. X
Padang.

Results of this research is similar to research done

Ibrahim (2016) factors associated with complaints
of hearing loss in manpower production PT. Japfa
Comfeed Indonesia, Tbk. Makassar unit results found no
correlation between age with symptoms of hearing loss

Figure 2. Age of Respondents

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 537
Table. 2: Relations with Hearing Loss Work Period Conclusion
Subjective
Based on research conducted by PT. X can be
Subjective Hearing Loss summarized as follows:
Years of Total p value
Disruption Normal
Service a. Less than half (49.2%) of respondents have a hearing
f % f % f %
loss subjectively PT. X .
Long 20 74.1 7 25.9 27 100
0,001 b. Less than half (39.3%) of respondents have a
New 10 29.4 24 70.6 34 100
Total 30 49.2 31 50.8 61 100 lifespan of at risk at PT. X .
c. More than half (55.7%) of respondents have long
According to the table 2can be seen that the
worked in PT. X .
proportion of workers with hearing loss subjectively
higher on longer working lives (74.1%) compared with d. There was a significant association of age with
the new working period (29.4%). Based on test results hearing loss subjectively PT. X .
obtained statistical p value = 0.001 (p <0.05) correlation e. There is significant correlation tenure with hearing
meaningful working lives with hearing complaints of loss subjectively PT. X.
subjective PT. X Padang.
f. There is significant correlation with the noise
The results are consistent with research conducted intensity of subjective hearing loss in PT. X .
Asriani Risk Factors Associated with Genesis Hearing
Conflicts of Interest: All authors have no conflict
on Mine Employees at PT Aneka Tambang (ANTAM)
interest to declare.
Pomalaa Southeast Sulawesi future results found no
relationship working with the incidence of hearing Source of Funding: the source of the research cost
loss12. from self.
Table. 3: The intensity of the relationship Subjective Ethical Clearance: This study was approved by
Noise with Hearing Loss Bord Etis institutional Baiturrahmah University, Faculty
of Public Health.
Subjective Hearing Loss
Intensity Total p value
Disruption Normal All subjects were fully informed about the
Noise
f % f % f % procedures and objectives of this study each subject
More than
25 59.5 17 40.5 17 100 prior to the study signed an informed consent form.
NAB
0,034
Less than
5 26.3 14 73.7 14 100 References
NAB
Total 30 49.2 31 50.8 61 100 1. Ridley. Occupational Health and Safety. 2016.
2. WHO. Prevalence of Hearing Loss in The World.
According to the table 3 can be seen the proportion 2012
of workers who have a hearing loss subjectively higher
3. Heryuna. Hearing Loss Due To Noise In Steel
the noise intensity over NAB (59.5%) compared with
Company Workers On Java Island. 2013;21 (NO
the intensity of the noise is less than the NAV (26.3%).
23)(Trisakti medicine):84–90.
Based on test results obtained statistical p value = 0.034
(p <0.05) there was a significant relationship with the 4. Bashiruddin. Hearing Conservation Program for
noise intensity of subjective hearing loss in PT. X Workers Exposed to Industrial Noise. 2009;59 (NO
Padang. 1)(Major Indonesian Medicine):14–9.
5. Rahmawati. Factors Associated with Hearing
Results of this research is similar to research Susanti, Disorders in Workers in the Metal Forming and
the fertilizer production plant, the results showed that Heat Treatment Department of PT. Indonesian
there was correlation between intensity of noise with Aerospace (Persero). J Thesis. 2015;
subjective complaints of hearing loss14, The results
6. Budiono. Hearing Loss Due to Noise (Noise
are consistent with research at the hospital Ulandari
Induced Hearing Loss). 2013.
Makasar results found no correlation of noise intensity
with subjective complaints of hearing loss15 7. Tarwaka. Ergonomics for Safety, Occupational
538 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Health and Productivity. Surakarta: UNIBA Press; at PT Aneka Tambang (ANTAM) Southeast
2014. Sulawesi Pomala. University Halu Oleo Medical
8. UI FKM. Factor analysis ... Amira Primadona, Faculty. 2016;
FKM UI, 2012. 2012. 14. Permaningtyas. Relationship Between The Duration
9. Yulianto. Factors Associated With Non‑Auditory of Work Period and The Incidence of noise‑induced
Disorders Due To Noise In Rock Musicians. hearing loss in Exhaust Industry Home Workers
JThesis. 2013; in Purbalingga LOR. Mandala Heal. 2011;Vol. 5
(NO).
10. Ibrahim H, Basri S, Hamzah Z. Factors Associated
With Complaints of Hearing Disorders in the 15. Susanti. Subjective Complaints on Noise and
Production Workforce of PT. Japfa Comfeed. Control Efforts in the NPK Granulation Unit 3
Al‑Sihah Public Heal Sci J [Internet]. 2016;8:121– of PT Petrokimia Gresik. J Thesis FKM UNAIR.
34. Available from: http://dx.doi.org/10.1016/ 2010;
B978‑1‑4557‑5134‑1.00001‑9 16. Ulandari. Noise Relationship with Hearing Loss
11. Notoatmodjo. Health Research Methodology. of Laundry Workers/Makassar City Hospitals. J
Jakarta: Rineka Copyright; 2012. Thesis Hassanuddin University. 2014;
12. Luknis. Health Statistics. 2006. 17. Pratama. Environmental Noise. semarang: Issuing
Agency UNDIP; 2010. from: http://dx.doi.
13. Asrun A. Risk Factors Associated with the
org/10.1016/B978‑1‑4557‑5134‑1.00001‑9
Occurrence of Hearing Loss in Mining Employees
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 539

The Role of Matrix Metalloproteinase‑9 (MMP‑9) and Tissue

Inhibitor Metalloproteinase‑1 (TIMP‑1) Level in Dengue
Hemorrhagic Fever

Dasril Daud1, Nina Cicci Hasnani1, Husein Albar1

1Departement of Pediatrics, Faculty of Medicine, Hasanuddin University, Makassar, South Sulawesi, Indonesia

Abstract
Introduction: Vascular leakage is a hallmark of Dengue Hemorrhagic Fever (DHF), due to changes in
interactions between cells and extracellular matrix in endothelial basement. It major components is type
IV collagen that can be destaged by MMP‑9. However, MMP‑9 has an endogenous regulator, TIMP‑1.This
study aimed to evaluate between MMP‑9 and TIMP‑1 serum levels in children with DHF.

Method: A cross‑sectional study, conducted in Wahidin Sudirohusodo Hospital Makassar, Indonesia.

Population of children aged 1 to 18 years from September 2014 to March 2015.

Results: Out of 38 subjects, DHF stage I (34,2%), stage II (39,5%), stage III (26,3%) and no stage IV. No
significant different levels of MMP‑9 and DHF (P>0.05). There was difference levels of TIMP‑1 in stage
I and II (P<0,05). Level of MMP‑9/TIMP‑1 ratio is higher in stage I than II (P<0.05). Positive correlation
between MMP‑9 and TIMP‑1 levels in stage II (P<0.05).

Conclusion: The levels of MMP‑9 serum could not represent vascular condition in DHF. However, TIMP‑1
serum, MMP‑9/TIMP‑1 ratio, and correlation between the levels of MMP‑9 and TIMP‑1 in DHF describe
the vascular state instage I and II.

Keywords: MMP‑9, TIMP‑1, Dengue Hemorrhagic Fever, Children.

Introduction be inhibited by natural inhibitors that TIMP‑1. TIMP‑1

binds non‑covalently with the active MMP with a molar
As the endothelium forms the primary barrier of
ratio of 1:1. The ability to inhibit MMP is shown by its
the circulatory system, dysfunction of the endothelial
ability to bind to the zinc‑binding site in the catalytic
cells during acute diseases can broadly affect vascular
domain of active MMP.5 Vitro studies on immature
permeability and cause plasma leakage.1 Plasma leakage
dendritic cells are infected and uninfected dengue virus
is a major marker of dengue hemorrhagic fever (DHF)
DV, an increase of about 5‑fold for MMP‑9 and 20‑fold
and dengue shock syndrome (DSS) associated with the
for TIMP‑1,1.6 however this has not been poven in
secretion of inflammatory mediators in the circulation
humans yet.
system, changes in adhesion cell interactions –
extracellular matrix (ECM) and adhesion cell.1,2,3 ECM The aim of this study was to evaluate the levels of
‑ adhesion cells in endothelial basement membrane MMP‑9 and TIMP‑1 in children with DHF. Hypothesis
with the main components is type IV collagen, which inthis study are MMP‑9 levels were higher in DHF with
is destaged by MMP‑9, causing detachment from the higher stages, TIMP‑1 levels were lower in DHF with
basement membrane.3,4 higher stages and the ratio of MMP 9 and TIMP‑1 were
higher in DHF with higher stages.
Matrix Metalloproteinase‑9 (gelatinase B) is a
local proteolysis by degrading elastin (fibrous structural
Method
protein), collagen type IV and some other ECM
molecules. MMP‑9 which has been fully activated can This is a cross sectional study to evaluate the MMP‑9
540 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
and TIMP‑1 levels in patients with DHF. The study significantly different in DHF.
conducted in pediatric ward of Child Health Department
of Dr. Wahidin Sudirohusodo hospital, Makassar, However, Kruskal Wallis test between TIMP‑1
Indonesia from September 2014 until March 2015. levels of DHF stage I, stage II and stage III shows a
significant difference with p = 0.043 (p<0.05).Post Hoc
The study population was patients with DHF analyses to determine which DHF group has difference
without shock (stageI and II) and with shock (stage III by using a Mann Whitney test, it is found a significant
and IV), aged 1 to 18 years.On the day of admission all difference of TIMP‑1 levels in group DHF stage I and
patients diagnosed with DHF based onWHO criteria. II,p value = 0.020 (p<0.05) (table 3). Presumably it
The diagnosis was confirmed by IgM and IgG anti has something to do with the binding between MMP‑9
dengue serological examination. Patients who met the and TIMP‑1; therefore, the levels of TIMP‑1 were
inclusion criteria were grouped into DHF stage I, II, significantly only in DHF stage I and II.
III and IV according to the WHO 1997. The age, sex,
weight, height, and nutritional status were measured. Kruskal Wallis test between MMP‑9/TIMP‑1
From each group, blood sample were taken to evaluate ratioin DHF stage I, stage II, and stage III does not
the MMP‑9 and TIMP‑1 levels. The inclusion criteria show a significant difference with p = 0.074 (p >0.05).
are the dengue patient, age from 1‑18 years and want to Nevertheless, there is a significant difference with p =
be the sample of study and signed the informed consent. 0.018 (p<0.05) between MMP‑9/TIMP‑1 ratio in DHF
While the exclusion criteria are the dengue patient with stage I and II (table 4).This is influenced by the levels of
another disease, blood transfusion, and corticosteroids. MMP‑9 and TIMP‑1 serum so the meaningful significant
The study protocol was approved by Commission on is only between DHF stage I and II.
Human Biomedical Research Ethics, Faculty of Medical, Linear regression analyses between MMP‑9 and
Hasanuddin University. TIMP‑1 in table 5 shows a positive correlation of 0.220
The obtained data were grouped based on the in DHF stage 1 and 0.531 in DHF stage 2, negative
objective and types of data into DHF wihout shock correlation of‑0.139 in DHF stages 3. There is no
(stageI and II) and DHF with shock (stage III and IV) to significant correlation inDHF stage 1 and 3 with p 0.470
be analyze using appropriate statistic method; univariat, and 0.701 (p >0.05). There is a significant correlation
bivariat, and multivariate analyses. between MMP‑9 and TIMP‑1 in DHF stage 2 with p
0.042 (p <0.05) (table 5). Allegedly this is due to the
Results stage of complex 3 is formed MMP‑9: TIMP‑1 were
significantly.
Table 1 shows sample characteristics in term of sex,
age, nutritional status, DHF stage I, II, III, and IV, MMP‑9 Table 1: Characteristics sample
and TIMP‑1 levels. In sex category it is shown that there
are 23 (60.5%) male and 15 (39.5%) female. In age No. Characteristics Sample Total (n=38)
group it is found that the median is 6.75 year old, range 1 Sex
1‑14 years old, with mean age of 6.87 years and standard Male : Female (%) 23 : 15 (60.5 : 39.5)
deviation of 3.83 years. In nutritional status column, it 2 Age (Year)
is found that there is 1 patient who were overweight Median (Range) 6.75 (1 – 14)
(2.6%),23 (60.5%) with a good nourished,13 (3.42%) Mean (SB) 6.87 (3.83)
with undernourished,and 1 (2.6%) with malnourished. 3 Nutritional status
In DHF stage I group there are 13 (34.2%) patients, 15 Overweight: Good nourished
1 : 23 : 13 : 1 (2.6 :
(39.5%)in stage II, 10 (26.3%) in stage III, and none in Undernourished: malnourished
60.5 : 34.2 : 2.6)
(%)
stage IV DHF group.
Dengue Hemorrhagic Fever
Kruskal Wallis test results showed no significant 4 Without Shock : Shock (%)
difference with p = 0.766 (p >0.05) between MMP‑9 Stage I (%) 28 : 10 (73.7 : 26.3)
levels in group DHF stage I, stage II, and stage III Stage II (%) 13 (34.2)
(table 2). Allegedly it is associated with the function of Stage III (%) 15 (39.5)
MMP‑9 as a local proteolysis and binding of MMP‑9 to Stage IV (%) 10 (26.3)
TIMP‑1 in vascular that serum MMP‑9 levels were not
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 541

No. Characteristics Sample Total (n=38) Table 3. Analyses comparison between TIMP‑1 level
MMP-9 (ng/ml) level 0 (0) in DHF stage I, stage II and stage III
5 Median (Range)
DHF
Mean (SB) 1.77 (0.20 – 31.01)
TIMP‑1 levels Without shock (n=28)
TIMP-1 (ng/ml) level 4.74 (7.93) (ng/ml) Shock/Stage
Stage I Stage II III (n=10)
6 Median (Range) 2.38 (0.18 – 10.97) (n=13) (n=15)
Mean (SB) 2.95 (2.27) Median 1.77 3.01 2.78

Kruskal Wallis test results showed no significant difference with Standard

1.15 2.53 2.09
p = 0.766 (p >0.05) deviation
Range 0.17 – 5.15 0.88 – 10.97 1.13 – 8.22
Table 2. Analyses of comparison between MMP‑9 Kruskal Wallis test df = 2 (p <0.05)
level of DHF stage I, stage II and stage III
Table 4: Analyses Comparison between MMP‑9/
DHF TIMP‑1 ratio in DHF stage I, stage II and stage III
MMP‑9 Levels Without Shock (n=28) Shock/
(ng/ml) Stage I Stage II Stage III DHF
(n=13) (n=15) (n=10) MMP‑9/TIMP‑1 Without shock (n=28) Shock/
Median 1.84 1.10 1.81 Ratio Stage I Stage II Stage III
Standard (n=13) (n=15) (n=10)
7.12 7.76 9.63
deviation Median 2.18 0.59 0.37
Range 0.27 – 27.06 0.20 – 29.08 0.36 ‑31.01 Standard
5.49 1.65 4.81
Kruskal‑Wallis test df = 2 (p > 0.05) deviation
Range 0.11 – 17.83 0.09 – 6.53 0.18 ‑14.85
Kruskal Wallis test df = 2 (p >0.05)

Table 5: Linear regression analyses between MP‑9 and TIMP‑1 in DHF

DHF Stage 1 (n=11) DHF Stage 2 (n=13) DHF Stage 3 (n=10)

Variable
Correlation p value Correlation p value Correlation p value
MMP‑9 and TIMP‑1 0.220 0.470 0.531 0.042 ‑0.139 0.701
Spearman’s rho correlations

Discussion TIMP‑1 and VD so far are obtained only a study in

vitro.7,8,9
The results of this study, there were no significant
difference between the levels of MMP‑9 and DHF, but In vitro study by Luplerdlop et al.he obtained a
there is a difference between the levels of TIMP‑1 DHF significant difference between the levels of MMP‑9
stage I, stage II and stage III with significant differences imature dendritic cells are infected and uninfected
in stage I and II. There is a significant difference between VD and research by Luplerdlop and Misse obtained a
the ratio of the levels of MMP‑9/TIMP‑1 DHF stage I non‑significant difference between the levels of MMP‑9
and stage II, and there is a significant positive correlation MVEC (macrovascular endothelial cells) of infected
between levels of MMP‑9 and TIMP‑1 in DHF stage and uninfected VD.7,8 It means that VD activate the
II. Retrieved 38 samples were grouped into 4 groups, dendritic cells or monocytes to produce MMP‑9 and did
DHF stage I have 13 samples (34.2%), stages II have not activate endothelial cells to produce MMP‑9. This
15 samples (39.5%), stage III have 10 samples (26.3%) study was supported by the research of Seanpong et
and none in stage IV. Analyses was performed on the al.which he found that the levels of MMP‑9 increased
levels of MMP‑9 and TIMP‑1. Study on MMP‑9 and in monocytes (U937) and not in hepatocytes (HepG2)
virus dengue (VD) is still rare. Some of these studies are infected with VD.9
studied in vitro and vivo, while the relationship between
542 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
In this study found a mean value of the MMP‑9 of MMP‑9/TIMP‑1 were higher in stage I compared
DHF levels corresponding increase in rank, but there the stage II. This is not in accordance with the initial
was no significant difference with p = 0.766. This is hypothesis. MMP‑9 as a function of local proteolysis,
according to the research by Voraphani et al. which thereby MMP‑9 are found abundantly in the vascular
obtained a non‑significant difference between dengue tissue and not so that play a role in DHF stage I and
and DD. This is related to the function of MMP‑9 as II are TIMP‑1, which is visible from the ratio of the
a local proteolys is and binding of MMP‑9 by TIMP‑1 levels of MMP‑9/TIMP‑1. But for DHF stage III, the
in vascular; therefore,the levels of MMP‑9 serum did levels of MMP‑9 ratio/TIMP‑1 and TIMP‑1 is no longer
not differ significantly on dengue and the study did meaningful, presumably this is due to the binding of
not measure the levels of MMP‑9 complex: TIMP‑1 TIMP‑1 to MMP‑9 which can be measured with a complex
that measures MMP‑9 after it tied with TIMP‑1.4 In MMP‑9: TIMP‑1 examination. This is supported by the
vitro study obtained significant difference between results of the linear regression correlation is performed
the levels of TIMP‑1 imature dendritic cells infected as TIMP‑1 is a specific endogenous inhibitor of MMP‑9.
and uninfected VD, while the other ones obtained a [5] There is a positive correlation between levels of
significant difference between the levels of TIMP‑1 MMP‑9 and TIMP‑1 in DHF stage I and stage II, this
MVEC (macrovascular endothelial cells) of infected and means that the levels of MMP‑9 in line with the levels of
uninfected VD. This means VD activates the monocytes TIMP‑1. However, the only significant correlation when
and derivatives to produce MMP‑9, the monocyte and there is spontanously bleeding (DHF stage II).
endothelial derivatives to produce TIMP‑1. This study
was supported by the research of Seanpong et al.9which However, this study has absence of data and dengue
found that there were expressions of TIMP‑1 in fever on how day longof patient in stage IV, the number
monocytes (U937) and not in hepatocytes (HepG2) were of small sample, and not an examination of the serotypes
infected with VD. TIMP‑1 is activated by endothelial VD because of differences would affect the levels
due to stress on the blood vessels due to changes in the of MMP‑9 and TIMP‑1, and the absence of MMP‑9
interaction between endothelial‑MES and endothelial complex measurements: TIMP‑1. The strengths of this
caused by MMP‑9. study is dengue is a disease that causes changes in the
interaction or adhesion between endothelial vascular
Studies in vivo TIMP‑1 and dengue have not been and between endothelial‑MES that cause vascular
obtained by the author. Kruskal Wallis test results leakage. Vascular leakage rate is directly proportional
between the levels of TIMP‑1 DHF stage I, stage II, stage to the severity of DHF. This study describes the various
III and obtain the result of significant differences with pathomechanism MMP‑9 and TIMP‑1 in DHF, the in
p values of 0.043 (p <0.05). After a post hoc analyses vivo studies that provide new insights into the levels of
to determine the DHF group that have different, with TIMP‑1, the ratio of MMP‑9/TIMP‑1, and the correlation
Mann Whitney test obtained significant differences in between MMP‑9 and TIMP‑1 in various DHFstages.
the levels of TIMP‑1 DHF stage I and II, the value of p Thus providing new insights into the MMP‑9, TIMP‑1,
= 0.020 (P <0.05).TIMP‑1 Activated by monocytes and and vascular function.
derivatives as well as endothelial response to vascular
leakage caused by MMP‑9. Allegedly levels of TIMP‑1 We concluded that there is no relationship between
gives an overview of the initial damage vascular function serum MMP‑9 levels and severity of dengue. But there
due to vascular leakage caused by MMP‑9 destages is a relationship between serum levels of TIMP‑1 and
collagen type IV result, whereas type IV collagen is a the ratio of MMP‑9/TIMP‑1 against DHF stage I and
major component of basement membranes endotel.3 II, as well as a significant and positive correlation
between levels of MMP‑9 and TIMP‑1 in DHF stage II.
Study for MMP‑9/TIMP‑ 1 ratio and DHF has not This means that the levels of MMP‑9 serum could not
been found in the journals, but the research ratio of represent vascular condition in DHF. However, serum
MMP‑9/TIMP‑1 in community acquired pneumonia levels of TIMP‑1 and MMP‑9/TIMP‑1 ratio describe the
showed higher than control.[10] In this study, there were vascular state in DHF stage I and II.
no significant differences between the ratio of MMP‑9/
TIMP‑1 DHFstage I, stage II and stage III, but there Conflict of Interest: None.
is significant difference between the ratio of MMP‑9/ Source of Funding: All the study’s fund was borne
TIMP‑1 DHF stage I and stage II with ratio of the levels by the authors.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 543
Ethical Clearance: Ethical clearance was given by approach to Prevent heart failure? Circ Res. 2011;
the Faculty of Medicine of Hasanuddin University ethic 89:201‑10.
committee. 6. World Health Organisation. Comprehensive
guidelines for prevention and control of dengue and
References dengue haemorrhagic fever revised and expanded.
1. Lee, Ying‑Ray. Liu, Ming‑Tao. Lei, Huan‑Yao. 2011
Liu, Ching‑Chuan. Wu, Jing‑Ming, Chen, 7. Luplerdlop N., Missè D., Bray D. Dengue virus
Shun‑Hua. etc. MCP‑1, a highly expressed infected dendritic cells trigger vascular leakage
chemokine in dengue haemorrhagic fever/dengue through metalloproteinase overproduction. EMBO
shock syndrome patients, may cause permeability Rep. 2006; 7: 1176‑81.
change, possibly through reduced tight junctions 8. Luplertlop N, Missè D. MMP cellular responses to
of vascular endothelium cells. Journal of General dengue virus infection‑induced vascular leakage.
Virology. 2006; 87: 3623–3630 Jpn. J. Infect. Dis. 2008; 61: 298‑301.
2. Nagase.H., Visse. R., Murphy. G. Structure and 9. Seanpong P., Srisaowakarn C., Thammaporn A.,
function of matrix metalloproteinases and TIMPs, Leardkamolkarn V., KumkateS. Different responses
cardivascular research. 2006 in MMPs/TIMPs expression of U937 and Hep G2
3. Rovensky Y.A. Adhesive Interactions in Normal cells to dengue virus infection. Japanese Journal of
and Transformed Cells. Springer Science. 2011 Infectious Diseases. 2015
4. Voraphani, N., Khongphatthanayothin, A., Srikaew 10. Chiang TY, Yu YL, Lin CW, Tsao SM, Yang SF,
K. Matrix metalloproteinase‑9 (MMP‑9) in children Yeh CB. The circulating level of MMP‑9 and its
with dengue virus infection. Jpn. J. Infect. Dis. ratio to TIMP‑1 as a predictor of severity in patients
2010; 63: 346‑8. with community‑acquired pneumonia. Clin Chim
5. Creemers E.E.J.M., Cleutjens J.P.M., Smith Acta. 2013; 23: 424:261‑6.
J.F.M., Daemen M.J.A.P. Matrix metalloproteinase
inhibition after myocardial infection. A new
544 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Ethanol Extract with Black Cumin (Nigella Sativa) Against

sFlt‑1 Level and VEGF Serum on Laboratory Mice with
Preeclampsia

Deasy Irawati1, Hidayat Suyuti2, Titi Maharrani3, Fitriah1, Ani Media Harrumi3, Suryaningsih1, Nursalam4
1Bangkalan Midwifery Diploma Study Program, the Health Ministry Polytechnic of Surabaya, 2Master Program
in Biomedical Sciences, Brawijaya University, 3Soetomo Midwifery Diploma Study Program, Health Ministry
Polytechnic of Surabaya, 4Faculty of Nursing, Universitas Airlangga

Abstract
Introduction: Preeclampsia is one of the complications that occur in pregnancies. This study was aimed
to study the factors that affect the of giving ethanol extract with black cumin (Nigella sativa) against sFlt‑1
level and VEGF serum on laboratory mice induced preeclampsia.

Method: Laboratory experimental research with post test only control group design. This study used 30
BALB/C laboratory mice, divided into 6 groups, namely negative controls: pregnant mice injected serum
from normal pregnant women, positive controls; mice modeled preeclampsia, and treatment groups 1, 2,
3 and 4 are preeclampsia mice received a dose of 500 mg, 1000 mg, 1500 mg and 2000 mg/kg weight of
Nigella sativa ethanol extract for 5 days. Statistical analysis using ANOVA

Result: The mean serum sFlt‑1 level in mice modeled preeclampsia and treatment group dose 500mg,
1000mg, 1500mg and 2000mg (2510.3+182.2 pg/mL, 2142.5+171.9 pg/mL, 1309+161.3 p/mL, and
1500+169.9, respectively) pg/mL) showed a significant difference (p<0.05) and found a decrease in serum
sFlt‑1 levels with increasing doses. The mean serum VEGF levels in preeclampsia mice and treatment groups
were 500 mg, 1000 mg, 1500 mg and 2000 mg (50.25±2.85b pg/mL, 60.18±4.81c pg/mL respectively,
71.89±2.38d pg/mL, 66.51±1.87 e pg/mL) showed a significant difference (p<0.05) and found an increase in
serum VEGF levels as the dose increased.

Conclusion: Giving of Black Cumin extract (Nigella sativa) decreases serum sFlt‑1 levels and increases
serum VEGF levels in preeclampsia mice model and the effect is dependent dose.

Keywords: sFlt‑1, VEGF, Nigella sativa, preeclampsia.

Introduction of proteinuria 300 mg or more than 30 mg/dL per 24

hours1. Preeclampsia occurs in about 3‑5% of pregnant
Preeclampsia is one of the complications that
women worldwide and the number two cause of death for
occur in pregnancies of more than 20 weeks which is
pregnant women. In the United States, 15% of maternal
characterized by an increase in systolic blood pressure
deaths are caused by preeclampsia 2’3.
greater or equal to 140 mmHg or diastolic pressure
greater than or equal to 90 mmHg and the amount The pathogenesis of preeclampsia occurs with a
variety of mechanisms, but placental ischemia/hypoxia is
likely to be a major factor due to disruption of trophoblast
invasion4. Placental ischemia will stimulate excessive
Corresponding Author: production of sFlt‑1 or VEGFR‑1. The presence of
Nursalam sFlt‑1 as a competitor for surface VEGF receptors
Faculty of Nursing, Universitas Airlangga (Flt‑1), causes VEGF cannot attach to receptors on the
e-mail: [email protected] cell surface. This situation causes serum VEGF levels
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 545
to decrease and induce endothelial cell damage in the mice injected with serum of normal pregnant women
glomerulus, producing a urine protein5’6. were used as negative controls, preeclampsia mice were
as positive controls, and 4 groups of preeclampsia mice
Black cumin has been used as a traditional were treated with BC‑e with a dose of 500 mg, 1000
medicine for thousands of years for various diseases mg, 1500 mg and 2000 mg/kg of body‑weight/day for
such as asthma, coughing, bronchitis, headaches, 5 days. Mice model preeclampsia made by injecting
fever, and rheumatism7. Seed extracts of both water serum of preeclamptic pregnant women on the 10th and
and oil have the potential to be anti‑tumor, antioxidant, 11th days of gestation each 0.1cc intraperitoneally13.14.
anti‑inflammatory, anti‑hypertensive, anti‑diabetic and The manifestation of preeclampsia in mice is obtained
anti‑seizure. Thymoquinone (TQ) is the main constituent by finding hypertension and proteinuria on the 15th
of Black Cumin essential oil8,9. As an antioxidant, day of gestation. Maintenance of mice and modeling
thymoquinone synergizes with other compounds such as of preeclampsia were carried out at the Pharmacology
dithymoquinone and thymol as a free radical scavenger10. Laboratory of the Faculty of Medicine, University of
As TQ Anti‑inflammatory inhibits activation of NFĸβ. Brawijaya and got standard food and drink.
In cases of preeclampsia where placental hypoxia
occurs, activation of NFĸβ will affect the expression Mice are terminated at 20 weeks’ gestation and
of hypoxia‑inducible factor 1‑α (HIF1‑α)11 which is a blood and kidney organs are collected. Examination of
VEGF12 transactivator. sFlt‑1 and VEGF levels in mice serum was measured
using an ELISA kit, pg/Ml unit.
By referring to the above facts because Black Cumin
(Nigella Sativa) has the potential as an antioxidant and Result
anti‑inflammatory, it is necessary to conduct research on
the molecular mechanism of Black Cumin extract (BC‑e) The comparison test results showed a difference
on serum sFlt‑1 and VEGF levels in preeclampsia mice. (p = 0.000 <) the mean serum sFlt‑1 level between the
negative control group (healthy mice) (579.8 ± 114.8
Design and Method pg/mL) and the positive control group (preeclampsia
mice) (2752.8 ± 188.7 pg/mL)) Likewise there was a
This research is a laboratory experimental study with significant difference (p = 0.000 <) mean serum VEGF
a post test only control group design. This study measured levels between healthy groups (88.56 ± 5.58 pg/mL)
serum sFlt‑1 and VEGF levels in the mice model of with preeclampsia mice model (44.85 ± 2.15 pg/mL).
preeclampsia after being given several doses of Nigella As shown in table 1.
sativa extract. A total of 30 pregnant BALB/C mice
were used in this study, divided into 6 groups: pregnant

Table 1: Results of Comparison of Control Groups

Variable Negative Control (Healthy) Mean ± SD Positive Control (Eclampsia) Mean ± SD p‑value
sFlt‑1 serum level (pg/mL) 579.8±114.8 2752.8±188.7 0.000
VEGF serum level (pg/mL) 88.56±5.58 44.85±2.15 0.000

Based on the results of the one way ANOVA treatment group gave ethanol extract Nigella sativa
test on serum sFlt‑1 level data, there were significant doses 500mg (2510.3±182.2b pg/mL), with a dose
differences in the mean serum sFlt‑1 level in the of 1000mg (2142.5±171.9cpg/mL), with a dose of
five observation sample groups (p‑value<0,000). 1500mg (1309±161.3dpg/mL), and also with a dose of
Furthermore, the Multiple Comparisons with the 2000mg (1500±169.9dpg/mL). This means that there is
Least Significant Difference (LSD) showed that there a treatment effect of giving 500mg, 1000mg, 1500mg
was a difference between the mean serum sFlt‑1 and ethanol Nigella sativa extracts to serum sFlt‑1 levels
levels between the positive control group (model in preeclampsia mice.
preeclampsia mice) (2752.8±188.7apg/mL) and the
546 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 2: The influence of Nigella sativa ethanol extract on mean serum sFlt‑1 levels and VEGF levels

Intervention Group Mean Serum sFlt‑1 levels (pg/mL) Mean Serum VEGF (pg/mL)
Negative control 579,8 88,56
Positive control 2752,8 44,85
Preeclampsia Mice + Ethanol Extract 500 mg 2510,3 50,25
Preeclampsia Mice + Ethanol Extract 1000 mg 2142,5 60,18
Preeclampsia Mice + Ethanol Extract 1500 mg 1309,0 71,89
Preeclampsia Mice + Ethanol Extract 2000 mg 1500,0 66,51

Based on the results of the One Way ANOVA test TNF serum levels in pregnant mice. Increased levels
on VEGF level data, there were significant differences of sFlt‑1 in preeclampsia patients can reduce levels
in the mean VEGF levels of the five observation sample of free VEGF and PlGF in the circulation resulting in
groups (p‑value=0,000). Furthermore, the Multiple the onset of symptoms of preeclampsia16,17. Soluble
Comparisons with the Least Significant Difference Fms‑like tyrosine kinase‑1 (sFlt‑1), also known as
(LSD) showed that there were significant differences Soluble vascular endothelial growth factor receptor
in the mean VEGF levels between the positive control 1 (sVEGFR‑1) which is a soluble receptor for VEGF
group (preeclampsia mice) (44.85±2.15 pg/mL) and the and PlGF18 which acts as VEGF and PlGF against by
treatment group administered ethanol extract Nigella binding and inhibiting interactions both of them against
sativa at a dose of 500mg, 1000mg, 1500mg and 2000mg endogenous receptors19.
(50.25±2.85b pg/mL, 60.18±4.81c pg/mL, 71.89±2.38d
pg/mL and 66.51±1.87e pg/mL). There appears to be an This study showed the serum VEGF levels
increase in serum VEGF levels along with an increase of preeclampsia mice have a significant decrease
in the dose of ethanol extract except at doses of 2000 compared to control mice. The injection of serum
mg. If based on the average value of VEGF levels, the for pregnant women PEB in pregnant mice causes
treatment group doses 1500mg show the highest value of pre‑eclampsia‑like symptoms because TNF‑α found in
the average VEGF level (71.89±2.38d pg/mL) compared maternal serum binds to TNF type 1 receptors (TNFR‑1)
to the group in other doses and can be considered the mice which in turn activate the NF‑κB20 transcription
fastest dose in increasing VEGF levels in mice models factor. NF‑κβ activation by TNF α may play a role in
preeclampsia. inducing HIF‑1α21 which is a transcription factor for
sFLT formation in the placenta22. sFlt does not have a
The occurrence of a decrease in serum sFlt‑1 levels transmembrane domain and membrane6 cytoplasmic
and an increase in VEGF in line levels in increasing domain, so the bond between VEGF and PlGF to sFlt‑1
doses. The 1500mg dose seems to be the optimal dose cannot provide a second messenger for angiogenic and
of reducing serum sFlt‑1 levels and increasing serum has an antiangiogenic effect5. The presence of sFlt‑1 as
VEGF levels. a competitor for surface VEGF receptors (Flt‑1) causes
VEGF cannot attach to receptors on the cell surface.
Discussion This condition causes serum proangiogenic VEGF
This study showed that sFlt‑1 serum levels in levels to drop by 5/6. Decreasing levels of free VEGF
pregnant mice injected with pre‑eclampsia maternal can also indirectly increase in blood. The low levels of
serum (2752.8±188.7 pg/mL) significantly increased free VEGF in serum could decrease in nitric oxide (NO)
compared with negative control mice. The administration which cause in blood vessel vasoconstriction followed
of pre‑eclampsia serum intraperitoneal injection with by an increase in blood pressure.
high TNF levels in pregnant mice increase blood There was a significant difference in serum sFlt‑1
pressure and serum sFlt‑1 levels14 which caused by an levels in preeclampsia mice with a treatment group
increase in angiotensin II15. given a dose of BC‑e dose of 500 mg, 1000 mg,
The previous study reported that the administration 1500 mg, and 2000 mg. Antioxidant supplements to
of IgG injection of preeclampsia mothers increase preeclampsia patients able to reduce serum sFlt‑1 levels
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 547
and increase serum PlGF levels. Black cumin with the given and the optimal dose of NS in increasing VEGF
main content of Thymoquinone (TQ) has the potential as levels in serum is 1500 mg. At a dose of 2000 mg, there
an antioxidant so that it can reduce serum sFlt‑1 levels in is a decrease in serum VEGF levels. This is presumably
preeclampsia mice significantly23. TQ is able to inhibit because the effect of hormesis is found in the effects of
organ damage caused by free radicals10. The antioxidant the response dose27, where at low doses black cumin
effects of TQ, dithymoquinone, and thymol be able to ethanol extract has a beneficial effect while at high doses
inhibit some reactive oxygen species (ROS). TQ and it has a detrimental effect.
dihydrothymoquinone (DHTQ) have the ability as free
radical scavengers with a half inhibitory concentration Conclusion
(IC50) in nanomolar concentrations and micromolar10. Giving of Black Cumin extract (Nigella sativa)
All ingredients of black cumin have a strong antioxidant decreases serum sFlt‑1 levels and increases serum
effect, where thymol works by quelling single oxygen VEGF levels in preeclampsia mice model and the effect
production, while TQ and dithymoquinone show is dependent dose.
activities such as superoxide dismutase (SOD)24.
Ethical Clearance: Ethical approval was obtained
There was a significant difference in the mean serum from the ethics committee of Brawijaya University.
VEGF levels of preeclampsia mice with a treatment
group that was given a dose of 500 mg, 1,000 mg, Funding: Self Funded
1500 mg, and 2000 mg of BC‑e. The effect of BC‑e on
increasing serum VEGF levels in preeclampsia mice Conflict of Interest: None
is not fully understood. TQ has the ability to inhibit
transcription factors, nuclear factor kappa β (NFĸβ) is
References
thought to be the cause. TQ as an inflammatory inhibitor 1. Noris M, Perico N, Remuzzi G. Mechanisms
works through anti‑inflammatory and proapoptotic of Disease: pre‑eclampsia. 2005;1(2):98‑114.
action25. doi:10.1038/ncpneph0035.
2. Cindrova‑davies T. The therapeutic potential
TQ can inhibit the bonding of NFĸβ to DNA
of antioxidants, ER chaperones, NO and H 2 S
through direct interaction with sub‑unit p65. TQ will
donors, and statins for treatment of preeclampsia.
inhibit activation by IkBα kinase which in turn will
2014;5(May):1‑13. doi:10.3389/fphar.2014.00119.
inhibit degradation and phosphorylation of IĸBα thereby
inhibiting the activation and translocation of NFĸβ 3. Conti E, Zezza L, Ralli E, et al. Growth factors
from the cytoplasm to the cell nucleus26. Barriers to in preeclampsia: A vascular disease model: A
activation of NF‑kβ cause decreased HIF1‑α expression. failed vasodilation and angiogenic challenge
In preeclampsia placenta, the inhibition of activation of from pregnancy onwards Cytokine Growth
HIF1‑α can reduce the synthesis of sFlt anti‑angiogenic Factor Rev. 2013;24(5):411‑425. doi:10.1016/j.
factors, and ultimately increase the VEGF angiogenic cytogfr.2013.05.008.
factor that enters the maternal circulation. 4. Gilbert JS, Ryan MJ, Lamarca BB, et al.
Pathophysiology of hypertension during
The role of BC‑e as an antioxidant is also thought preeclampsia: linking placental ischemia with
to play a role in increasing VEGF levels. Antioxidant endothelial dysfunction. 2008;4505. doi:10.1152/
supplementation caused a significant decrease in the ajpheart.01113.2007.
concentration of sFlt‑1 and increased PlGF in plasma.
5. Shibuya M. JB Review Vascular endothelial
Whereas in vitro studies showed beneficial effects
growth factor and its receptor system: physiological
of antioxidants on VEGF. BC‑e has considerable
functions in angiogenesis and pathological roles in
antioxidant properties both in vivo and in vitro8,24. In
various diseases. 2013;153(1):13‑19. doi:10.1093/
its activity as an antioxidant, thymoquinone synergizes
jb/mvs136.
with other compounds such as dithymoquinone and
thymol to capture free radicals10. 6. Levine RJ, Maynard SE, Qian C, et al. Circulating
angiogenic factors and the risk of preeclampsia. N
The average increase in serum VEGF levels along Engl J Med. 2004;350(7):672‑683. doi:10.1056/
with the increase in the dose of black cumin extract NEJMoa031884.
548 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
7. Meziti A, Meziti H, Boudiaf K, Mustapha B, T‑cells signaling. Hypertension. 2008;51(4
Bouriche H. Polyphenolic Profile and Antioxidant PART 2 SUPPL.):1010‑1019.doi:10.1161/
Activities of Nigella Sativa Seed Extracts In Vitro HYPERTENSIONAHA.10
and In Vivo. World Acad Sci. 2012;64:24‑32. 17. Irani R a, Zhang Y, Zhou CC, et al.
8. Paarakh PM. Nigella sativa Linn .– A comprehensive Autoantibody‑mediated angiotensin receptor
review. 2010;1(December):409‑429. activation contributes to preeclampsia
9 Ahmad A, Husain A, Mujeeb M, et al. A review on through tumor necrosis factor‑alpha signaling.
therapeutic potential of Nigella sativa: A miracle Hypertension. 2010;55(5):1246‑1253. doi:10.1161/
herb. Asian Pac J Trop Biomed. 2013;3(5):337‑352. HYPERTENSIONAHA.110.150540.7.097790
doi:10.1016/S2221‑1691(13)60075‑1. 18. Chen Y. Novel Angiogenic Factors for Predicting
10. Mansour Nagi, M.N. El‑Khatib, A.S. Al‑Bekairi, Preeclampsia: sFlt‑1, PlGF, and Soluble Endoglin~!
A.M M a. Effects of Thymoquinone on Antioxidant 2008‑08‑29~! 2008‑12‑15~! 2009‑01‑02~! Open
Enzyme Activities, Lipid Peroxidation and Clin Chem J. 2009;2(1):1‑6. doi:10.2174/1874241
Dt‑Diaphorase in Different Tissues of Mice; A 600902010001.
Possible Mechanism of Action. Cell Biochem 19. Wang A, Rana S, Karumanchi SA. Preeclampsia:
Funct. 2002;20(October 2001):134‑151. the role of angiogenic factors in its pathogenesis.
11. Görlach A, Bonello S. The cross‑talk between Physiology (Bethesda). 2009;24:147‑158.
NF‑kappaB and HIF‑1: further evidence for a doi:10.1152/physiol.00043.2008.
significant liaison. Biochem J. 2008;412(3):e17‑e19. 20. Parameswaran N, Patial S. Tumor necrosis factor‑α
doi:10.1042/BJ20080920. signaling in macrophages. Crit Rev Eukaryot
12. Fukuda R, Hirota K, Fan F, Jung Y Do, Ellis LM, Gene Expr. 2010;20(2):87‑103. doi:10.1016/j.
Semenza GL. Insulin‑like growth factor 1 induces bbi.2008.05.010.
hypoxia‑inducible factor 1‑mediated vascular 21. Jung Y, Isaacs JS, Lee S, Trepel J, Liu Z‑G,
endothelial growth factor expression, which is Neckers L. Hypoxia‑inducible factor induction by
dependent on MAP kinase and phosphatidylinositol tumour necrosis factor in normoxic cells requires
3‑kinase signaling in colon cancer cells. J Biol receptor‑interacting protein‑dependent nuclear
Chem. 2002;277(41):38205‑38211.doi:10.1074/ factor kappa B activation. Biochem J. 2003;370(Pt
jbc.M203781200. 3):1011‑1017. doi:10.1042/BJ20021279.
13. Kalkunte S, Boij R, Norris W, et al. Sera 22. Nevo O, Soleymanlou N, Wu Y, et al. Increased
from preeclampsia patients elicit symptoms expression of sFlt‑1 in in vivo and in vitro
of human disease in mice and provide a models of human placental hypoxia is mediated
basis for an in vitro predictive assay. Am J by HIF‑1. Am J Physiol Regul Integr Comp
Pathol. 2010;177(5):2387‑2398. doi:10.2353/ Physiol. 2006;291(4):R1085‑R1093. doi:10.1152/
ajpath.2010.100475. ajpregu.00794.2005.
14. Wicaksono BA, Candra S, Baktiyani W, Fitri LE. 23. Poston L, Igosheva N, Mistry HD, et al. Role of
Intraperitoneal Injection of High Tumor Necrosis oxidative stress and antioxidant supplementation in
Factor (TNF‑ α) Serum Increase Soluble Fms‑like pregnancy. Am J Clin Nutr. 2011;94:1980‑1985.
Tyrosine Kinase 1 (sFlt‑1) and Blood Pressure of doi:10.3945/ajcn.110.001156.1.
Pregnant Mice. 2015;5(1). 24. Leong X, Mustafa MR, Jaarin K. Nigella sativa
15. Murphy SR, Cockrell K. Regulation of soluble and Its Protective Role in Oxidative Stress and
fms‑like tyrosine kinase‑1 production in response Hypertension. 2013;2013.
to placental ischemia/hypoxia: role of angiotensin 25. Chehl N, Chipitsyna G, Gong Q, Yeo CJ, Arafat H
II. Physiol Rep. 2015;3(2):e12310‑e12310. a. Anti‑inflammatory effects of the Nigella sativa
doi:10.14814/phy2.12310. seed extract, thymoquinone, in pancreatic cancer
16. Zhou CC, Ahmad S, Mi T, et al. Autoantibody from cells. Hpb. 2009;11(5):373‑381. doi:10.1111/
women with preeclampsia induces soluble Fms‑like j.1477‑2574.2009.00059.x.
tyrosine kinase‑1 production via angiotensin type 1 26. Sethi G, Ahn KS, Aggarwal BB. Targeting
receptor and calcineurin/nuclear factor of activated nuclear factor‑kappa B activation pathway
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 549
by thymoquinone: role in suppression of 27. Mattson. MP. NIH Public Access. Natl Institutes
antiapoptotic gene products and enhancement of Heal. 2008;18(9):1199‑1216. doi:10.1016/j.micinf.
apoptosis. Mol Cancer Res. 2008;6(6):1059‑1070. 2011.07.011.Innate.
doi:10.1158/1541‑7786.MCR‑07‑2088.
550 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Effect of Nutritional Status, Hemoglobin Levels and

Psychosocial Emotional Behavior with Cognitive Function of
Female Teenager

Diana Septaria Abidin1, Roedi Irawan2, Windhu Purnomo3

1Magister Program of Public Health, Faculty of Public Health, 2Department of Child Health, Faculty of Medicine,
3
Department of Biostatistics, Faculty of Public Heath, Airlangga University, Surabaya, Indonesia

Abstract
Teenager are the future generation, with the cognitive abilities of a good expected level of education will
be good. The impact of nutritional status abnormal, low hemoglobin levels, and disorders psychosocial
emotional behavior associated with cognitive abilities in teenager, especially in female teenager. The
objective of this study is to analyze the effect between nutritional status, hemoglobin levels, and psychosocial
emotional behavior with cognitive function in female teenager. This research used observational analytic
method with cross sectional approach. Data were collected during February‑March 2019. Respondents in
this study were students or female teenager in accordance with the inclusion and exclusion criteria. Sampling
technique in this research is probability sampling type simple random sampling with a total sample of 72
female teenager respondents. The independent variables studied are nutritional status, hemoglobin levels,
and psychosocial emotional behavior and dependent variable was cognitive function in female teenager.
Data nutrition status collected by BMI measurements according to age, hemoglobin levels by hemocue
tool, psychosocial emotional behavior was measured by PSC‑35 and cognitive function was measured by
MMSE‑test. Analysis was using logistic regression. The results of research obtained that there is effect
between the nutritional status of skinny, low hemoglobin levels (anemia) and suspect there are disorders
psychosocial emotional behavior with a value of p < 0.05. Risk factors nutritional status of skinny, low
hemoglobin levels (anemia) and suspect disorders psychosocial emotional behavior on cognitive function
below normal, amounted to 81,4% and 18.6% was caused by other factors. Nutritional status, hemoglobin
levels, and behavior psychosocial emotions affect the cognitive function of female teenager.

Keywords: Nutritional status, hemoglobin levels, psychosocial emotional behavior, cognitive function,
female teenager.

Introduction results of cognitive function in students of Vocational

High School as a whole in 2015 is 62,11 and 2016 have
Teenager is a time of transition from children to adult.
average 57,66.(3)Nutritional problems in teenager will
A period when a lot of things in life changed with a very
have an impact on the decline of brain function, decrease
high speed and this period is a preparation for adulthood
in body to do physical activity, and loss of physical
that will pass through several stages of development is
fitness will affect the health of a teenager.(4)
important.(1)Some research mention, teenagers at risk of
impaired development of cognitive function caused by The prevalence of the risk of lack of energy chronic
several factors such as factors of physical and mental in women of childbearing of age group 15‑19 years
health, family, environment and peers.(2) in Indonesia in 2007 amounted to 30,9% increased to
36,3% in 2018. Overall, the prevalence of the risk of
Data from the Ministry of education and culture
less energy chronicle women of childbearing of age
occurs to a significant decrease in the average yield of
group 15‑19 years is high when compared with other
the ability of cognitive function of learners of Indonesian
age groups. Based on Basic Health Research 2018
in the school. The upper level, the obtained average
the prevalence of obesity in teenager ( ≥15 years) in
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 551
Indonesia increased from 26,6% in 2013 to 31.0% in The method of sampling is with simple random
the year 2018. In addition to the prevalence of the risk sampling technique. This study the independent
of lack of energy chronic and obesity in teenager, the variables are nutritional status, hemoglobin levels, and
prevalence of anemia in female teenager has increased psychosocial emotional behavior, the dependent variable
from 37,1% in 2013 to 48.9% in the year 2018.(5) is cognitive function. Datanutrition status collected by
BMI measurements according to age, hemoglobin levels
In addition to the nutritional problems in teenager, by hemocue tool, psychosocial emotional behavior
there is a relationship between the psychosocial was measured by PSC‑35 and cognitive function was
conditions of a person with a cognitive ability. The measured by MMSE‑test.
stability of the psychosocial is very important in the
development of cognitive abilities, the inability of a Statistical analysis using a computer program
person to control the depression and emotions will lead namely SPSS version 21. The analysis of the analytic
to instability of the psychosocial so that individuals will wear test statistics non parametriclogistic regression to
experience difficulties in learning. Learning difficulties determine whether there is influence between nutritional
are due to instability of the psychosocial is one of the status, hemoglobin levels, and psychosocial emotional
causes of low academic potential.(6) According to the behavior with the cognitive function of female teenager.
data of Basic Health Research, the prevalence of mental This analysis is used for dependent variables with a
emotional disorder in the population aged ≥15 years measurement scale of categorical variable. In logistic
increased from 6% in 2013 to 9.8% in the year 2018.(5) regression the quality of the formula is obtained from
the ability of discrimination and calibration. Calibration
Based on preliminary studies conducted in 22 by the method of Hosmer and Lameshow. In addition,
female teenager in SMK Negeri 1 Grogol, showed the value of Nagelkerke R Square is also seen to see
female teenager with the status of malnutrition, anemia, how much the proportions of independent variables can
and disorders psychosocial emotional behavior, 22% predict the occurrence of the dependent variable.
to obtain the value of the cognitive function that is not
This research has received approved from the
normal. Teenager are the future generation, with the
Health Research Ethics Committee from the Public
cognitive abilities of a good expected level of education
Health Faculty of Airlangga University Surabaya by
will be good.
letter No.76/EA/KEPK/2019.
The impact of nutritional status, hemoglobin levels, Finding: The number of samples obtained by
and psychosocial emotional behavior associated with simple random sampling technique as many as 72 female
cognitive abilities in adolescents, especially in female teenager respondents.
teenager. These things clearly corroborate that the health
of the teen determine the effort in quality of the next Table 1: Distribution of nutritional status,
generation in the future. This research was conducted hemoglobin levels, psychosocial emotional behavior
because the author wanted to examine the influence of and cognitive functions of female teenager.
nutritional status, hemoglobin levels, and psychosocial
Total (n = 72)
emotional behavior with cognitive function of female Variable
Frequency Percentage (%)
teenager in SMK Negeri 1 Grogol Kediri.
Nutritional Status

Materials and Method Underweight 22 30,6

Normal 27 37,5
The study was conducted with cross sectional Overweight 23 31,9
method. Sample of this study is female teenager in Hemoglobin Levels
SMK Negeri 1 Grogol Kediri during February‑March Anemia 19 26,4
2019 that meet the inclusion and exclusion criteria. The Normal 53 73,6
criteria for inclusion of respondents in this research is Psychosocial Emotional Behavior
female teenager, are already experiencing a menstrual Suspect Disorder 19 26,4
and sign a letter of informed consent to be a respondent. Normal 53 73,6
Exclusion criteria from this study are the respondents Cognitive Function
who are menstruating and respondents who have health Under normal 20 27,8
problems such as diarrhea and menorrhagia. Normal 52 72,2
552 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 2: Effect of nutritional status, hemoglobin levels, psychosocial emotional behavior with cognitive
function of female teenager

Variable β Exp (β) p Description

Nutritional Status 0,137 Not Significant
Underweight ‑3,547 0,029 0,048 Significant
Normal ‑1,253 0,286 0,366 Not Significant
Overweight Reference Group
Hemoglobin Levels
Anemia ‑6,133 0,002 0,001 Significant
Normal Reference Group
Psychosocial Emotional Behavior
Suspect Disorder ‑3,808 0,022 0,007 Significant
Normal Reference Group
Constant 6,276 531,524 0,001 Significant
Nagelkerke R square = 0,814

Test results analysis using logistic regression ability of cognitive function below normal 0,029 times
showed there is the influence of the nutritional status compared to respondents with normal nutrition status.
of skinny, low hemoglobin levels (anemia) and suspect
disorders psychosocial emotional behavior with a value Teenagers have nutritional needs that are unique
of p < 0.05. The influence of risk factors nutritional when viewed from the point of view of biology,
status of underweight, low hemoglobin levels (anemia) psychology, and from a social point of view. As if
and suspect disorders psychosocial emotional behavior viewed from the point of view of the social and the
on cognitive function below normal, amounted to 81,4% psychological, the adolescents themselves believe that
and 18.6% was caused by other factors. they do not pay too much attention to health factors
in the dropping of food choices, but rather paid more
Discussion attention to other factors such as the adults around them,
the hedonistic culture, the social environment, and other
Teenagers actively construct their cognitive world, factors that strongly affect it.(8)
where the information obtained is not directly accepted
so just into their cognitive schema. Teenagers have been The results of the other studies mentioned teenagers
able to distinguish between ideas that are more important with malnutrition give poor results on test of attention,
than other ideas, and adolescents also develop this idea. working memory, learning and memory as well as the
A teenager does not just organize experienced and ability visuospatial except on the test of motor speed and
observed, but also able to process their way of thinking coordination.(9) The nutritional Status of low or excess
thus giving rise to a new idea.(7) will lead to a difficult teenager to live in a healthy, active
and productive. State of malnutrition can hinder the
The effect of nutritional status on cognitive intelligence of the teenage brain because of the cognitive
function: The results of the statistical test of the effect abilities of a person affected by the nutrients consumed.
of nutritional status on cognitive function showed that (10)
nutritional status has no effect on cognitive function.
The results obtained p‑value = 0,137 (p > 0.05) showed When it reaches peak growth velocity, teenagers
that the nutritional status is not a factor that affects the usually eat more often in large quantities. After the
cognitive function of respondents is below normal, but on growth spurt, they usually will be paid more attention
the nutritional status of underweight p = 0.048 (p < 0.05) to her appearance, especially female teenager. They
showed that the nutritional status of the underweight is are often times too strict in your diet in maintaining her
a factor that affects cognitive function below normal. appearance, so it could cause nutritional deficiencies.
The value of Exp(β) = 0,029 mean that the respondents Increased activity, social life, and the busy teen will
nutritional status underweight then it is likely to have the affect their eating habits. Food consumption patterns
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 553
are often irregular, frequently snack, often do not eat Teenager is a period marked by the rapid development
breakfast and not lunch.(11) of aspects of biological, psychological, and also social.
These conditions resulted in a variety of disharmony
The effect of hemoglobin levels on cognitive which requires offsets so that teens can reach the level
function: The results of the statistical test the effect of of development of psychosocial emotional behavior are
hemoglobin levels on cognitive function showed that mature and adequate in accordance with the age level.
hemoglobin levels have an effect on cognitive function. These conditions vary greatly between the young and
The results of the research the value of p = 0.001 (p < show the difference that is individualized.(6)
0.05) showed that the levels of hemoglobin is a factor
that affects cognitive function below normal. The value In general, symptoms of conduct disorder
of Exp(β)= 0.002 to mean that respondents with anemia psychosocial emotional behavior can be divided into
then it is likely to have the ability of cognitive function three kinds, namely disorder externalization, disorders
below normal to 0.002 times compared to respondents of the internalization and attention disorders. Disorders
with hemoglobin levels normal. of internalization in the form of various kinds of
disorders such as anxiety, depression, withdraw from
Iron deficiency is prolonged it will limit the amount social interactions, eating disorders, and a tendency to
of oxygen carried by red blood cells to the body suicide. Disorders externalization can impact directly or
and the brain. The impact of anemia which is most indirectly to others, for example aggressive behavior,
clearly visible is the reduced ability of concentration, defiant, disobedient, lie, steal, and lack of self‑control.
in addition anemia can also interfere with cognitive While attention disorders either do not want to learn, the
development and physical.(12) Levels hemoglobin is child cannot be silent, fast switching of attention, both at
one of the indicators of the determinant of anemia. Iron home and at school. The third interruption of that type
deficiency causes motor coordination is disturbed and have the same effect of the poor against the failure of
the concentration of attention or concentration to be teenagers learning in school.(14)
decreased. Anemia that occurs in teenager had an impact
on the inhibition of mental and intelligence as well as A variety of psychosocial stressors often associated
decreased concentration and enthusiasm for learning. with the occurrence of emotional disturbance and
(13)
The low power of concentration effect on the focus behavior in adolescents, such as the presence of physical
students in accepting and understanding the subjects that illness, parenting the inadequate, domestic violence,
can have an impact on learning outcomes. In addition to relationships with peers inadequate, as well as poverty.
anemia, a factor that can affect learning achievement is Psychosocial stressors that affect the process of cognitive
intelligence, learning motivation and learning style.(14) development.(16)
According to the study, iron deficiency with or without
accompanied with anemia in infancy is connected with Perception, recollection (memory), thinking,
the increasing problem of cognitive function in the and process‑cognitive processes that others can be
aspect of internalization, externalization, and social in influenced by the emotional state is ongoing in one’s
teenager.(15) self. A person’s emotional state can affect the cognitive
processes, for example stress, depression, anxiety, and
The effect of psychosocial emotional behavior mood. the influence of emotions can occur on any part
on cognitive function: The results of the statistical of the overall cognitive activity of man; ranging from
test of the effect psychosocial emotional behavior recording information, transformation information,
on cognitive function showed that the psychosocial storage of information in the arsenal of memory, then
emotional behavior have an effect on cognitive function. extracting information that has been stored in the
The results of the research value of p = 0.007 (p < 0.05) memory to appear back in order to give a response to a
shows that the psychosocial emotional behavior are task, until the process of thinking, problem solving, and
factors that affect cognitive function under normal. The creativity.(14)
value of Exp(β) = 0,022 mean that the respondents with
suspicious disorder psychosocial emotional behavior Conclusion
then it is likely to have the ability of cognitive function From this study, we can concluded that the risk
below normal 0,022 times compared to the respondents factors for female teenager with cognitive function
with the psychosocial emotional behavior are normal. abnormal is nutritional status, hemoglobin levels and
554 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
psychosocial emotional behavior. Therefore, it takes 7. Indonesian Ministry of Health. Infodatin (Data
the role of all parties such as family, peers, teachers, and Information Centre): Situation of Adolescent
and government for the prevention and handling of the Reproductive Health). Data and Information Center
problem of low cognitive function of female teenager of the Indonesian Ministry of Health. 2015.
through programs of cooperation with related parties. 8. Indonesian Ministry of Health. Assesment of
Nutritional Status. Jakarta: Indonesian Ministry of
Conflict of Interest: The Authors declare no
Health. 2017.
conflicts of interest
9. Muscari, A., Spiller, I., Bianchi, G., Fabbri, E., Forti,
Source of Funding: Self P., Megalotti, D., Pandolfi, P., Zoli, M., & Pianoro
Study Group. Predictors of Cognitive Impairment
Ethical Clearance: Female teenager who agreed
Assessed by Mini Mental State Examination in
to be involved in this study signed informed consent.
Community‑Dwelling Older Adults: Relevance
This research has received approved from the Health
of The Step Test. Experimental Gerontology.
Research Ethics Committee from the Public Health
2018:108:69‑76.
Faculty of Airlangga University Surabaya by letter
No.76/EA/KEPK/2019. 10. Scarmeas, N., Anastasiou, C.A., & Yannakoulia, M.
Nutrition and Prevention of Cognitive Impairment.
References The Lancet Neurology. 2018:17(11):1006‑1015.
11. Berg, T., Magala‑Nyago, C., & Iversen, P.O.
1. WHO. Adolescent Development: Topics at
Nutritional Status Among Adolescent Girls in
Glance. 2015. Available from: http://www.who.
Children’s Homes: Anthropometry and Dietary
int/maternal_child_adolescent/topics/adolescence/
Patterns. Clinical Nutrition. 2018:37(3):926‑933.
dev/en/#
12. Li, L., Huang, L., Shi, Y., Luo, R., Yang, M., &
2. Kim‑Spoon, J., Maciejewski, D., Lee, J.,
Rozelle, S. Anemia and Student’s Educational
Deater‑Deckard, K., & King‑Casas, B. Longitudinal
Performance in Rural Central China: Prevalence,
Associations Among Family Environment, Neural
Correlates and Impacts. China Economic Review.
Cognitive Control, and Social Competence
2018:51:283‑289.
Among Adolescents. Developmental Cognitive
Neuroscience. 2017:26:69‑76. 13. WHO. Haemoglobin Concentrations for the
Diagnosis of Anaemia and Assessment of Severity.
3. Ministry of Education and Culture.The
Geneva: World Health Organization. 2011
Achievements of The Ministry of Education and
Culture in the Year 2016. Ministry of Education 14. Yee, D.M., & Braver, T.S. Interactions of
and Culture. 2016 Motivation and Cognitive Control. Behavioral
Sciences. 2018:19:83‑90.
4. WHO. Guideline: Implementing Effective Actions
for Improving Adolescent Nutrion. World Health 15. Doom, J.R., Richards, B., Caballero, G., Delva, J.,
Organization. 2018:1‑48. Gahagan, S., & Lozoff, B. Infant Iron Deficiency
and Iron Supplementation Predict Adolescent
5. Basic Health Research. The main Result of
Internalizing, Externalizing, and Social Problems.
Indonesian Basic Health Research 2018. The
The Journal of Pediatrics. 2018:195:199‑205.
Agency for Health Research and Development:
Ministry of Health. 16. Zheng, Y., Rijsdijk, F., & Arden, R. Differential
Environmental Influences on The Develompment of
6. Cambridge, O.R., Knight, M.J., Mills, N., & Baune,
Cognitive Abilities During Childhood. Intelligence.
B.T. The Clinical Relationship Between Cognitive
2018:66:72‑78.
Impairment and Psychosocial Functioning in
Major Depressive Disorder: A Systematic Review.
Psychiatry Research. 2018:269:157‑171.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 555

Life Experience of Adolescents with Thalassemia:

A Qualitative Research with Phenomenological Approach

Dini Mariani1,2, Sri Mulatsih3, Fitri Haryanti4, Sutaryo3

1Doctoral Program, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada, Yogyakarta,
Indonesia, 2Health Polytechnic Ministry of Health of Republic of Indonesia, Tasikmalaya, West Java,
Indonesia, 3Department of Pediatrics, Dr.Sardjito Hospital Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada, Yogyakarta, Indonesia, 4Department of Pediatrics and Maternity Nursing Faculty of
Medicine,Public Health and Nursing Universitas Gadjah Mada, Yogyakarta, Indonesia

Abstract
Introduction: Adolescents with thalassemia, an inherited blood disorder resulting in anemia, have multiple
problems. Not only do the sufferers have to face developmental issues, but also the challenges that arise
from their disease both physically and psychologically. This research aimed to understand the variety of
difficulties or problems faced by adolescents with thalassemia in Tasikmalaya, West Java, Indonesia.

Method: This research was a qualitative study. Samples used in this research were 7 adolescents with
thalassemia who were chosen by purposive sampling with inclusion criteria as follows: 1) Adolescents
with thalassemia aged 11‑19 years old, 2) Regularly visit Hospital dr. Soekardjo and. Prasetya Bunda for
transfusion purposes, and 3) Willing to be involved in the research. For data triangulation, interviews were
also conducted with 3 mothers of children with thalassemia. Data were analyzed using Creswell’s 6 steps for
data analysis which consist of data transcription, data reading, data coding, reducing information to themes
and categories, making data and theme description into qualitative narration, and transforming findings and
results into qualitative interpretations and report writing.

Results: From the interviews conducted with adolescents with thalassemia and their parents, several
findings were addressed: physical problems that arise from thalassemia are slowed growth and development
rate, fatigue and weakness, and pain. Meanwhile, other problems arise in psychological aspects, such as
emotional burden, anxiety and sadness about the future and frustration because of feeling different from
others. In addition, the research also found that adolescents with thalassemia are experiencing difficulties in
social interactions because of bullying and isolation.

Conclusions: This research provides basic information to define proactive strategies for interventions in
order to increase the quality of life of adolescents with thalassemia.

Keywords: Thalassemia, adolescence, quality of life experience, bullying, social stigma.

Introduction
Thalassemia is a group of genetic blood disorders
Corresponding Author: from synthesis of alpha or beta globin chain either
Dini Mariani totally or partially. Symptoms of thalassemia are varied
Nursing Program of Health Polytechnic Ministry based on the amount and effected globin chain type.
of Health of Republic of Indonesia, Tasikmalaya, Thalassemia is commonly found in the Mediterranean,
Indonesia Middle East, India Subcontinent, North Africa, Central
Phone (or Mobile) No.: +6281313818070 Africa and Southeast Asia including Indonesia. The
e‑mail: [email protected] number now has the attention of the Government of
556 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Indonesia considering that it has seen the numbers of approximately 60 minutes for each participant using
populations with thalassemia and also the fact that interview guide, field notes, and tape recorder to record
Indonesia is one of the countries that has high many participants’ responses. Data were then analyzed using
thalassemia carriers, with a frequency of 3‑8% and up Creswell’s 6 steps for data analysis, which consist of
to 10% in several regions. In Indonesia, there are 9082 making data transcription, data reading, data coding,
people with thalassemia and these patients are spread in reducing information to themes and categories, making
every region of Indonesia with the highest number in data and theme description into qualitative narration,
West Java region with 40.3%4,8,14. and transforming findings and results into a qualitative
interpretations and report writing.
Thalassemia is well‑known as a lifetime genetic
disorder. The sufferer would experience many problems Results
not only as part of the impact of the disease itself but
also from the impact of the medication. Considering the From the semi‑structured interviews conducted with
impact of the disease, it is necessary for us to put our six adolescents aged 11‑19 years old with education
attention to the sufferer, especially those in the age range level from elementary school to university with
of child to adolescent who have physical maturation thalassemia and three parents, three common themes
and development phases which determine their quality from the discussions were obtained, which were physical
of life15. Moreover, adolescents with thalassemia are problems, psychological problems, and social problems.
the most susceptible regarding the social issues because Physical Problems: It is common that several
they tend to have dual problems, both physically and physical problems are found in people with
psychologically. Besides the impacts from medication, thalassemia. From several issues, the physical problems
they sometimes are losing control and have the tendency were categorized as follows: delayed growth and
to involuntarily embrace the differences with their development rate, fatigue and weakness, and pain.
normal friends5. Other research about adolescents with Those categorizations are in‑line with the statements of
thalassemia using the Pediatric Quality of Life (Peds the participants as follows:
QoL) instrument has shown that their QoL only 68.91,
and a low rate is also shown on emotional function and “From the physical appearance, it is can be seen that
school performance, while average QoL from control normal adolescents look normal as the way they should,
groups is 79.7911.To have a better understanding about but those who suffer thalassemia there is physical
the experience of adolescents with thalassemia and how differences from body weight, and body height aspects.”
they embrace their chronic condition, it is necessary to (P.5)
explore these dimensions with qualitative research.
“In people with thalassemia, puberty is delayed,
Method unlike normal people. We also suffer delayed growth,
especially menstruation, we experienced it delayed
This research is a qualitative study. Samples used in compared to normal people, but it is relatively the same
this research include seven adolescents with thalassemia between other people with thalassemia.” (P.6)
who were chosen by purposive sampling with inclusion
criteria as follows: Adolescents with thalassemia aged Delayed growth and development in people with
11‑19 years old, regularly visit for transfusion purposes, thalassemia are also confirmed by parent as follows:
and willing to be involved in the research by completing
an informed consent form. For data triangulation, “For body growth, we could see from elementary
interviews were also done with three mothers of children school to junior high school compared to their relatives,
with thalassemia. Semi‑structured interviews were used their body looks smaller.” (P.1)
for the data collection. The research was conducted in Three participants explained how their thalassemia
2017 in the Thalassemia Unit of Tasikmalaya Indonedsia. makes them fatigue easily. It is explained as follows:
All participants had already been explained about the
purposes of the research and completed the consent form “Something I feel the most is fatigue, sometimes
before participating. The semi‑structured interviews dizzy... either I do activities at home or at school, I am
were done in the Thalassemia Unit when all participants easily tired.” (P.1)
were undergoing blood transfusion. The interview took
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 557
“If my Hb is low, I feel so dizzy, tired, exhausted “I once did not disclose it to my boyfriend because I
and sometimes also have fever.” (P.5) am afraid that he will not accept me and I’m also afraid
of being underestimated.” (P.6)
“Nowadays I often feel dizzy. I was, maybe once
in a month, felt exhausted, but now that I have monthly Those arguments are also supported by the
menstruation, I feel it more often” (P.6) statements from parents as follows:

Physical disorders are also confirmed by parents of “As my son is growing up, it is undeniable that I
adolescents with thalassemia as follows: have my own anxiety about their future especially about
their acceptance and love life in the future. I am afraid
“Since being diagnosed with thalassemia for the that they won’t get married because no one will accept
first time, He has always been weak, easily tired. After them.” (P.1)
having transfusion, it only supports his body for 7‑10
days, a week later, he becomes weak again” (P. 2) “I cannot imagine their future.” (P.2)

Some of participants also experienced pain related Another psychological problem faced by sufferer of
to their disease, such as follows: thalassemia is that they feel that they are different from
normal people. It is obviously stated from the statements
“During transfusion, I experienced back pain until I of the participants as follows:
have to be treated in hospital.” (P.2)
“I have tried getting a job, but it was so difficult for
“I have never done any exercise because I could not me to get one. For a normal people, getting a proper job
do much of it. My body become easily exhausted, also has been already a difficult task, then how about people
there are no friends of mine who have the same things like me? Of course, I feel disappointed with this. I do
and have big and painful stomach.” (P.4) hope that I will get the same opportunity for job, I want
Psychological Problems: Psychological problems to be like others.” (P.4)
that arose for adolescents with thalassemia can be “I do feel different from others. If normal people
categorized as follows: emotional burden, anxiety can do anything they want, I have to have transfusion
and sadness about the future and frustration because regularly in hospital. I also never had any exercise
of feeling different from others. Those categories are because I have no friends like me.” (P.7)
constructed from the explanations below from patients:
“I have ever in a condition where I feel abandoned
“I once was so angry when I was tired. I was so by other people. Maybe it was because I am just being
irritable.” (P.2) myself, we are different physically.” (P.6)
“It is so sad and maddening when I was mocked by The different feelings towards others are also
other people but I cannot defend myself.” (P.5) strengthened by statements from parent about people
Emotional burden of thalassemia sufferers was also with thalassemia, as follow:
confirmed by parents as follows; “In school, their friends are much bigger and taller.
“When transfusion time comes, they (sufferer) tend I told my child that maybe a miracle will come to us in
to be easily angered, such as when I yelled at them, they the future someday.” (P.3)
were so emotional. I think they just tired.” (P.3) Social Problems: On social interaction issues,
“Other psychological problems experienced by people with thalassemia also experience problems
adolescents with thalassemia are anxiety and sadness that can be categorized as follows: bullying and social
about the future, explained as follows: interactions difficulties. Those categories are constructed
from the explanations below from participants:
“I am obviously slowly becoming old. I am afraid
that my future children will experience the same thing “It is a common for me to be mocked at school. I
with me and have a lot of friends who are not able to do hope that my friend will never bully me again.” (P.5)
fully embrace my weakness.” (P.3)
558 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Bullying towards people with thalassemia are also frequent number of growth failures happen in children
reported by parents, as follows; and adolescents with thalassemia causing body image
disorder. The research also highlights the number of
“Way back from school, they had nosebleed. At events between 30‑50% 12.
first, I think that they have fatigue or something, but
when I force them to tell me, they told me that they have Psychological problems in adolescents with
been bullied.” (P.2) thalassemia among others are emotional burden, anxiety
about future, and feeling different from others. For
Bullying is also corroborated by other parents, adolescents and parents who have chronic disease, they
written as follows: face specific problems related to their health issues.
“Based on their explanation, they often being hit in Specific problems for sufferers and their parents are
the head and stomach. Sometimes their belongings, like feeling of failure and despair about the future, low
book, bottle, hat are just thrown by their friends so if my self‑esteem and emotional burden. Adolescents with
child were trying to get that, they will throw it further. thalassemia have higher number of psychosocial
Maybe it is just fun for them.” (P.3) problems than normal adolescents 10,13.. Another
systematic review also found that several psychosocial
Other social problems faced by adolescents with problems such as distress, less social function, problems
thalassemia is social interactions difficulties. It is in‑line in school performance, feeling guilty, rejection due to
with the explanations of participants as follows: disease and/or medication impact are also experienced
by adolescents with thalassemia3.
“I have no friends, maybe just playing around with
kindergarten children.” (P.5) Social interaction problems experienced by
adolescents with thalassemia in this research are
The argument is also supported by parents: “I am bullying and social interaction issue. Bullying happens
afraid that they will just be fatigued when they play with as an outcome from physical problems experienced by
my friends, so I asked them to just directly go home to sufferers who position themselves as a victim and an
sleep and not play.” (P.2) object to be bullied. Self‑identity in chronic sufferers
“In the neighborhood they are only able to play can become compromised and their dependency to
around with younger children, around 5‑6 years old or others become higher than normal adolescents. Those
on the 1st or 2nd grade of elementary school. The point psychosocial problems then impact on adolescents with
is that they are not able to play with their friends.” (P.3) thalassemia in many aspects such as education, playing
time with friends, physical activities, and ability to
Discussion adapt. Those conditions further impact on the emergence
of anxiety, social isolation, and depression. The results
This research provides basic information to define of systematic review about bullying prediction on
proactive strategies for effective interventions in order adolescents with thalassemia showed that most bullying
to increase the QoL of adolescents with thalassemia, is related to their physical condition. One systematic
especially in physical, psychological and social aspects. review explained that adolescents with chronic
The qualitative research with phenomenological approach thalassemia who have physical disorders have higher
has produced some themes, such as physical problems, risk to be the object of bullying6.
psychological problems, and social interaction problems.
Physical problems in adolescents with thalassemia can Conclusion
be categorized by several points that include: slowed
growth and development rate, fatigue and weakness, and The interviews with adolescents with thalassemia
pain. Delays of sexual developments were reported by and parents provide several themes of physical problems
50% of males and females. Glucose tolerance disorder, which consist of slowed growth and development rate,
short body, hypocalcemia, and hypothyroidism also fatigue and weakness and pain. Psychological issues
often happen to adolescents with thalassemia. It shows consisted of emotional burden, anxiety about the future
that the effect of excessive iron depends on disease and feeling different. Social interaction problems consist
duration and frequency of blood transfusion and slow of bullying, and stigma from looking different. The
disease development progress1. Other research showed research provides basic information to define proactive
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 559
strategies for effective interventions in order to increase with beta‑thalassemia. BMC blood disorders. 2012;
the quality of life of adolescents with thalassemia. 12(1), 6.
7. Creswell, J. W. Research Design, (4th ed) United
Conflict of Interest: The authors declare that there
Kingdom: Sage.2014
are no conflicts of interest in this study
8. Dahlui, M., Hishamshah, M. I., Rahman,
Source of Funding: Thanks to Indonesian Ministry A. J. A., & Aljunid, S. M. Quality of life in
of Health for funding this research. transfusion‑dependent thalassaemia patients on
desferrioxamine treatment. Singapore medical
Ethical Clearance: This research was approved by
journal.2009; 50(8), 794
the Medical and Health Research Ethics Commission of
the Faculty of Medicine, Universitas Gadjah Mada with 9. Evans, C. B., Fraser, M. W., & Cotter, K. L. The
Ref: KE/FK/0775/EC/2017. effectiveness of school‑based bullying prevention
programs: a systematic review. Aggression and
References Violent Behavior. 2014; 19(5), 532‑544.
10. Hamed, H., Ezzat, O., & Hifnawy, T. Psychological
1. Abdulzahra, M. S., Al‑Hakeim, H. K., & Ridha,
manifestations in adolescents with thalassemia.
M. M. Study of the effect of iron overload on the
Middle East Current Psychiatry. 2011; 18(4),
function of endocrine glands in male thalassemia
237‑244.
patients. Asian journal of transfusion science.
2011; 5(2), 127‑131 11. Ismail, M., Chun, C. Y., Shahar, S., Manaf, Z. A.,
Rajikan, R., Yusoff, N. A. M., ... & Jamal, A. R.
2. Álvarez‑García, D., García, T., & Núñez, J. C.
A. Quality of life among thalassaemia children,
Predictors of school bullying perpetration in
adolescent and their caregivers. Sains Malaysiana.
adolescence: A systematic review. Aggression and
2013; 42(3), 373‑380.
Violent Behavior. 2015; 23, 126‑136.
12. Singh, P., & Seth, A. Growth and endocrine issues
3. Anie, K. A., & Massaglia, P. Psychological
in children with thalassemia. Pediatric Hematology
therapies for thalassaemia. Cochrane Database of
Oncology Journal. 2017; 2(4), 98‑106.
Systematic Reviews. 2001; (3).
13. Shaligram, D., Girimaji, S. C., & Chaturvedi, S.
4. Baghianimoghadam, M. H., Sharifirad, G., Rahaei,
K. Psychological problems and quality of life in
Z., Baghianimoghadam, B., & Heshmati, H. Health
children with thalassemia. The Indian Journal of
related quality of life in children with thalassaemia
Pediatrics.2007; 74(8), 727‑730.
assessed on the basis of SF‑20 questionnaire in
Yazd, Iran: a case‑control study. Central European 14. Thalassemia International Federation. Guidelines
journal of public health. 2011; 19(3), 165‑169 for the management of transfusion dependent
thalassemia (TDT) (3rd ed. Vol.3) Nicossia, Cyprus:
5. Baraz, S., Miladinia, M., & Mosavinouri, E. A
Thalassemia International Federation Publisher.
comparison of quality of life between adolescences
2014
with beta thalassemia major and their healthy peers.
International Journal of Pediatrics. 2016 4(1), 15. Qari, M. H., Wali, Y., Albagshi, M. H., Alshahrani,
1195‑1204. M., Alzahrani, A., Alhijji, I. A., & Al Rustumani,
A. Regional consensus opinion for the management
6. Caocci, G., Efficace, F., Ciotti, F., Roncarolo, M.
of Beta thalassemia major in the Arabian Gulf area.
G., Vacca, A., Piras, E., ... & Mandelli, F. Health
Orphanet Journal of Rare Diseases. 2013; 8(1),
related quality of life in Middle Eastern children
143.
560 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

The Effect of Metabolic Syndrome on Systolic Function of

Left Ventricle Using Echocardiographic Examination

Doaa H. EL‑Farook1, Hatem A. Sarhan2, Manal M. Mohamed3, Ahmed EL‑Barbary4, Khaled A. Khaled2
1Clinical Pharmacy Department-Faculty of Pharmacy –Misr University for Science and Technology, Egypt,
2Pharmaceutical Department-Faculty of Pharmacy-Menia University, Egypt, 3Internal Medicine Department-
Faculty of Medicine-Misr University for Science and Technology, Egypt, 4Cardiology Department Faculty of
Medicine‑Misr University for Science and Technology, Egypt

Abstract
Objective: Metabolic syndrome may cause bad prognosis on diastolic or systolic function of the left
ventricle. Thus, this research aimed to recognize the possible effect of metabolic syndrome on systolic and
diastolic function of left ventricle using ECHO.

Study Design: Prospective case‑control study.

Place and duration of study: Soad Kafafi Hospital, Egypt, from May 2016 to March 2018.

Methodology: This research included forty patients with metabolic syndrome (18 male, 22 female, mean
age=54.13±6.33 years) and forty control matching age and sex volunteers without history of metabolic
syndrome disorder (15 male, 25 female, mean age=52.20±5.27).MS was defined according to ATP‑NCEP
III criteria. Waist circumference will be measured to all participants at the start of study inclusion. Height
and weight was measured to calculate Body mass index using standardized formula. Participants underwent
laboratory investigations and complete echo cardiography. Left ventricular function of the heart was assessed
using Echo cardiographic examination.

Results: There was a statistical significant difference regarding Left atrial (LA) diameter, Interventricular
septum and posterior wall thickness in metabolic syndrome patients than normal control persons. The
incidence of diastolic dysfunction was significantly higher in metabolic syndrome group compared to control.

Conclusion: MS may cause LV diastolicdysfunction although systolic function was preserved.

Keywords: Metabolic syndrome, diastolic dysfunction, diabetes, hypertension, left ventricular function.

Introduction Interestingly it was found that metabolic syndrome

components(diabetes, obesity,and hypertension develop
Metabolic syndrome is defined as a group of
before the development of cardiovascular disease[6].
interacted risk factors which includetruncal obesity,type
Previous studies demonstrated that heart failure may
II diabetes mellitus (DM), hypertension,high triglyceride
occur as a result of diastolic dysfunction although
level and low high density lipoprotein level[1]. The
ejection fraction was normal[7]. The mechanisms by
component ofmetabolic syndrome may be the cause
which Left Ventricular diastolic dysfunction developed
development of cardiovascular disease (CVD) [2].
to heart failure were not completely identified. Some
Its prevalence is further growing in both males and
proposed mechanisms are that metabolic syndrome may
females due to a life style characterized by high calorie
alter function and geometry of the left ventricle which
consumption and low physical activity [3, 4]. Plandevall
may results in coronary heart disease. Some studies have
et al. recommend routine waist circumference
shown that LV dysfunction independently to metabolic
measurement to determine metabolic syndrome and
syndrome components. However,some studies have
its related diabetes and coronary heart disorders[5].
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 561
shown relation between hypertension as a component random blood sugar, liver and renal function test and
of metabolic syndrome and increased left ventricular urinalysis using standard operating procedures.
mass inMS patients. Further studies might conduct
to define different mechanisms for the development The study approved by ethical committee of
of cardiovascular disease as a result of metabolic Soaad‑Kafafi hospital. The exclusion criteria include;
syndrome[8]. Patients suffer from MI, cor pulmonale, atrial fibrillation,
cardiomyopathy, valvular heart disease,atrioventricular
Methodology block hypothyroidism and renal failure.

This research included forty patients with metabolic Echo cardiographic examination wasdone with
syndrome (18 male, 22 female, mean age=54.13±6.33 available machine (GE Vingmed, Horten, Norway) with
years) and forty control matching age and sex volunteers a 1.5 or 3.2 MHZ phased array transducer. Patients were
without history of metabolic syndrome disorder (15 lying in the left lateral position and breathing gently.A
male, 25 female, mean age=52.20±5.27). Patients were comprehensive echo cardiographic study following
recruited from the outpatient department at soad‑kafafi standardized protocols was carried for all subjects[9].
hospital. Diagnosis of metabolic syndrome was Participants are asked to perform passive expiration the
performed according to IDF criteria. According to this whole cardiac movement.
criterion MS diagnosed with waist circumference ≥80
cm for women or ≥90 cm for men plus abnormal two Statistical analysis: Statistical package SPSS version
parameters of the following: High density lipoprotein 21 was used for entered of statistical data. Data was
cholesterol ≥50 mg/dL for women or ≥40 mg/dL for summarized using number and percentage for qualitated
men; triglyceride levels ≥150 mg/dL and random blood variables,mean and SD for quantitative variables which
glucose levels ≥100 mg/dL, blood pressure ≥130/85 are normally distributed while median and interquirtile
mmHg. range formula were used for quantitative variables which
are not normally distributed. Independent sample t‑test
At inclusion medical history of all subjects was was used for quantitative variables which are normally
taken then echo cardiographic examination was done distributed while non‑parametrical Mann‑Whitney
for all subjects included in the study. Blood pressure Test was used for quantitative variables which are not
was measured by available sphygmo­manometer. Height normally distributed. P value<0.05 was considered
and weight was measured to calculate Body mass index statistically significant. Normality was checked by
using standardized formula. Complete lipid profile test, Shapiro test.

Results
Table 1: Clinical characteristics of the study groups

Variables Metabolic Syndrome Control P‑Value

Age 54.13±6.33a 52.20±5.27a .143*
BMI 36.22 ± 7.53a 25.55±4.96a <.001*
WC (cm) 119.65±14.36a 83.03 ± 7.24a <.001*
SBP 142.50 (130:160)b 114.50 (110.00:120.00)b <.001**
DBP 90.00 (80.00:95.00)b 76.00 (75.00:80.00)b <.001**
RBS 97.00 (83.00: 143.00)b 87.00 (81.00:90.00)b .003**
TG 146.50 (120.00:210.75)b 131.00 (113.00:144.75)b .003**
HDL 43.68±8.47a 53.10 ±6.56a <.001*

BMI: Body mass index; WC; waist circumference; SBP: systolic blood pressure; DBP: diastolic blood pressure; RBS: random blood
sugar; HDL: high density lipoprotein cholesterol.
⁎Indicatesa significant p‑value (p < 0.05). mean ± standard deviation (a), median (IQR) (b), P value by independent sample t‑test (*); P
value by Mann‑Whitney Test (**).
562 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 2: Sex distribution among control and metabolic syndrome groups

Metabolic Syndrome Control

Sex P‑Value
N % N %
Female 22 55.0 25 62.5
0.496
Male 18 45.0 15 37.5

Both gender and age were not significantly different II (normal controlgroup) (Table 1a). Among laboratory
among the two studied groups (Table 1a & b). Regarding investigations, triglyceride level and random blood
clinical parameters, the result shown that both body sugar were statistically significant higher in metabolic
mass index and waist circumference were found to be syndrome group compared to control group. However,
significantly higher in patients with metabolicsyndrome HDL‑cholesterol level was found to be significantly
group compared to normal control group. The prevalence higher in control group compared to metabolic syndrome
of hypertension was found to be significantly higher in group compared to (Table 1a).
group I (metabolic syndrome group) compared to group

Table 3: Comparison of standard echo cardiographic parameters between metabolic syndrome group and
normal control group

Variables Metabolic Syndrome Group Control P‑value

a a
LVED(mm) 47.58±5.08 46.48±4.96 .330*
a a
LVES(mm) 29.90±4.83 28.33±4.03 .118*
EF% 68.58±8.48a 67.68±5.50a .575*
FS% 37.30±6.26a 38.58±8.67a .453*
LA(mm) 38.53±3.83a 27.98±3.77a <0.001*
AO(mm) 29.83±4.90a 28.23±4.69a .140*
IVS 10.00 (10.00:11.00)b 9.00 (9.00:10.00)b .002**
PW 11.00 (10.00:12.00)b 9.00 (9.00:10.00)b <0.001**

LVED: left ventricular end‑diastole; LVES: left ventricular end‑systole; EF% : ejection fraction; FS: fractional shortening; LA: left
atrium; AO: Aortic root dimension, IVS: Interventricular septum; pw: Posterior Wall thickness.
Mean ± standard deviation (a), median (IQR) (b), P value by independent sample t‑test (*); P value by Mann‑Whitney Test (**).

LVED, LVES,and LV ejection fraction LV fractional difference (Table 2). However, Left atrial anteroposterior
shortening were shown to be within normal ranges and no diameter, posterior wall thickness and Interventricular
statistically significant difference was detected between septum and were found to be statistically significant
both studied groups regarding the previously mentioned higher in metabolic syndrome group compared to normal
ECHO features (Table 2). Additionally, AO was found control group (Table 2).
to be normal within the two groups with no significant

Table 4: Effect of controlled and uncontrolled hypertension on diastolic dysfunction of the left ventricle

Hypertension
Diastolic Dysfunction Absent Controlled Not Controlled P‑Value
N % N % N %
Present 1 16.7 0 0.0 14 87.5
<0.001
Absent 5 83.3 18 100 2 12.5
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 563
Uncontrolled hypertensive patients show to controlled hypertensive patients and normotensive
echocardiographic features of diastolic dysfunction patients.
which was found to be significantly higher compared

Table 5: Effect of controlled and uncontrolled diabetes on diastolic dysfunction of the left ventricle

Diabetes
Diastolic
Absent Controlled Not Controlled P‑Value
Dysfunction
N % N % N %
Present 6 30 1 10 8 80
0.003
Absent 14 70 9 90 2 20

Uncontrolled diabetic patients show echocardiographic features of diastolic dysfunction which was found to be
significantly higher compared to controlled diabetic patients and patients with no diabetes.

Table 6: Effect of controlled and uncontrolled dyslipidemia on diastolic dysfunction of the left ventricle

Dyslipidemia
Diastolic
Absent Controlled Not Controlled P‑Value
Dysfunction
N % N % N %
Present 5 37.5 3 23.1 7 53.8
.281
Absent 9 64.3 10 76.9 6 46.2

This table shows that there is no difference in the fraction and fractional shortening which represents left
frequency of diastolic dysfunction among the three ventricular systolic function were not different among
studied groups. MS patients and normal control group. The major
finding of the current study was that metabolic syndrome
Discussion causes diastolic dysfunction as assessed by standard
The term metabolic syndrome (MS) represents echocardiographic measurements. Previous studies have
a clustering of components including truncal demonstrated the effect of metabolic syndrome on the
obesity,hypertension,diabetes mellitus anddyslipidemia. function of left ventricle, but consensus is still lacking.
Eachcomponent of metabolic syndromemay be A study by12 has examined the impact of metabolic
considered as important risk factors for the development syndrome on diastolic function of left ventricle in
of cardiovascular disease[10]. Previous literatures study American Indians using ECHO. They noticed altered
the impact of both insulin resistance and obesity on left of both left ventricular relaxation and of left ventricular
ventricular function; however, there is lack of studies diastolic function which is consistent with the current
that show the impact of MS on left ventricular function. study. Also they concluded that American Indians with
Furthermore, some studies demonstrated that individuals the metabolic syndrome had greater posterior wall
with idiopathic dilated cardiomyopathy were diagnosed thickness, left atrial diameter and diastolic dysfunction
with insulin resistance;these studies concluded that MS which are consistent with the current study [12]. In the
may cause coronary heart disease[11]. Thus, the present present study, left atrial diameter of metabolic syndrome
study was conducted to evaluate the impact of metabolic group was increased compared to control group,
syndrome on left ventricular performance using ECHO. which corresponds to results from other literature[13].
[14]
Have shown that left ventricular diastolic function
In the current study, all components of metabolic was impaired in MS patients; however ejection fraction
syndrome were found to be signifi­cantly higher and fractional shortening (left ventricular systolic
in patients with metabolic syndrome compared to function) is preserved which corresponds to the findings
normal control group. The analysis of traditional of the present study.[15] Also have shown that only left
echocardiographic parameters showed that both ejection ventricular diastolic function altered in patients with MS
564 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
although systolic function is preserved. In contrast, [16] Association of the metabolic syndrome with
some studies demonstrated that metabolic syndrome early coronary disease in families with frequent
is associated with global left ventricular dysfunction myocardial infarction. Am J Cardiol. 2006;
(diastolic and systolic) in subjects with MS but no 97:964‑7.
CVD. Previous studies have demonstrated that diastolic 3. Ford ES, Li Cand Zhao G. Prevalence and correlates
function observed in the current study may be as a result of of metabolic syndrome based on a harmonious
hypertension. Arterial Stiffness, caused by hypertension definition among adults in the US. J. Diabetes
may be results in cardiovascular abnormalities [17].In 2010; 2(3): 180–193.
contrast, another study demonstrated that hypertension
4. Friend A, Craig L, and Turner S. The prevalence
and obesity were not associated with left ventricular
of metabolic syndrome in children: a systematic
diastolic dysfunction.
review of the literature. Metab. Syndr. Relat.
4. Watcher et al.,demonstrated that left ventricular Disord. 2013; 11(2): 71–80.
diastolic dysfunction occurs at a higher percentage in 5. Plandevall M, Singal B, Williams L, Brotons C,
diabetic patients (80.6%) when compared with patients Guyer H, Sadurni J, Falces C, Serrano‑Rios M,
with no diabetes (69.2%). furthermore, diabetes cause Gabriel R, Shaw JE, Zimmet PZ. and Haffner S.
serious effect on the left ventricular diastolic function[18]. A single factor underlies the metabolic syndrome.
In the current study the incidence of diastolic dysfunction Diabetes Care. 2006; 29(1): 113‑122.
rise significantly. The rate of Prevalence of diastolic 6. Alexander, CM, Landsman, PB, Teutsch, SM and
dysfunction was found to be significantly higher Haffner, SM. NCEP‑defined metabolic syndrome,
among uncontrolled diabetic patients (80%) compared diabetes, and prevalence of coronary heart disease
topatients under glycemic control(10%) and patients among NHANES III participants age 50 years and
with no diabetes (30%). Both studies are comparable. older. Diabetes. 2007; 52(5):1210–1214.
Control of glycemiaby drug or life style modification
7. Kane GC, Karon BL, Mahoney, DW, Redfield,
in diabetic patients can help in maintaining normal
MM, Roger VL, Burnett JC, Jacobsen S.J.,
diastolic function. According to the Strong Heart Study
Rodeheffer R.J. Progression of left ventricular
there was a relation between degrees of glycemic control
diastolic dysfunction and risk of heart failure.
and diastolic function [19]. However, in the present study
JAMA. 2011; 306:856e863.
glycemic control markers were excluded from the
research. 8. Ford ES. Risks for all‑cause mortality,
cardiovascular disease, anddiabetes associated with
The potential limitations of the present study are a the metabolic syndrome: a summary of theevidence.
small sample size and lack of randomization. Diabetes Care.2006; 28:1769e1778.
9. Alberti KG, et al. Metabolic syndrome—a new
Ethical Clearance: Taken from Faculty of
world‑wide definition. A Consensus Statement
Pharmacy, Minia University committe, 61519 Minia,
from the International Diabetes Federation. Diabet
Egypt.
Med 2001; 23(5):469–4800.
Source of Funding: Self‑funding. 10. Kenchaiah S, Evans JC, Levy D, Wilson PW,
Benjamin EJ, Larson MG, et al. Obesity and the
Conflict of Interest: There is no conflict of interest.
risk of heart failure, N. Engl. J. Med. 2002; 305–
313:347.
References
11. Witteles RM, Fowler MB.Insulin‑resistant
1. Grundy SM, Brewer Jr. HB, Cleeman JI, Smith Jr. cardiomyopathy clinical evidence, mechanisms,
SC, Lenfant, C, National Heart, Lung, and Blood and treatment options. J Am Coll Cardiol
Institute, American Heart Association, Definition 2008;51(2):93–102.
of metabolic syndrome: Report of the National
12. Chinali M, Devereux RB, Howard BV, Roman
Heart, Lung, and Blood Institute/American Heart
MJ, Bella JN, Liu JE, et al. Comparison of cardiac
Association conference on scientific issue related
structure and function in American Indians with
to definition, Circulation. 2004; 433:438‑109.
and without metabolic syndrome (the Strong Heart
2. Reinhard W, Holmer, SR, Fischer, M, et al. Study). Am J Cardiol 2004; 93(1):40–4.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 565
13. Azevedo, A, Bettencourt, p, Almeida, PB, et al. vascular dysfunction and exercise capacity in
Increasing number of com­ponents of the metabolic the metabolic syndrome, Am. J. Cardiol. 2005;
syndrome and cardiac structural and func­tional 96:1686–1691.
abnormalities – cross‑sectional study of the general 17. Peterson LR, Waggoner AD, Schechtman, KB,
population. BMC Cardiovascular Disorders 2007; Meyer T, Gropler RJ, Barzilai B, Davila‑Roman,
7: 17. VG. Alterations in left ventricular structure and
14. Grandi AM, MarescaAM, Giudici E, Laurita E, function in young healthy obese women: Assessment
MarchesiC, SolbiatiF. et al. Metabolic syndrome by echocardiography and tissue Doppler imaging. J
and morphofunctional characteristics of the left Am Coll Cardiol. 2004; 43:1399–1404.
ventricle in clinically hypertensive non diabetic 18. Wachter R, Lüers C, Kleta S, Griebel K,
subjects, Am. J. Hypertens. 2006; 19: 199–205. Herrmann‑Lingen C, Binder L, et al. Impact of
15. Masugata H, Senda S, Goda F, Yoshihara Y, diabetes on left ventricular diastolic function in
Yoshikawa K, Fujita N, et al.Left ventricular diastolic patients with arterial hypertension. Eur J Heart Fail
dysfunction as assessed by echocardiography in 2007; 9:469–76.
metabolic syndrome, Hypertens. Res. 2006; 29: 19. Liu JE, Palmieri V, Roman MJ, Bella JN, Fabsitz
897–903. R, HowardB.V. et al.The impact of diabetes on
16. Wong CY, O’Moore‑Sullivan T, Fang ZY, Haluska left ventricular filling pattern in normotensive and
B, Leano R. and Marwick, TH. Myocardial and hypertensive adults: the Strong Heart Study. J Am
Coll Cardiol.2001; 37: 1943–9.
566 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

The Role of Mean Arterial Pressure (MAP) Roll Over Test

(ROT) and Body Mass Index (BMI) in Preeclampsia
Screening in Indonesia

Dwi Putri Rahayu Tampubolon1, Lilik Herawati2, Nursalam3, Ernawati4

1Student in Midwifwery Program, 2Physiology Department Faculty of Medicine, 3Faculty of Nursing,
4
Obstetrics and Gynecology Department Faculty of Medicine Universitas Airlangga

Abstract
Objective: To evaluate the role of MAP, ROT, and BMI in preeclampsia screening in low resources setting.

Method and Material: This is a retrospective study conducted on 1011 pregnant women who had an
antenatal care at Public Health Center in Indonesia. Data taken from public health medical report. The
sample groups were 45 preeclampsia patients who have had complete screening of MAP, ROT and BMI.
The control groups were normal pregnant women who attained same inclusion criteria.

Results: The pre eclampsia group had positif MAP and obesity result respectively 95.6% and 40% of
patients, but in control group only had 40% and 11.1% of patient have positive MAP and obesity respectively.
Statistical test illustrates a significant association between MAP and BMI screening with the incidence of
preeclampsia (p 0.0001, OR = 32.250 and p 0.002, OR = 5.333).Whereas positive ROT showed in 40%
PE groups and 57.8% control group. There is no association between ROT screening and the incidence of
preeclampsia (p 0.092).

Conclusion: MAP and BMI can be used as baseline screening tools of preeclampsia in low resources setting.
But ROT is not associated with the incidence of preeclampsia.

Keywords: Preeclampsia Screening, MAP, ROT, BMI.

Introduction of pregnancy is important to identify women who are at

risk of developing PE so that early enough prevention
Preeclampsia (PE) is a complex medical disorder,
treatment could start to prevent or reduce the frequency
who is is responsible for neonatal and maternal deaths
of its occurrence.
worldwide. It is also becomes the biggest cause of high
Maternal Mortality Rate (MMR) in Surabaya Indonesia Preeclampsia screening vary from clinical to
from 2013‑20171. Accurate prediction and aggressive biomolecular level depend on the resources availability.
prevention allowed to elude this pregnancy complication. In low and middle income countries where resources are
Effective screening to predict PE in the first trimester limited, variations of the first‑trimester combined test
can be considered but difficult to reached. The baseline
test which is possible to do are combine of maternal risk
factors with Mean Arterial Pressure (MAP) and Roll
Corresponding Author:
over Test (ROT). In the absence of other biomarker(s),
Ernawati
risk calculation can still be done but the detection rates
Obstetrics and Gynecology Department Faculty of
will be reduced .
Medicine, Universitas Airlangga Surabaya, Jawa Timur,
Indonesia MAP and ROT are a method to describe
Phone : +6281232850261 hemodynamic conditions in patients with preeclampsia.
email: [email protected] ROT is not a perfect predictor, but it still have advantages
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 567
to use in populations with high PIH associated maternal medical report. The sample groups were 45 preeclampsia
and perinatal mortality, mostly in low resources setting2. patient during that period time who fulfilled inclusion
It has been used in many contries but some literature criteria: patients in the first and second trimesters who
shows that ROT is not related to the incidence of have had complete screening of MAP, ROT and BMI.
preeclampsia3. The purpose of this study is to determine The control groups were normal pregnant women
the effectiveness of preeclampsia screening (MAP, ROT, who attained same inclusion criteria. It was takenby
and BMI) to the incidence of preeclampsia in Indonesia. consecutive sampling. Positive result noted if MAP is
> 90 mmHg. ROT classified as positive result if there
Material and Method were different of diastolic pressure between supine and
This is a retrospective study conducted on 1011 lateral position more than 15 mmHg3. The values on
pregnant women who performed an antenatal care at BMI screening classified as obesity if the result >30.The
Sidotopo Wetan Public Health Center (Puskesmas samples were traced retrospectively to see the MAP,
Sidotopo Wetan), Surabaya, Indonesia from October ROT and BMI screening history and demographic data.
2017 to October 2018. Et Data taken from public health

Finding:
Table 1: Demographic Characteristics

PE group Control group Total

Age (Year)
n (%) n (%) n (%)
< 20 0 (0) 3 (6.7) 3 (3.3)
20‑35 37 (82) 38 (84.4) 75 (83.3)
> 35 8 (18) 4 (8.9) 12 (13.3)
Parity
Primi 9 (20) 13 (28.9) 22 (24.4)
Multips 36 (80) 32 (71.1) 68 (75.6)
Risk Factor
Anemia 3 (6.7) 0 (0) 3 (3.3)
Gestational diabetes 5 (11.1) 2 (4.4) 7 (7.8)
History of Preeclampsia 1 (2.2) 0 (0) 1 (1.1)
Obesity 16 (35.6) 5 (11.1) 21 (23.3)
Tuberculosis 2 (4.4) 0 (0) 2 (2.22)
HbsAg (+) 1 (2.2) 0 (0) 1 (1.1)
History of IUFD 1 (2.2) 0 (0) 1 (1.1)
Under nutrition 1 (2.2) 6 (13.3) 7 (7.8)

Baseline demographics of study participants are nulips. Obesity has the highest rank in PE risk factor in
presented in Table 1. Most pregnant women in both this study. It counts a percentage of 35.6% obesity cases.
groups are in reproductive ages. It also worked on parity Followed by Gestational diabetes and anemia.
data, which is multips showed have larger number than

Table 2: MAP, ROT, BMI and the incidence of preeclampsia

PE Group Control Group Total

Screening P OR
n (%) n (%) n (%)
MAP (‑) 2 (4.4) 27 (60) 29 (32.2)
0.0001 32.250
MAP (+) 43 (95.6) 18 (40) 61 (67.8)
ROT (‑) 27 (60) 19 (42.2) 46 (51.1)
0,092 ‑
ROT (+) 18 (40) 26 (57.8) 44 (48.9)
Obesity (‑) 27 (60) 40 (88.9) 67 (74.4)
0,002 5.333
Obesity (+) 18 (40) 5 (11.1) 23 (25.6)
568 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
The MAP test in this study pointed out that 95.6% on MAP measurement of more than 9000 pregnancies
preeclampsia samples have a value of positive MAP, at 11–13 weeks of gestation compared the screening
while only 40% samples of control groups have a positive using systolic blood pressure, diastolic blood pressure,
MAP. This study in accordance with another study by and MAP.MAP performed best as a marker, with an
Gasse et al in 2017, which is showed that first‑trimester increasing of detection rate for early onset PE from
MAP is a strong predictor of gestational hypertension 47% (based on maternal factors alone) to 76% (based
and preeclampsia in nulliparous women4. on MAP and combination of maternal factors) at 10%
false positive rate8.MAP screening in first‑trimester
Table 2 also showed that 60% preeclampsia is a strong predictor of gestational hypertension and
patients have negative ROT screening and are inversely preeclampsia9,10.
proportional to control group that most of them have
positive ROTscreening with p value 0.092 which means The value of roll‑over test has advantages in its
that there is no association between ROT measurement simplicity. It requires simple equipment and no special
and the incidence of preeclampsia. skill. ROT is performed by positioning the patient in a
lateral state and then a blood pressure measurement is
The results of BMI measurement and the incidence made until there is no change in blood pressure. Then,
of preeclampsia in this study showed that 40% the tension is measured in the supine position and the
preeclampsia patient are obese but only 11.1% control tension results are recorded again.
group patient recorded obese. Statistical analysis noted
p value 0.002 which could be explained that there Some study showed roll‑over test are highly variable
is a relationship between BMI and the incidence of among different investigators and also inconsistent
preeclampsia. reproducibility in the same patient. Literature review
reveals sensitivities varying between 0 to 93% and
Discussion specificities between 54 – 91% and false positive results
Baseline data in this study discordant with the theory up to 90%. Walia et all study in 2015 also reported
of preeclampsia and other study which is reproductive roll‑over test performed at 24 weeks had negative in all
ages and multips are low risk group to have hypertension study cases. So, it is clear that ROT has no role as early
in pregnancy. It could be explained that reproductive age predictive in preeclampsia3.
in this study has preeclampsia risk factor ie gestational The relationship between preeclampsia and obesity
diabetes, obesity, history of preeclampsia and infection. has been greatly studied. Obesity prevalence has
Another study from Indonesia also pictured that more increased over 25 years it is similar to preeclampsia
than 50% patients who experienced preeclampsia are prevalence. This study showed obesity has correlation
between 20 to 35 years old5.Parous women without with incidence of PE. It revealed OR 5.3 in obesity cases
prior history of PE have lower risk of PE; however, this compare non obesity cases.
protective effect will change when they have different
conception partner6. This data support substantial evidence which is
show that obesity (BMI ≥30 kg/m2) confers a higher risk
MAP test showed strong relationship with for PE10,11,12. Obesity also state as meta inflammation,
incidence of preeclampsia in this study, it revealed odd associated with chronic stress and inflammatory response.
ratio 32.25. This data inline with Poon study in 2008 The inflammatory response was found to increase
which reported first study on MAP measurement using in obese women and contribute to vascular targets
validated automated blood pressure devices according and vascular changes induce endothelial dysfunction
to a standardized protocol and maternal variables in and placental ischemia in turn exaggerated maternal
11+0 to 13+6 weeks pregnancy can predict PE.Maternal inflammatory response and induce preeclampsia13,14,15.
blood pressure was measured in 5590 singleton pregnant
women. the detection ratesfor PE, at 10% false positive This study in line with FIGO guideline on
rate, were 38% and 63%, respectively for MAP alone preeclampsia screening where state that if it is not
and in combination with maternal history7. possible to measure biomarker (PLGF) and/or uterine
artery doppler, combination of maternal risk factor and
MAP is a reflection of hemodynamic perfusion MAP has advantages than maternal risk factor alone.
pressure from vital organs. Another follow‑up study Simple method to measure in Public health will increase
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 569
awareness, access, affordability, and acceptance prenatal weeks in the prediction of preeclampsia.
screening of preeclampsia16. Hypertension. 2008;51(4):1027-33
8. Poon LC, Kametas NA, Valencia C, Chelemen
Conclusion T, Nicolaides KH. Hypertensive disorders in
MAP and BMI can be used as baseline screening pregnancy: Screening by systolic diastolic and
tools of preeclampsia in low resources setting with OR mean arterial pressure at 11-13 weeks. Hypertens
= 32.250 and 5.333. But ROT is not associated with the Pregnancy. 2011;30:93–107
incidence of preeclampsia. 9. Gallo, D., Poon, LC., Fernandez, Wright, D.,
Nicolaides, KH. Prediction of Preeclampsia by
Conflict of Interest: None
Mean Arterial Pressure at 11–13 and 20–24 Weeks’
Funding: Self‑funding. Gestation. Fetal Diagnosis Therapy, 2014;36:28‑37
10. Liu L, Hong Z, Zhang L. Associations of
Ethical Clearance: Approved by the Ethics prepregnancy body mass index and gestational
Committee Medical Faculty Universitas Airlangga weight gain with pregnancy outcomes in nulliparous
women delivering single live babies. Sci Rep.
References 2015;5:12863.
1. Surabaya Health office 5 year report, 2017. 11. Rahman MM, Abe SK, Kanda M, et al. Maternal
Unpublished data body mass index and risk of birth and maternal
2. Narvaez, M, Weigel, M.M, Felix, A, Jaramilo, health outcomes in low and middle income
L P. The clinical utility of the roll-over test in countries: A systematic review and meta-analysis.
predicting pregnancy-induced hypertension in a Obes Rev. 2015;16:758–770.
high-risk Andean population. International Journal 12. Wei Y-M, Yang H-X, Zhu W-W, et al. Risk of
of gynecology& Obstetrics. 1990;vol 31:1; 9-14 adverse pregnancy outcomes stratified for pre-
3. Walia, D and Gupta. Comparison between roll-over pregnancy body mass index. J Matern Fetal
test and placental localization for early prediction Neonatal Med. 2016;29:2205–2209.
of preeclampsia. 2015; DOI: 10.18203/2320-1770. 13. Gregor MF, Hotamisligil GS. Inflammatory
ijrcog20150784 mechanisms in obesity. Annu Rev Immunol.
4. Gasse C., Boutin A., Cote M., Chaillet N., Bujold E., 2011;29:415–445.
and Demers S. First-trimester mean arterial blood 14. Spradley FT, Palei AC, Granger JP. Immune
pressure and the risk of preeclampsia: The Great mechanisms linking obe- sity and preeclampsia.
Obstetrical Syndromes (GOS) study.Pregnancy Biomolecules. 2015;5:3142–3176.
Hypertens,2017.;12:178-182. doi: 10.1016
15. Reslan, O. M. and Khalil, R. A. Molecular And
5. Ernawati, Erry Gumilar, Kuntoro, Joewono Vascular Targets In The Pathogenesis And
Soeroso & Gus Dekker. Expectant management of Management Of The Hypertension Associated With
preterm preeclampsia in Indonesia and the role of Preeclampsia. Cardiovascular & hematological
steroids, The Journal of Maternal-Fetal & Neonatal agents in medicinal chemistry. 2010; 8(4), pp. 204–
Medicine. 2016;29(11):1736-40. 26. doi: 10.2174/187152510792481234.
6. Robillard PY, Hulsey TC, Alexander GR, Keenan 16. Poon. L, Shennan. A, Hyeet. J.A, Kapur. A, Hadar.
A, de Caunes F, Papiernik E. Paternity patterns E, et al. The International Federation of Gynecology
and risk of preeclampsia in the last pregnancy in and Obstetrics (FIGO) initiative on pre-eclampsia:
multiparae. J ReprodImmunol. 1993;24:1–12. A pragmatic guide for first-trimester screening and
7. Poon, LC., Kameta NA., Valencia C., Nicolaides prevention. Int J Gynecol Obstet, 2019; 145 (Suppl.
KH. Mean arterial pressure at 11(+0) to 13(+6) 1): 1–33
570 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Strategic Contribution of Health Services in the

Indonesia‑Malaysia Border to The National Resilience:
Analysis of Implementation in the West Kalimantan Province

Dwi Rachmatullah1, Dumilah Ayuningtyas2, Raden Roro Mega Utami2

1National
Resilience Strategic Study, Strategic and Global Study School, Universitas Indonesia,
2
Department of Health Policy and Administration, Faculty of Public Health, Universitas Indonesia

Abstract
Background: The length of “open access” areas from Indonesia which leads to the vulnerability state
is the factor that influence terrorism, disease, and other transnational crimes. This study aims to analyze
the contribution strategies made by the Government of Indonesia in efforts to equalize health services in
the Indonesia‑Malaysia border region in order to strengthen health resilience as an important part that is
inseparable from national security.

Method: The method used in this study is narrative review of published articles and news related to the
policy environment and health service facilities in the border regions of Indonesia and in the other countries
that have been published in Scopus‑accredited and indexed journals.

Results: It was found that there were obstacles faced by the health providers during the implementation
process, including the lack of availability of human resources as health workers as well as health facilities in
the border area. As such, many Indonesians living on the border choose to seek treatment in Malaysia. The
entry and exit routes from neighbor countries are inevitably becoming vulnerable areas which need attention
to prevent various threats from entering the border line which will have an impact on National Resilience.

Conclusions: The fulfillment of human resources availability for health workers and health facilities in the
border area has not been maximized due to the difficulty of distribution and limited access. Managing the
Indonesian border by relying solely on security and military approaches is not enough, that it requires a
multi‑sector approach that involves all relevant stakeholders. Good management of border areas is needed
as an effort to strengthen Indonesia’s national security.

Keywords: Cross‑Border; Health Sector; Health Personnel; Health Facility; National Resilience.

Introduction threat, but it can also another non‑military threat, such as

health, which can disrupt national stability and resilience
Indonesia has a very long border line, which is
especially in the border region.
around 2914.1 km. The length of the “open access” of the
Indonesian border region has resulted in the vulnerability Health policies in Disadvantaged Areas, Border and
of the state gates to be the entry point for threats that have Islands are an integral part of the Government’s efforts
the potential to disrupt national stability and resilience, to accelerate health development, especially in the
particularly in the form of terrorism, diseases, narcotics, aspect of equity. The limitations of existing facilities,
and other transnational crimes. Health is an integral part amount and quality of Human Resources, geographical
in supporting national resilience. and weather conditions are among the most important
factors in this regard.1 One of the efforts in accelerating
As the front line, the border community in Indonesia
the health development that has been done is providing
will be the first guard to face the threats coming from the
Social Assistance funds according to the Decree of
outside. This threat is not only classified as a military
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 571
the Minister of Health No. 329/MoH/Reg/III/2010 Hence, this study aims to analyze the contribution
concerning social assistance for health services in strategies made by the Government of Indonesia in efforts
disadvantaged areas, border and islands year 2010. In to equalize health services in the Indonesia‑Malaysia
addition, the issued Decree of the Minister of Health No. border region in order to strengthen health resilience
758/MoH/DL/IV/2011 appointed Districts and Primary as an important part that is inseparable from national
Health Care in land borders and outer population islands security.
that became the target of national priority programs for
health services for disadvantaged areas, border, and Method
islands. Based on the Decree of Health Ministry, 45 The study was using a narrative review of
regions are designated as the main targets of healthcare published articles associated with health services in the
programs in DABI. The uneven distribution of health Indonesia‑Malaysia cross‑border area to the national
workers in the lower DABI, as in Minister of Health resilience as well as other countries experiences. The
Regulation No. 027 of 2012 concerning health troubled study focused on obtaining secondary information sources
regional disaster management shows that 90 districts/ from the articles published in several accredited indexes
cities including DABI struggled in health problems. This in Scopus which were searched by using the keywords
fact indicates that the public health development index is of health service, cross‑border, Indonesia‑Malaysia,
quite low ranging between the average of ‑1 (minus one) national resilience, and Kalimantan. The search was
raw intersection, but has an above average value based limited to the last 10 years (2008‑2018). A critical
on economic status data.2 appraisal of selected articles was performed by using the
Further to the above issue, realizing the importance PRISMA method.
of health issues as a threat to national security of a
country, the Ministry of Defense of the Republic of
Result and Discussion
Indonesia (MOD) and the Ministry of Health of the Between West Kalimantan and Sarawak, land routes
Republic of Indonesia (MOH) signed a Memorandum of have been opened between countries, namely through
Understanding on Cooperation in Health until June 26, Pontianak‑Entikong‑Kuching (Sarawak, Malaysia) for
2015. This agreement aims to increase the capacity of about 400 kilometers and can be reached in six to eight
health institutions in MOD and MOH in implementing hours. In the northern part of West Kalimantan, there
health services and health support functions to improve are four districts that are directly adjacent to Malaysia,
public health as a potential and strength of the national namely Sambas Regency, Sanggau District, Sintang
defense. One of the scopes discussed in this agreement is District, and Kapuas Hulu Regency, which stretch along
the implementation of health services on DABI. Although the Kalingkang‑Kapuas Hulu Mountains.4
the leading sector for non‑military threat control in the
health sector is held by MOH, MOD is also responsible Based on data from the Central Bureau of Statistics
if the threat has disrupted the country’s defense system. in 2016, there were 244 Primary Health Care units, 899
To date, MOH and MOD have taken various steps to Supporting Primary Health Care units, and 277 mobile
anticipate the existence of any outbreaks happening Primary Health Care units in West Kalimantan. The
both at home and abroad. One of which is to build the hospital is one of the most vital health infrastructures
infrastructure including the equipment, facilities, and in West Kalimantan. The number of hospitals in
health workers which can deal with non‑military threats the same year was 45 units with the number of beds
in the health sector.3 available were 4,143 units. In 2015, the total population
of West Kalimantan Province reached 4.89 million
Health is an inseparable part of Indonesia’s national with a population growth of 1.67 in 2010‑2015.5West
security. Health is one of the variables of the welfare Kalimantan is one of those border areas. State border
aspects in the social and cultural context. There are management is a very important and strategic thing that
twelve indicators of measuring instruments that are aims to:
used as parameters for National Resilience in health
variables. 8 out of 12 of these indicators have a focus a. Ensuring territorial integrity and upholding the
on measuring the quality and quantity of facilities and sovereignty of the Unitary Republic of Indonesia;
human resources. b. Enforcing the national defense and security;
572 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
c. Utilizing the resources and equitable distribution of State border crossing is the entry and/or exit point
development and its results for the benefit of public of people and goods. There are three patterns of crossing
welfare; people/goods in the state border area. The unofficial
crossing pattern has caused disruption to national
d. Building the competitiveness of the border
security stability. Appropriate cross‑border management
community members to be able to balance the
is needed to answer complex and specific problems.
more superior social economic activities of the
State boundary management requires the integration of
neighboring countries;6
various elements, including the elements of security,
Various threats that disturb Indonesia’s national customs, immigration, quarantine, and other elements or
security often occur in the state border area. Based supporters.
on the mapping carried out by the National Border
Management Agency, the most frequent illegal activity In the West Kalimantan Region, there are four
in the province of West Kalimantan is illegal border districts that are directly adjacent to the Malaysian State,
entry and narcotics smuggling. These two activities are namely Sambas Regency, Sanggau District, Sintang
serious threats to the Indonesian state which can disrupt District, Kapuas Hulu Regency. The following is the
the stability of Indonesia’s national security.6 distribution of the number of health workers and health
facilities in the four districts:

Table 1: Number of Health Personnel by Regency in 20165

Medical Specialist General Practitioners Dentist Midwife Nurse Total

Sambas 14 47 6 304 386 757
Sanggau 15 38 4 83 182 322
Sintang 24 42 11 50 216 343
Kapuas Hulu 11 50 2 252 456 771

Table 2. Number of Hospitals and Beds in 2016 5

Supporting Primary Mobile Primary

Districts/City Primary Health Care Hospital Number of Beds
Health Care Health Care
Sambas 28 92 25 3 330
Sanggau 19 90 21 3 300
Sintang 20 60 51 3 161
Kapuas Hulu 23 85 39 2 145

Health problems in border areas are very complex Specialist Hospital (KPJ). It is estimated that the number
and considered as a threat that can interfere Indonesia’s of visits will increase by 8 percent every year.7
national resilience, partly because it allows the entry
or exit of disease‑causing agents. The small number The elevated level of visit of Indonesian citizens
of hospitals and health workers in the border region who seek for treatment in Malaysia is caused by
of West Kalimantan has caused many Indonesians to the transportation access problems. A resident from
seek treatment in Malaysia, instead of in Indonesia. Sekayam District, Sanggau Regency, West Kalimantan
Consulate General of the Republic of Indonesia (KJRI) Province said that the road to the primary health care in
in Kuching, Malaysia, records an average of 300 West Sanggau District was terrible and difficult to pass. This
Kalimantan residents per day visit a hospital in Kuching, condition causes the cost needed to go there is very high.
Sarawak, Malaysia for treatment. Even in 2011, there For example, if he uses an ambulance to go there, it takes
were more than 415,000 Indonesians visiting Sarawak around 700 thousand rupiahs and two‑hour travel time.
for treatment. Of that amount, the most visited hospitals Whereas for seeking treatment to Malaysia, he spent
were Normah Hospital, Timber Lyne, and Kuching at most 7 ringgit, which is equivalent to 25 thousand
rupiahs.8
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 573
The progress of information and technology does before crossing over.
not rule out the possibility of causing an increase in the
volume of people in choosing treatment. The location Port Health Office said that in safeguarding the
of the primary health careis far from the capital and border, the officer has the duty and function to prevent
adjacent to neighboring countries causes the population deterrence from the entry and exit of diseases, and to
to have the option to go to a neighboring country, even supervise drugs, food, cosmetics, medical devices,
though the primary health care as a health facility and addictive substances. The Head of the Pontianak
has been equipped with adequate health workers and Port Health Office added that for the land route, the
medical devices. Based on the results of interviews in Port Health Office placed several officers in Entikong,
a study conducted by Laksmiarti (2014), there was an Badau, Aruk, and JagoiBabang. This officer is in charge
Indonesian citizen who lived very close to the primary of supervising the people’s means of transportation and
health care in Entikong (only about 10 minutes), while their luggage. The supervision also includes the corpse
going to the polyclinic in Malaysia took him 20 minutes that enters. The body must be ensured to not carry an
from the border. But for a long time, these residents prefer infectious disease agent that can cause emergency. In
to seek for treatment in Malaysia. According to him, he carrying out its duties, the Port Health Office working
received excellent service from nurses and midwives at area also cooperates with the agricultural quarantine
the Malaysian clinic. He spent 200 thousand rupiah for division in the local cross‑border posts which is
one treatment – 70 thousand for transportation and 100 responsible in carrying out operational activities in
thousand for medical expenses. He claimed that it was quarantining animals and plants, as well as animal‑based
not a problem to spend that much money, provided that biological safety security.10Unfortunately, the existence
the services provided made him comfortable. He did of this port health work area is not supported by
not check himself at the Entikong health center because adequate health laboratory facilities in the border area
the health workers at the primary health care were still although it was mandated by the International Health
young because the senior officers and the head of the Regulation (IHR) 2005 which was updated to be the
Primary health care were often not in place. Therefore, Global Health Security Agenda (GHSA). The regulation
he trusted his health and his family’s in the Malaysian said that in order to maintain global health, each country
polyclinic. Moreover, for the people of Entikong, they should have a national laboratory system in the Detect‑1
do not need to use a passport, they only need to provide package action. As such, health‑related security becomes
their KTP to the immigration officers, then they can pass the concern in the Indonesia‑Malaysia border region in
and enter Malaysia.9 West Kalimantan.

Based on the above description, it is clear that the Conclusion

border which is not effectively supervised can be used as One of the problems in the border region is
a gateway to activities that are likely to disturb national border management that has not been carried out in an
security. In the West Kalimantan region, there are three integrated manner. The problem of several border areas
state boundary posts namely Entikong National Budget is still handled ad‑hoc, temporarily (temporarily) and
in Sanggau District, Badau National Budget in Kapuas partially so as not to provide optimal results. Managing
Hulu District, and Aruk National Budget in Sambas the Indonesian border by relying solely on security
District. There should be a good integration between and military approaches is not enough, it requires
immigration, customs, and health quarantine in the a multi‑sector approach that involves all relevant
PLBN, which is one of the functions carried out by the stakeholders. Good border area management is needed
port health office. as an effort to strengthen Indonesia’s national security.
Every PLBN is reminded to tighten the supervision Doing so will help to realize not only the third verse
efforts on health quarantine to prevent the spread of of nawacita, which is to develop Indonesia from the
unwanted diseases. This was emphasized by the Minister periphery by strengthening regions and villages within
of Health of the Republic of Indonesia when he visited the framework of a unitary state, but also the third
the Entikong National Budget in Sanggau District, West principle of Pancasila, namely Indonesian Unity.
Kalimantan in April 2018. Special attention should be Conflict of Interest: The authors have no conflicts
given to disease vectors such as animals that come in of interest with the material presented in this manuscript.
and out the neighboring countries to be ‘cleaned up’
574 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Sources of Funding: The authors declared that the 5. BPS‑Statistics of West Kalimantan. West
authors received no specific funding for this work. Kalimantan In Figures 2017. Pontianak:
BPS‑Statistics of Kalimantan Barat; 2017.
Ethical Clearance: The authors declare there is no
6. National Border Management Authority Republic
any ethical issues that may arise after the publication of
of Indonesia. The General Information on
this manuscript.
Cross‑Border Post [Internet]. Jakarta; 2018.
References Available from: https://setkab.go.id/wp‑content/
uploads/2018/04/PLBN‑BNPP.pdf
1. Lestari TRP. Health Services in Disadvantaged
7. Turniani L, Budisuari MA, Ardani I. People’s
Areas, Borders and Islands. Info Singk Kesejaht
Health Service Preference at the State Borders:
Sos. 2013;V(12/June):9–12.
A Policy Analysis. Bul Penelit Sist Kesehat.
2. Husein R. Evaluation Studies Of Health Workers 2014;17(4):353–62.
Availability In Health Care Center In District/City
8. Kamaliah A. A Lot Of People In The Border That
Of Disadvantaged Regions, Borders, And Islands
Medical Care To Malaysia, Apparently This Is
To Performance Indicators Achievement Of
Why [Internet]. 2018 Apr; Available from: https://
Minimum Service Standards District/City [Thesis].
health.detik.com/berita‑detikhealth/d‑3977472/
Universitas Indonesia; 2013.
banyak‑warga‑perbatasan‑berobat‑ke‑malaysia‑
3. Ministry of Defense Republic of Indonesia. The rupanya‑ini‑alasannya
Ministry of Defense and The Ministry of Health
9. Suara Pembaruan. The More Indonesian Citizens To
Signed a Cooperation Agreement in the Health
Malaysia For Medical Treatment. Suara Pembaruan
[Internet]. Ministry of Defense Republic of
[Internet]. 2012 Feb; Available from: https://
Indonesia. 2015 [cited 2018 Jul 18]. Available
sp.beritasatu.com/nasional/semakin‑banyak‑wni‑
from: https://www.kemhan.go.id/2015/06/23/
ke‑malaysia‑untuk‑berobat/17034
kemhan‑dan‑kemkes‑tandatangani‑kesepakatan‑
kerjasama‑bidang‑kesehatan.html 10. Ministry of Health Republic of Indonesia. Scope
Health Office Port Work [Internet]. Ministry of
4. Government of Kalimantan Barat. General
Health Republic of Indonesia. 2012 [cited 2018
Description of Geographical Aspects of West
Apr 14]. Available from: http://www.depkes.go.id/
Kalimantan [Internet]. Government of West
article/print/1976/ruang‑lingkup‑kerja‑kantor‑
Kalimantan. 2018 [cited 2018 Aug 29]. Available
kesehatan‑pelabuhan.html
from: http://kalbarprov.go.id/info.php?landing=2
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 575

Survival Analysis of Chronic Kidney Failure with a

History of Degenerative Disease

Efri Tri Ardianto1, Alinea Dwi Elisanti2

1Medical Record Program Study, 2Clinical Nutrition Program Study, Health Department, Politeknik Negeri Jember

Abstract
Survival analysis is a statistical procedure for analyzing data with variables that are in focus is time until an
event occurs. Kaplan‑Meier is one simple method to describes a survival curve. Chronic Kidney Disease
(CKD) is the 18th cause of death in the World. CKD has been classified as number two catastrophic disease
after heart disease. Many studies have been conducted on the survival of CKD patients, but there have
not been many studies on CKD based on degenerative disease. The study want to assess the survival of
hemodialysis patients with degenerative comorbidities. This retrospective non‑reactive design cohort study
uses the right sensor. 34 samples were selected according to the inclusion criteria from 155 populations
through simple random sampling. Secondary data were taken from the medical record at 2010 to 2015.
The estimated survival of CKD patients with degenerative diseases in men reaching 144 weeks and women
132 weeks, patients with a basic education of 112 weeks and an advanced education of 180 weeks, patients
working 132 weeks and not working 212 weeks, patient normal nutrition 200 weeks and abnormal 112
weeks. Need screening efforts on CKD, increased endurance, regular exercise and maintenance of nutritional
status in hemodialysis patients.

Keywords: Survival Analysis, Chronic Kidney Failure, History of Degenerative Disease, Kaplan‑Meier,
Hemodialysis Patient.

Introduction of financing from BPJS after heart disease. East Java,

including number 2, has the highest prevalence of
Survival analysis is a statistical procedure for
kidney failure, which is 0.3% higher than the national
analyzing data with variables that are in focus is time
average5, which is 0.2%4. This increase is same with the
until an event occurs1. One of the simplest and easiest
increasing number of elderly people, the incidence of
method of survival analysis is Kaplan Meier. It does not
diabetes mellitus and hypertension.
require too much data, only describes the survival curve
and descriptive analysis. Descriptive analysis in survival The number of patients with CKD at Ibnu Sina
data must be done statistically, because the differences Gresik General Hospital in 2012 reached 481 patients
that appear descriptively are not necessarily descriptive. and experienced an increase every year 6. Risk factors for
The statistical test used is the Log Rank test. It can show CKD include age, gender, history of diabetes mellitus,
the differences between categories in each factors2. and a history of consumption of supplemental drinks7.
Other opinions describe sex, hypertension, diabetes,
Chronic Kidney Disease (CKD) is a public health
gout, traditional drug use and a history of kidney stone
problem throughout the world3. The prevalence and
disease as risk factor of CKD8,9 there is relationship
incidence of CKD continues to increase, has a poor
between kidney failure and a history of hypertension,
prognosis and requires high medical costs. The Global
diabetes mellitus, urinary tract infections and urinary
Burden of Disease in 2010 report CKD was the 27th
tract stones.10 obesity can increase risk factors for
leading cause of death in the world in 1990 and rose
CKD. 11 The high body mass index have the potential
to 18th in 2010. In 2016 the global prevalence of CKD
for kidney failure. Indonesian Ministry of Health, 2017
reached 13.4% 4. About 1 in 10 global populations
reports that triggering chronic kidney failure is Diabetes
experience CKD at a certain stage. In Indonesia, the
mellitus, Hypertension, Chronic Glomerulonephritis,
treatment of kidney disease is the second largest ranking
576 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Chronic Intersial Nephritis, Polycystic Kidney Disease, Method
Obstruction, Urinary Tract Infection, Obesity, and
This study is a non‑reactive study, with a type of
unknown causes.Indonesian Renal Registry (IRR),
observational analytic study. Using a retrospective cohort
(2017) has report from January to October 2016, there
design. Observations use the right sensor calculation
were 44.2% of dialysis service facilities in Indonesia
(Right Censoring). Independent variables of diabetes
that sent data.
mellitus and hypertension influence the response
Hypertensive kidney disease increased to 37% variable, namely survival of hemodialysis patients.
followed by diabetic nephropathy by 27% 12.Diabetes
The population in this study were 155 new patients
mellitus (DM) was included in the second cause after
at Hemodialysis Poly Ibnu Sina Gresik Hospital. This
hypertension in CKD cases. 13, reported the prevalence
study uses secondary data of patients’ medical records
of diabetics in Indonesia was 5.7%, but only 26.3%
from 2010 to 2015. Inclusion criteria are patients with
had been diagnosed. This condition is an obstacle in
renal failure who have two degenerative concomitant
establishing a diagnosis of CKD based on co‑morbid
diseases (hypertension and diabetes mellitus). The
diseases, especially DM which certainly requires prior
sampling technique used was simple random sampling,
investigation. Risk factors for hypertension and DM
with a sample size of 34 people. The instruments in this
are the focus of the study in this study because it has
study use the form of data collection sheet and checklist.
the potential to cause damage to various organ systems
if not handled properly. 14reported the explanatory
Result
research that blood sugar levels of 2 hours post fasting
independently influence the incidence of terminal renal The relationship identification between the response
failure in DM patients. and the predictor variables using the Kaplan‑Meier
method. Failure survival function expressed as reaching
The highest number is still patients with failure event (death) and the rate of failure to achieve
Hypertensive Kidney Disease (E4), as in previous the death is expressed as a function of hazard. Estimated
years. This still needs to be evaluated with regard to the survival function and hazard function performed by
possibility of shifting trends in world epidemiological Kaplan‑Meier. Characteristics of patient and statistic
data, although it is still possible that in Indonesia the valuecan be showed on the table 1.
etiological distribution of dialysis patients is indeed not
similar to other countries.

Table 1: Characteristics of Hemodialysis Patients Based on Degenerative Diseases

Status Median of Survival

95%
Characteristics No P‑value
Censor Estimation Lower Upper
Censor
Bound Bound
1. Man 7 14 144.00 89.985 198.015
Gender 0.892
2. Woman 5 8 132.00 18.318 245.682
1. Basic Education (Primary School to Senior
Education High School) 10 20 112.00 55.192 168.808
0.392
2. Further Education (Diploma to Doctoral) 2 2 180.00 ‑ ‑
1. Work 8 18 132.00 83.688 180.312
Job Status 0.632
2. Unwork 4 4 212.00 ‑ ‑
Nutritional 1. Normal 7 5 200.00 169.826 230.174
0.074
Status 2. Abnormal 5 17 112.00 56.022 167.978

Table 1.61.7% of hemodialysis patients are male, The female patient have a higher chance of survival
have a history of primary education (elementary to than male. Log‑Rank test results p‑value> 0.05, expain
high school) (88.2%), work (76.5%), have abnormal there was no difference in survival time between female
nutritional (64.7%). and male. Statistically the survival time of male patients
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 577
is estimated at 144 weeks, while the female reaches no difference in the survival time of the working and
132 weeks. There are differences in the survival life of not working patient. Statistically the survival time
male and female, the survival life of male hemodialysis of working patient has an estimated 132 weeks and
patients is 12 weeks higher than women. non‑working patient have an survival time of 212 weeks.

Hemodialysis patients with advanced education have Hemodialysis patients with normal nutritional had
a higher survival than primary education (elementary to a higher survival than abnormal nutritional. Log‑Rank
high school). The results of the Log‑Rank test, obtained test results p‑value> 0.05, show there was no difference
p‑value> 0.05, meaning that there was no differences in in survival time of normal nutritional and abnormal
survival time of the basic education and the advanced nutritional. Statistically the survival time of normal
education. Statistically the survival time of hemodialysis nutritional has an estimated of 200,000 weeks, while
patients with advanced education levels has an estimated the abnormal nutritional reach 112,000 weeks. So the
180‑week and primary education have an estimated survival time of hemodialysis patients with normal
112‑week. Hemodialysis patients with working status nutritional is higher. Thefollowing figure is the
have a higher likelihood of survival than non‑working Kaplan‑Meier analysis curve based on the predictor
status. Log‑Rank test results p‑value> 0.05, there was variables of hemodialysis patients:

     
(a)                           (b)

     
(c)                           (d)

Figure 1. The Results of Kaplan‑Meier Analysis (a) Gender, (b) Education, (c) Job Status, (d) Nutritional
Status.
578 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Figure 1. Kaplan‑Meier curves showed there is a patients have a higher survival than female patients. This
difference in time between two categories, but the curve fact is in line with the Ministry of Health’s statement
is merely subjective. Based on statistical values, the (2017), the prevalence of CKD in men (0.3%), higher
Log‑rank statistics show the significant variables was than women (0.2%). The trigger factors as background
Gender, Education, Job Status and Nutritional Status. It of this fact are the late recognition of early disorders of
concluded that there are no differences in survival time. the kidneys, because CKD initially does not show typical
symptoms. Signs and symptoms that arise from kidney
Discussion disease are very common and can be found in other
Hypertension and diabetes mellitus (DM) are the diseases such as high blood pressure, changes in the
factors that cause death of hemodialysis patients in Ibnu frequency of urination in a day, the presence of blood in
Sina General Hospital. The results of this study was urine, nausea, vomiting and swelling especially in the feet
simmilar with the9 research that there is relationship and ankles 4 In addition 20states that the characteristics
between kidney failure and a history of hypertension, of chronic renal failure in women are slower, and also
DM, urinary tract infections and urinary tract stones. the occurrence of psycho‑socioeconomic barriers such
15
has reported that 78.9% of CKD patients have as low awareness of women related to kidney disease
hypertensive comorbidities. Likewise, 8stated that and low family income as a cause of female dialysis
hypertension, diabetes, gout, can affect the occurrence delay. This condition eventually led to lower prevalence
of chronic kidney failure. of hemodialysis in women compared to men.

The research of16, explained patients with CRF Patients with advanced education levels have
caused by DM nephropathy reached 21.9%. 17reports higher survival than primary education. This fact is
that 30% of CKD patients have DM and 70% are caused related to the level of understanding of patients which
by non‑DM. The results of this study also reported that has an impact on patient compliance both in treatment
the characteristics of hemodialysis patients, allegedly and in patient health care. This result is same with 21
contributed to the incidence of CKD. According to8, age, researchthat reported the relationship between the level
gender, hypertension, diabetes, gout, traditional drug use of education and patient compliance in limiting fluid
and a history of kidney stones can affect the occurrence of intake in patients with chronic renal failure with p value
CKD. 18 explain CKD causes were glomerulonephritis, 0.019. 22showed patients with a higher level of education
chronic infections, vascular disease (nephrosclerosis), will have broader knowledge and also enable patients to
obstruction (calculi), collagen disease (systemic lupus), control themselves in dealing with problems they face,
nephrotic agents (amino glycosides), endocrine disease have high self‑esteem and understand what is suggested
(diabetes). 19, show CKD were causes by infection such by health workers.
as chronic pyelonephritis, inflammatory diseases such as The hemodialysis patients who do not work have
glomerulonephritis, hypertensive vascular disease such a longer life than work. It was related to the mind
as benign nephrosclerosis, malignant nephrosclerosis, burden of working hemodialysis patients. 23reported that
renal artery stenosis, connective tissue disorders such depression can affect immunological function, nutrition,
as systemic lupus erythematosus, polyarteritis nodosa, and compliance factors that can affect prescription
progressive systemic sclerosis, congenital and hereditary and administration of dialysis. Depression can be
disorders such as polycystic kidney disease, renal an independent factor in influencing the survival of
tubular acidosis, metabolic diseases such as DM, gout, hemodialysis patients. Physical activity actually affects
hyperparathyroidism, amyloidosis, toxic nephropathy the survival of hemodialysis patients, as stated by24who
eg analgesic abuse, lead nephropathy, obstructive reported that there was a relationship between exercise
nephropathy such as upper urinary tract: calculi 4 to 5 times a week with an increase in survival life of
neoplasm, netroperitoneal fibrosis. 7 explain that age, dialysis patients. 25explain that low income jobs are
gender, history of DM, and a history of consumption of prone to cause infections because there is a tendency to
supplement drinks are risk factors for CKD. consume poor quality of foods.
The majority of hemodialysis patients with Patients with normal nutritional have higher survival
degenerative diseases were male, had basic education, than abnormal nutritional. 25stated that good energy
worked and had abnormal nutritional status. The male intake would not cause nausea and vomiting. The in
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 579
adequacy of energy continuously will cause the protein 3. Selvin, E. et al. Prevalence of Chronic Kidney
to be broken down into an energy source and cause an Disease in the United States. J. Am. Med.
increase in the remaining protein metabolism in the Assoc.298, 2038–2047 (2007).
form of blood urea. Protein requirements for CKD that 4. Health Ministry. Disease, Chronic Situation,
get hemodialysis treatment are higher than CKD without Kidney. info DATIN (2017).
hemodialysis. Protein requirements are used to maintain
5. Saragih, D. A. Relationship between Family
nitrogen balance and replace amino acids lost during
Support and Life Quality of Chronic Kidney Failure
the dialysis process. Protein plays an important role as a
Patients Undergoing Hemodialysis Treatment in
result of the accumulation of prenatal catabolism in the
Haji Adam Malik Hospital Medan. (2010).
body when symptoms of uremic syndrome occur 26
6. Kompas. 142 Patients Washing the Blood in Ibnu
Conclusions Sina Gresik Hospital ‑ Kompas.com. (2009).
Available at: https://regional.kompas.com/
The estimated survival time for male hemodialysis read/2009/05/28/16103914/142.pasien.cuci.darah.
patients is 144 weeks, and women reach 132 weeks, di.rs.ibnu.sina.gresik. (Accessed: 28th January
hemodialysis patients with advanced education levels 2019)
have an estimated 180‑week survival time and 112‑week
7. Restianika, N. Factors Relating to Chronic Kidney
for primary education level, working hemodialysis
Failure in Patients Hospitalized in the Internal
patients have an estimated 132 weeks and not working
Medicine Room at Dr. Soeroto Hospital Ngawi
reach 212 weeks, hemodialysis patients with normal
Regency. 8, 44 (2014).
nutritional have an estimated 200 weeks survival time,
and abnormal nutritional reaches 112 weeks. 8. Ingsathit, A. et al. Prevalence and risk factors of
chronic kidney disease in the Thai adult population:
Suggestions: This research is expected to be used Thai SEEK study. Nephrol. Dial. Transplant.25,
as a reference and initial screening for health workers 1567–1575 (2010).
in dealing with chronic renal failure through counseling 9. Tjekyan, S. Sex, Age. 46, 275–282 (2014).
especially for patients with chronic renal failure with
10. Foster, M. C. et al. Overweight, Obesity, and the
a history of degenerative diseases. providing health
Development of Stage 3 CKD: The Framingham
education to the community, routine follow‑up to
Heart Study. Am. J. Kidney Dis.52, 39–48 (2008).
working patients, increasing endurance, routine exercise
and maintaining nutritional status in hemodialysis 11. Hsu, C.‑Y., McCulloch, C., Iribarren, C., Darbinian,
patients and can be used as a reference for future studies J. & Go, A. Body mass index and risk for end‑stage
with variables that have not been studied. renal disease. Ann. Intern. Med. 144, 21–28 (2006).
12. Pernefri. 5 th Report Of Indonesian Renal Registry
Ethical Clearance: Taken from Health Research. 2012. 5 th Rep. Indones. Ren. Regist. 2012 12–13
Ethics Committee: Public Health Faculty, (2012). doi:10.2215/CJN.02370316
Airlangga University, Indonesia. 13. Ministry Health. Basic Health Research. 6, (2013).
14. Arsono, S. Diabetes Melitus as a Risk Factor for
Source of Interest: Nill
Terminal Kidney Failure (Case Study in Patients of
Conflicts of Interest: Nill RSUD Prof. Dr. Margono Soekarjo Purwokerto).
(2005).
Reference 15. Nurcahyati, S. & Karim, D. Implementation of
1. Kleinbaum & Klein, 2012. The Cox proportional self care models in an effort to improve the quality
hazards model and its characteristics. Springer of life for patients with chronic kidney failure.
(2012). Progr. Stud. ilmu keperawatan Univ. Riau 3, 25–32
(2016).
2. Yulianto, D., Basuki, H. & Widodo. Survival
Analysis of Patients with Chronic Kidney Disease 16. Sagala, P. Analysis of Factors Affecting the
with Hemodialysis in Dr. Soetomo Surabaya. J. Quality of Life of Chronic Kidney Failure Patients
Manaj. Kesehat. Yayasan RS.Dr. Soetomo 3, 96 Undergoing Hemodialysis at the Adam Malik Haji
(2017). General Hospital in Medan. J. Ilm. Keperawatan
580 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
IMELDA1, 8–16 (2015). 22. Kamaluddin, R. & Rahayu, E. Neonatal seizures
17. Yuwono, A. Quality of Life According to Spitzer on EEG after in utero exposure to venlafaxine. J.
in Patients with Terminal Kidney Failure who Keperawatan Soedirman 4, 20–31 (2009).
Underwent Hemodialysis in the Hemodialysis Unit 23. Kimmel, L. & Peterson, R. A. in Hemodialysis
of Dr. RSUP Kariadi Semarang. (2000). Patients: on. Nephrology 4, (1993).
18. Doenges, M. E. Nursing Care Plans: guidelines 24. Stack, A., Molony, D., Rives, T., ... J. T.‑A. J. of
for planning and documenting patient care. (Alih & 2005, undefined. Association of physical activity
Bahasa: I Made Sumarwati, 2000). with mortality in the US dialysis population.
19. Price, S. A. & Lorraine, M. W. Pathophysiology Elsevier
of Clinical Concepts of Disease Processes. (EGC, 25. Fahmia, N. I., Mulyati, T. & Handarsari, E.
1995). Relationship between Energy and Protein Intake
20. Pencawan, Y. This is the reason why women with Nutritional Status in Patients with Chronic
should be more aware of chronic kidney disease. Kidney Failure who Underwent Outpatient
(2018). Available at: https://lifestyle.bisnis.com/ Hemodialysis at Tugurejo Hospital Semarang. 1,
read/20180317/106/750959/javascript. (Accessed: 1–11 (2012).
29th January 2019) 26. Almatsier, S. Basic Principles of Nutrition. (PT
21. Umayah, E. Relationship between Education Level, Gramedia Pustaka Utama, 2002).
Knowledge and Family Support with Compliance
in Limiting Fluid Intake in Patients with Chronic
Kidney Failure. (2016).
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 581

Capital Knowledge Concept:

Accounting Behavior and Health Management in Indonesia

Entar Sutisman1, Bambang Tjahjadi2, Hamidah2

1Ph.D. Student in Universitas Airlangga Surabaya, Indonesia, 2Universitas Airlangga Surabaya, Indonesia

Abstract
The purpose oft his study is to discuss the accounting behavior oft he capital knowledge concept in which
gender and skills playa role in the performance of financial statements. Types and sources Data, this study
uses secondary data manufacturing company financial statements in Indonesia from 2009 to 2016. The
research met ho de used is a quantitative correlation and variable control for independent variables have
a greater influence on financial performance. The results showed that the skill influenced the asset turn
over (0.007), current ratio (0.004), cash ratio (0.001), and fixed asset turnover (0.002) and Gender had an
effect on financial performance. DER (0.048), Asset turnover (0.000), debt ratio (0.005) and ROA (0.045).
Originality research, capital knowledge concept plays an important role to improve the performance of
corporate financial statements.

Keywords: Capital Knowledge, Accounting Behavior, Financial Performance.

Introduction The important role of free cash flow in

investment decisions Investor’s decision to invest is
Aboard of directors provides strategic direction
subjective10,21,22,23,24. The decision depends on the
using their networks to provide resources for the
expected cost,decision depends on the expected cost
organization4,7,15,25,36,44. To improver elations hips with
techniques and his perceived risk, which is entirely
shareholders and other externals take holders, a board of
a subjective factor1,6,34,43,50. For good investment
directors must be more strict in delegating operational
decisions, investors need to fully understand and correct
management,operational management balance
the opportunities that may occur and this decision
accountability at the management level. Business is a
should not bed one in a hurry. A wrong investment
multi‑dimensional partnership and openness is essential
decision can cause the company to even bankruptcy. It
to building trust;the relationship between owner and
is important to understand the basic idea of investment
manager,shareholder relationship and asymmetric
decisions to get the most value from the assessment
bondholders information between both parties leads
process. In the investment evaluation, indicators should
to agency conflict and agency costs14,19. The feature
be selected on the specific nature of the project and
of the company’s condition means that the owner oft
profitability3,11,17,37,38,42,33,36,41,45
he company cannot observe and therefore he monitors
all managerial actions,the bondholder cannot observe
Material and Method
managerial and shareholder actions, because he limits
them from potential actions that endanger the wealth of The method used is the quantitative correlation
the bondholder. between independent and dependent variables and
control variables. This study is to assess financial
performance13,16,22,24,30,31,37,5,18,32,39,46
Corresponding Author:
Entar Sutisman Data Collection and Samples: This study is
Ph.D. Student in Universitas Airlangga Surabaya, quantitative correlation research using secondary data
Indonesia such as financial statements Manufacturing companies
e‑mail: [email protected] listed on the 2009 to 2016.
Telp. +6281357630423
582 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Variable Measurement: and guidance to the CEO; and Think of it as a source
of external knowledge. Collaborative work experience,
Variable Independent:
expertise,reputation,politics, and organizational
a. Skill2,9,27,45, to develop the agency theory,it is knowledge reflect the board of director’s more effective
important to consider human capital, external social performance dimensions 8,39,52 Characteristics of a board
capital and internal social capital to develop board of directors are also important indicators of a board of
capabilities called Aboard capital, ie the ability director’s performance appraisal.
of knowledge,skills and ties to impact company
performance8,12,25, Skill Sets Represented: To develop the agency
theory, it is important to consider human capital,
Skills= β0+β1 firmsizet+ β2a board of directors+Ɛt external social capital and internal social capital to
b. Gender,directors purpose β0+β1firmsizet+ β2a develop board capabilities called Aboard capital, the
board of director t +Ɛt ability of knowledge, skills and ties to impact company
performance8,12,25. This allows the board to function as a
Where: cohesive team that implements and mobilizes resources
derived from human capital,board members and external
Firmsize=Log (sales)
social capital33,35. The composition oft he board of
A board of directors= average of aboard to year directors also affects the performance oft he company18.
During the process of recruitment oft he board of
Dependent variable directors, new members are assessed fort heir ability to
Variable dependent corporate financial contribute the required technical skills; arole‑fit12
8,18,35,36,39,44,47,51
performance . In this research use 9 H1 = skills with education Ph.D. effect on financial
indicators that is DER, Profit Margin,Turnover Asset, performance
Current Ratio, Cash Ratio, Debt Ratio, NPM, Fixed
asset turnover and ROA. Gender: The gender component of a board of
directors has become an obligation of its purpose is to
Y = β0+ β1 Skillt+ β2Gendert+ β3firmsizet+ β4a improve the impact of corporate governance reform on its
boardof directort+Ɛt performance. Corporate Governance has been identified
Findings: as a very intense and controversial area of business
administration literature. For managers, shareholders and
Correlationof Skill to Financial Performance: policy makers the role of corporate governance affects
In this study, thes kills proxiedin Ph.D. statements. the company’s performance. Previous research has
From the table below shows the skill effect on (0.007), shown that a large number of boards impacts on better
current ratio (0.004), cash ratio (0.001), and fixed asset performance and has implications for multinational
turnover(0.002). corporations5,18,32,39,46

Gender Correlation to Financial Performance H2 = Gender in the board affect the financial
improve the impact of corporate governance reform on performance
its (0.048), Asset turnover (0.000), debt ratio (0.005) and
ROA (0.045). Conclusion
Ph.D. and Gender Education has an influence on
Discussion the performance of financial statements. From the table
The Board of Director’s Performance Assessment below shows that Ph.D. Education has an effect on Asset
differs from company performance as evidenced by Turnover (0.007), Current Ratio (0.004), Cash Ratio
annual financial and disclosure reports. The role of the (0.001), and fixed asset turnover (0.002) and Gender
Board of Directors is broader than that characterized by influences financial performance. DER (0.048), Asset
the agency’s control paradigm. Board of direct directors turnover (0.000), debt ratio (0.005) and ROA (0.045).
involved in the corporate strategy includes, that is then the approach to accounting behavior of Ph.D.
Overseeing managers as fiduciary shareholders, Advising and gender education can affect significant financial
CEOs and top management on strategic issues, Feedback performance.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 583
Conflict of Interest: The Author (s) declare that 11. Doğan, M. Does Firm Size Affect The Firm
they have no conflict of interest. Profitability? Evidence from Turkey. Research
Journal of Finance and Accounting. 2013;4(4):
Source of Funding: Others source. 53–60.
Ethical Clearance: This study was approved by 12. Elms,N, Gavin N. The Importanceof Group‑Fitin
the institutional review board of institution of Airlangga New Director Selection.‖ Management Decision
University The research received a certificate from 2015;53(6):1312–28.
Airlangga University. 13. GarcíaL, Manuel J, Osma, BG, Penalva. F.
Accounting Conservatism and Firm Investment
References Efficiency.‖ Journal of Accounting and Economics
1. Aguerrevere, Felipe L. Equilibrium Investment 2016;61(1): 221–38.
Strategies and Output Price Behavior: A 14. Alan, Wang Y.. Cash Acquirers.‖ Review of
Real‑Options Approach.‖Review of Financial Behavioural Finance. 2013;5(1): 35–57.
Studies. 2003;16(4): 1239–72. 15. Hassan CH, Rahman M, Mahenthiran S..
2. Apak, S, Mikail E, İsmail E, MetinA.2.―TheUse of 23 Managerial Auditing Journal Corporate
Contemporary Developments in Cost Accounting Governance, Transparency and Performance of
in Strategic Cost Management. Procedia‑Socialand Malaysian Companie 2018;23(3)
Behavioral Sciences. 2014;1: 528–34. 16. Heider, Ljungqvist A. AsCertain as Debt and
3. Babalola,YA..―The Effect of Firm Sizeon Firms Taxes: Estimating the Tax Sensitivity of Leverage
Profitability in Nigeria. Journal of Economics and from State Tax Changes. Journal of Financial
Sustainable Development. 2013;4(5): 90–94. Economics. 2015;118(3): 684–712
4. Beaver,G, Adrian D, and Paul J. Leadership 17. Holz,C. The Impact of the Liability ‑ Asset Ratio
Boards of Directors. Busines Strategy Series. on Profitability in China‘s Industrial State‑Owned
2007;8(4):318–24. Enterprises. China Economic Review. 2002;13(1):
5. Belkhir, M.Board of Directors‘ Size and 1–26.
Performance in the Banking Industry. International 18. Ilhan N, Tulay, Kalayciogl, O. The Effects of the
Journal of Managerial Finance. 2009;5(2): 201–21. Board Composition, Board Size and CEO Duality
6. Besanko, D, Ulrich D, Lauren XL, Sterthwaite M.― on Export Performance. Management Research
On the Role of Demand and Strategic Uncertainty in Review .2016;39(11):1374–1409.
Capacity Investment and Disinvestment Dynamics. 19. Michael C., Meckling WH. Theory of the Firm:
International Journal of Industrial Organization. Managerial Behavior,Agency Costs and Ownership
2010;28(4): 383–89. Structure.‖ Journal of Financial Economics
7. Calabrò, MT. Board of Directors and Financial 1976;3(4): 305–60.
Transparency and Disclosure. Evidence from Italy‘ 20. Khan,I, How Past Perceived Portfolio Returns Affect
Corporate Governance.‖ The International Journal Financial behaviors The Underlying Psychological
of Business in Society .2016;16(3): 1–32. Mechanism. Research in International Business
8. Cha, W, Abebe M. Board of Directors and and Finance 2017;42: 1478–88.
Industry Determinants of Corporate Philanthropy.‖ 21. Kim, T. The Impact of Cash Holdings and External
Leadership & Organization Development Journal. Financing on Investment‑ Cash Flow Sensitivity.
2016;37(5): 672–88. Review of Accounting and Finance 2007;13(3):
9. Cheung, E, Elaine E, Wright S. An Historical 251–73.
Review of Quality in Financial Reporting in 22. Kousenidis, Dimitrios V.2006. A Free Cash Flow
Australia.‖ Pacific Accounting Review 2010;22(2): Version of the Cash Flow Statement: A Note.‖
147–69. Managerial Finance. 2014;32(8):645–53.
10. Chong, W, Ting K, Cheng F. The Performance 23. Lee,CF et., all..Optimal Payout Ratio under
of Externally Managed REITs in Asia. Journal of Uncertainty and the Flexibility Hypothesis: Theory
Property Investment & Finance. 2017;35(2): 200– and Empirical Evidence. Handbook of Financial
227.
584 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Econometrics and Statistics. 2015;17(3):2135–76. 2007;7(2): 209–24.
24. Lee, H.The Long‐run Equity Performance of Zero‐ 36. Mwenja, D. Exploring the Impact of the Board
leverage Firms. Managerial Finance. 2011;37(10): of Directors on the Performance of Not‐for‐
872–89. profit Organizations.‖ Business Strategy Series.
25. Leticia V.A Framework for Board Capital 2009;10(6): 359–65.
‘Corporate Governance. The International Journal 37. Nimalathasan, B. Capital Structure And Its Impact
of Business in Society. 2016;16(3). On Profitability: A StudyOf Listed Manufacturing
26. Lin, Tom CW..―CEOs and Presidents.‖UCDavis Companies In Sri Lanka.‖ Revista Tinerilor
Law Review. 2014;57: 1351–1412. Economisti (The Young Economists Journal).
2010;1(15): 7–16.
27. Litt, B et., all. 2013. ―Environmental Initiatives
and Earnings Management.‖ Managerial Auditing 38. Obayelu,A. Effectof Rural Infrastructure on
Journal. 2013;29(1): 76–106. Profitability and Productivity of Cassava‑Based
Farms in Odogbolu Local Government Area, Ogun
28. Locke, G. 2 Studies in Public and Non‑Profit
State, Nigeria. Journal of Agricultural Sciences
Governance Financial Performance in Indian
2014;59(2):187–200
State‑Owned Enterprises Following Corporate
Governance Reforms. Emerald Group Publishing 39. Pratama, A. Pengaruh Current Ratio,debt to Equity
Limited. 2014;16(3). Ratio, Returnon Equity, Net Prfit Margin Dan
Earningper Share Terhadap Harga Saham (Studi
29. LynnH,.et., all .The Effect of Relative Performance
Kasus Pada Perusahaan Manufaktur Yang Terdaftar
Information on Performance and Effort Allocation
Di Bursa Efek Indonesia Periode 2008‑2011. Jurnal
in a Multi‑Task Environment.‖Accounting Review.
Akuntansi 2014;2(1): 24–42.
2013;88(2): 553–75.
40. Qaiser R. Impact of Board Structure on Firm
30. Malenko, A.A Theory of LBO Activity Based
Performance: Evidence from an Emerging Economy
on Repeated Debt‑Equity Conflicts.‖Journal of
.Journal of Asia Business Studies 2017;11(2).
Financial Economics. 2015;117(3):607–27.
41. Sainty, P. The Relationship among Board of Director
31. Mallick,S, Yang, Y. SourcesofFinancing,Pro
Characteristics, Corporate Social Performance and
fitabilityandProductivity:First Evidencefrom
Corporate Financial Performance”. International
Matched Firms.Financial Markets, Institutions and
Journal of Managerial Finance 2009;5(4): 407–23.
Instruments 2011;20(5): 221–52.
42. Shubita, M. The Relationship between Capital
32. McCabe,M, Nowak,M.
Structure and Profitability. International Journal of
IndependentDirectorontheBoard of Company Direc
Business and Social Science. 2012;3(16): 104–12.
tors.‖ManagerialAuditingJournal. 2008;23(6):545–
66. 43. Stokey, Nancy L. Wait‑and‑See: Investment
Options under Policy Uncertainty. Review of
33. McIyre, M. Boardof DirectorPerformanceReporting.
Economic Dynamics 2014;21: 246
CorporateGovernance:Theinternationaljournalofbu
sinessinsociety 2008;8(2):165–78. 44. Thille, H. Inventories, Market Structure, and Price
Volatility.‖Journal of Economic Dynamics and
34. Mook, L. ProQuest Dissertationsand Theses Social
Control 2006;30(7): 1081–1104.
and Environmental Accounting: The Expanded
Value Added Statement.http://search.proquest. 45. Ujunwa,A. Board Characteristics and the Financial
com/docview/304752008?accountid=14549% Performance of Nigerian Quoted Firms.‖ Corporate
5Cnhttp://hl5yy6xn2p.search.serialssolutions. Governance: The international journal of business
com/?genre=article & sid=ProQ: & atitle=Social+ in society 2012;12(5): 656–74
and+environmental+accounting:+The+Expanded+ 46. Ukaegbu, B. The Significance of Working Capital
Value+Added+Statement & title=Social+and+env Management in Determining Firm Profitability:
ironmental+ac counting. 2017 Evidence from Developing Economies in Africa.‖
35. Murphy,S. Board of Director Performance: A Group Research in International Business and Finance.
Dynamics Perspective.‖ Corporate Governance: 2014;31: 1–16
The international journal of business in society. 47. Uzonwanne, J. Corporate Governance: The
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 585
International Journal of Business in Society Article 51. Wu, M.I. Board Structure: An Empirical Study
Information. 2016;30(7): 101–114. of Firms in Anglo‑American Governance
48. Vand. Board Configuration: Are Diverse Boards Environments.‖ Managerial Finance.2014;40(7):
Better Boards?.Corporate Governance: The 681–99.
international journal of business in society 52. Yulia I. Board Structure, Board Committees and
2006;6(2):129–47. Corporate Performancein Russia‘, Managerial
49. William R.B. The Board of Directors: Beware of Finance. 2015
Those Triggers That Cause Board Change.‘Journal 53. Zhu,J. Board Hierarchy, Independent Directors,
of Business Strategy 1084, 5(1): 84–92. and Firm Value: Evidence from China.‖ Journal of
50. Wood, A. Investment Interdependence and the Corporate Finance 2016;41: 262–79.
Coordination of Lumpy Investments: Evidence
from the British Brick Industry. Applied Economics
2005; 37(1): 37–49.
586 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Early‑Onset Neonatal Sepsis in Low‑Birth‑Weight and

Birth‑Asphyxia Infants at Haji Hospital Surabaya, Indonesia

Euvanggelia Dwilda Ferdinandus1, Berliana Devianti Putri2

1Department of Maternal and Child Health, Faculty of Public Health, 2Department of Health,
Faculty of Vocational Studies, Universitas Airlangga, Kampus C Universitas Airlangga,
Kec. Mulyorejo, Kota Surabaya, Jawa Timur 60115

Abstract
Introduction: The incidence of early‑onset neonatal sepsis is still high, therefore special attention is needed
early detection of risk factors for early management. Many risk factors could affect early‑onset neonatal
sepsis such as birth‑weight and birth‑asphyxia.

Aim: This study explored the risk factors for early‑onset neonatal sepsis among neonates at Haji Hospital,
Surabaya City, Indonesia.

Method: This study was observational analytic with a cross‑sectional design. The data used retrospective
document review was conducted in NICUs of Haji Hospital, Surabaya City, Indonesia. 1.461 infants were
born from January 2018 to December 2018. The data analysis of this study was the Chi‑Square Test and
Multiple Logistic Regression Test using SPSS for windows v.17.

Result: This study involved 1.461 infants with one hundred seventy‑eight suffered of sepsis. The study
found out that low‑birth‑weight and birth‑asphyxia were significantly associated with neonatal sepsis
(p<0.001). Last, the result of multiple regression analysis showed that early‑onset sepsis was influenced by
low‑birth‑weight (p<0,001; RR: 10.405; CI: 6.346 to 17.061) and birth‑asphyxia (p<0.001; RR: 17.038; CI:
10.644 to 27.271).

Conclusion: The neonatal sepsis was influenced by low‑birth‑weight and birth‑asphyxia. Based on these
results we recommend to focus on the intensive treatment for infants who suffered asphyxia and had
low‑birth‑weight.

Keywords: Neonatal sepsis; low‑birth‑weight; birth‑asphyxia.

Introduction 22.23 per 1,000 live births while in East Java the IMR
in 2014 reached 26.66 per 1000 live births2. IMR in
Infant Mortality Rate (IMR) is an indicator that
East Java decreased compared to the previous year but
reflects the state of health in society including Indonesia
it was not significant, namely in 2013 several 27.5 per
and is a sensitive benchmark of all management efforts
1000 live births. IMR in the city of Surabaya in 2015
undertaken by the government, especially in the health
amounted to 6.48 per 1000 live births. This figure has
sector1. IMR in Indonesia in 2015 was still high at
increased compared to 2014 which was 5.62 per 100
live births. The United Nations set this indicator on the
2030 Suistanable Development Goals (SDG’s) at point
Correspondence Author:
3, namely in 2015‑2030, which is to reduce the infant
Euvanggelia Dwilda Ferdinandus
mortality rate to at least 12 per 1,000 live births.3.
Department of Maternal and Child Health, Faculty of
Public Health, Universitas Airlangga According to WHO in 2016 neonatal deaths account
e-mail: [email protected] for 45% of child deaths under 5 years. The majority of all
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 587
neonatal deaths (75%) occur in the first week of life, and Material and Method
between 25% to 45% of neonatal deaths occur within the
This study was observational analytic with a
first 24 hours. Almost all (98%) of five million neonatal
cross‑sectional design. The data used retrospective
deaths occur in developing countries. Neonatal sepsis
document review was conducted in NICUs of Haji
accounts for nearly 80% of neonatal deaths4.
Hospital, Surabaya City, Indonesia. 1.461 infants
Sepsis was initially defined as a suspicion or proven were born from January 2018 to December 2018. The
infection accompanied by clinical conditions of SIRS independent variables of this study were birth‑weight
(Systemic Inflammatory Response Syndrome) but the and birth‑asphyxia. The dependent variable of this study
definition is now abandoned. As per the consensus was early‑onset sepsis.
regarding the latest sepsis, sepsis is defined as a state
This study used SPSS Statistics 17.0 for data analysis.
of life‑threatening organ dysfunction/failure, caused by
Bivariate analysis was correlated using cross‑tabulations
an unregulated host response to infection. The cause of
and Chi‑Square Test with α=0.05. A multivariable
early onset neonatal sepsis is different from the cause
logistic regression model was created to examine the
of slow onset neonatorum sepsis. The cause of SNAD
causal association between independent variables
is microorganisms that are transmitted vertically from
and breast milk production using Multiple Logistic
mother to baby, both before and during labor5.
Regression with α=0.05. This study was received ethical
As per the consensus regarding the latest sepsis, approval from the Health Research Ethics Committee,
sepsis is defined as a state of life‑threatening organ Faculty of Medical, Universitas Airlangga.
dysfunction, caused by an unregulated host response
Findings: Most of the 928 infants (63.51%) were
to infection. Neonatal sepsis is divided into two
female while almost half were 533 infants (36.48%)
namely early‑onset neonatal sepsis (age <72 hours)
were male. Almost entirely, 1353 babies (92.61%) were
and advanced (age> 72 hours)6. Early‑onset neonatal
born with clear membranes while only a small portion,
sepsis causes high morbidity and mortality in newborns.
namely 108 babies (7.39%) were born with turbid green
The incidence of early‑onset neonatal sepsis is higher
membranes.
in developing countries (1.8 to 18 per 1000 live births)
than in developed countries (1 to 5 per 1000 live births). Furthermore, almost 1350 babies (92.40%) were
The case fatality in EONS ranges from 16.7% to 19.4% born full term and a small part, namely 107 babies
7. The incidence rates of neonatal infection in several
(7.30%) were born with a premature period as well as
referral hospitals in Indonesia is approximately 8.76% babies born over time (postdate) only a small portion,
–30.29% with the mortality rate is 11.56% –49.9%. The 4 babies (0.30%). Other data show that almost all 1340
incidence rates of neonatal sepsis in several referrals infants (91.72%) had no low birth weight (LBW) while
hospital in Indonesia is 1.5% –3.72% with the mortality only a small portion, 121 babies (8.28%) were born with
rate is 37.09% –80% 5. LBW.
In Haji Hospital Surabaya there was an increase in The data of asphyxia in infants shows that almost
cases of newborn infections in 2015‑2017 to 21.50%. all of 1333 infants (92.61%) were born not asphyxia
Several factors of mother, babies, and environment are while only a small proportion of 128 infants (8.76%)
contributed to the infection exposed and non‑optimal of experienced asphyxia. And it shows that almost all
NM immunologic response so as the newborn become 1420 babies (97.19%) were single born and only a small
susceptible to be infection8. The objective of this study is portion, 41 babies (2.81%) were born twin (multiple)
to explore the risk factors for early ‑onset sepsis among
neonates at Haji Hospital, Surabaya City, Indonesia. Based on data which fulfill our inclusion criteria.
These are the result.
588 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 1: Bivariate analysis between independent variables and early‑onset sepsis

Early‑Onset Neonatal Sepsis

Total
Variables EONS Non‑Sepsis p
n % n % n %
Birth‑weight
Low (< 2500 gram) 76 42.7 45 3.5 121 8.3
< 0.001*
Normal (> 2500 gram) 102 57.3 1238 96.5 1340 91.7
Asphyxia
Yes 87 48.9 41 3.2 128 8.8
< 0.001*
No 91 51.1 1242 96.8 1333 91.2
*Significantly correlate using Chi‑Square Test (p < 0.05)

Table 2: Summary of multiple logistic regression

Variables B SE P RR
Birth‑weight
Low
2.342 0.252 < 0.001* 10.405
Normal (Reference group)
Asphyxia
Yes
2.835 0.240 < 0.001* 17.038
No (Reference group)

*Significantly associate using Multiple Logistic Regression Test (p < 0.05)

This study involved 1.461 infants with one hundred The infants who had LBW were at risk for getting
seventy‑eight suffered of sepsis. As shown in Table early onset sepsis 10.405 times greater than infants who
1, there was a correlation between LWB and neonatal had normal weight. Then, infants who suffered asphyxia
sepsis (p<0.001). Most of infants who had normal weight were at risk for getting early onset sepsis 17.308 times
(96.5%) did not suffer sepsis than infants who had LBW. greater than infants who not suffered asphyxia. So that,
In contrast, almost half of participants (42.7%) who had asphyxia most likely has an influence.
LBW were suffer early onset sepsis highly than infants
who had normal weight. It could be concluded that the Discussion
early onset sepsis was more suffered by infants who had Following approval from the institutional ethical
low‑birth‑weight (less than 2500 gram). committee, almost half of participants (42.7%) who
Table 1 also shows that there was a correlation had LBW were suffering early onset sepsis highly than
between asphyxia and neonatal sepsis (p<0.001). Only infants who had normal weight. It could be concluded
3.2% (n=41) infants who are getting sepsis were infants that the early onset sepsis was more suffered by infants
who had asphyxia. In contrast, almost half of participants who had low‑birth‑weight (less than 2500 grams).
(48.9%) who had asphyxia were suffered early onset The results of this study are in line with the results
sepsis highly than normal infants. It could be concluded of a research namely LBW has three times the risk of
that the sepsis was more suffered by infants who had developing sepsis than non LBW9,10. This is in line that
asphyxia. infants with sepsis had more low birth weight (85.7%)11.
Table 2 shows that the results of multivariate The central regulation of breathing is not perfect, the
analysis with Multiple Logistic Regression Test (α respiratory muscles and ribs are still weak in LBW
= 0.05). The result showed that neonatal sepsis was infants resulting in less oxygen entering the brain, if
influenced by low‑birth‑weight (p<0,001; RR: 10.405; oxygen is lacking, anaerobic germs easily develop which
CI: 6.346 to 17.061) and birth‑asphyxia (p<0.001; RR: causes easy infection. In contrast to research conducted
17.038; CI: 10.644 to 27.271). by Rahmawati in Dr. M. Djamil Padang Hospital, the
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 589
results showed that there was no statistically significant survival of the baby and worsen the patient’s prognosis.
relationship between birth weight in the form of low The prognosis of neonatal sepsis depends on diagnosis
and normal categories with the incidence of neonatal and therapy. The prognosis of neonatal sepsis is good
sepsis. A significant relationship appears in LBW infants if the diagnosis is made early and the therapy is given
with prematurity where the maturation of their organs appropriately. Mortality rates can increase if clinical
(liver, lungs, enzymes, digestion, brain, immune system manifestations and risk factors for neonatal sepsis
against infection) is not perfect, so LBW babies often are not well identified. Midwives and doctors play an
experience complications that end in death12,13. important role in efforts to improve the health of mothers
and children, especially in clinical cases19,20.
Then, infants who lived asphyxia were at risk for
getting early onset sepsis 17,308 times greater than Conclusion
infants who didn’t live asphyxia. So that, asphyxia
most likely has an influence to. Neonatal asphyxia The neonatal sepsis was influenced by
facilitates systemic infections. This is due to inhibited low‑birth‑weight and birth‑asphyxia. Based on its
leukocyte activity because it requires energy (ATP) for conclusion, it is suggested to Health Service Centre
cytoskeletal microfilament contractions. The state of to focus on the intensive treatment for infants who
hypoxia will also inhibit the microbicidal activity of had low‑birth‑weight and suffered asphyxia. It is
polymorphonuclear cells14. Neonatal asphyxia increased also suggested to society, especially for husband, to
the risk of EONS with a positive blood culture result keep supporting the pregnant‑mothers for check their
4‑fold (RO = 4.102; 95% CI 1.04‑16.14)15,16. pregnancies regularly.

Neonatal asphyxia was assessed by examining Conflict of Interest: There was no conflict of
APGAR scores. A low APGAR score increases the risk interest in this study.
of EONS. Research conducted by Muhammad et al in Source of Funding: This study was supported by
2015 found that Apgar scores <7 in the first minute had the authors.
a risk of 14.05 times (95% CI 5.487‑35.987) for EONS
events17. APGAR scores <7 in the first minute were References
also reported by Shah et al., which were significant with
each OR being 5.7 for EONS eventsc. In general, the 1. Statistik BP. Badan pusat statistik. Diambil dari
first minute APGAR score is associated with Potential https//www bps go id. 2017;
Hydrogen (pH) umbilical cord blood and intrapartum 2. Kementerian Kesehatan RI. Data dan Informasi:
depression and is not related to the results, whereas Profil Kesehatan Indonesia. Jakarta Kemenkes RI.
the APGAR score then reflects changes in the baby’s 2017;
condition during resuscitation10,18. 3. Surabaya DKK. Profil Kesehatan Kota Surabaya
Tahun 2015. Surabaya Dinkes Kota Surabaya.
Asphyxia neonatorum is very closely related
2016;
to health problems of pregnant women, including
infections. Babies with asphyxia neonatorum appear 4. Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn
unfit and have a history of fetal distress before birth. JE, et al. Global, regional, and national causes of
Neonatal asphyxia facilitates systemic infections. child mortality in 2000–13, with projections to
Neonatal asphyxia increases the risk of early onset inform post‑2015 priorities: an updated systematic
neonatal sepsis with positive blood cultures. In addition, analysis. Lancet. 2015;385(9966):430–40.
low birth weight babies, including this risk group. Most 5. Utomo MT. Neonatal sepsis in low birth weight
problems occur in infants who weigh less than 1500 infants in Dr. Soetomo general hospital. Indones J
grams with high mortality and require special medical Trop Infect Dis. 2010;1(2):86–9.
care and treatment for infants at 2.75 times higher risk of 6. Cunningham M, Eyal FG, Gomella TL.
neonatal sepsis10,13,16. Neonatology: Management, Procedures, On‑Call
Problems, Diseases, and Drugs. McGraw‑Hill
The diagnosis of early onset neonatal sepsis is
Professional; 2009.
very important in the management and prognosis of the
patient. Delay in diagnosis can potentially threaten the 7. Jajoo M, Kapoor K, Garg LK, Manchanda V, Mittal
SK. To study the incidence and risk factors of
590 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
early onset neonatal sepsis in an out born neonatal 15. Stoll BJ, Gordon T, Korones SB, Shankaran S,
intensive care unit of India. J Clin Neonatol. Tyson JE, Bauer CR, et al. Early‑onset sepsis in
2015;4(2):91. very low birth weight neonates: a report from the
8. Shah GS, Budhathoki S, Das BK, Mandal RN. Risk National Institute of Child Health and Human
factors in early neonatal sepsis. Kathmandu Univ Development Neonatal Research Network. J
Med J (KUMJ). 2006;4(2):187–91. Pediatr. 1996;129(1):72–80.
9. Wirawan R. Hubungan Antara Bayi Berat 16. Stoll BJ, Hansen NI, Higgins RD, Fanaroff AA,
Lahir Rendah (Bblr) Dengan Terjadinya Sepsis Duara S, Goldberg R, et al. Very low birth weight
Neonatorum. Universitas Muhammadiyah preterm infants with early onset neonatal sepsis:
Surakarta; 2012. the predominance of gram‑negative infections
continues in the National Institute of Child Health
10. Simonsen KA, Anderson‑Berry AL, Delair SF,
and Human Development Neonatal Research
Davies HD. Early‑onset neonatal sepsis. Clin
Network, 2002–2003. Pediatr Infect Dis J.
Microbiol Rev. 2014;27(1):21–47.
2005;24(7):635–9.
11. Carolus W, Rompis J, Wilar R. Hubungan
17. Hayun M, Alasiry E, Daud D, Febriani DB, Madjid
Apgar skor dan berat badan lahir dengan sepsis
D. The risk factors of early onset neonatal sepsis.
neonatorum. e‑CliniC. 2013;1(2).
Am J Clin Exp Med. 2015;3(3):78–82.
12. Putri R. HUBUNGAN SEPSIS NEONATORUM
18. Ahmadpour‑Kacho M, Asnafi N, Javadian M,
DENGAN BERAT BADAN LAHIR PADA BAYI
Hajiahmadi M, Taleghani N. Correlation between
DI RSUP DR M. DJAMIL PADANG. Universitas
umbilical cord pH and Apgar score in high‑risk
Andalas; 2017.
pregnancy. Iran J Pediatr. 2010;20(4):401.
13. Schuchat A, Zywicki SS, Dinsmoor MJ, Mercer B,
19. Polin RA. Management of neonates with suspected
Romaguera J, O’Sullivan MJ, et al. Risk factors and
or proven early‑onset bacterial sepsis. Pediatrics.
opportunities for prevention of early‑onset neonatal
2012;129(5):1006–15.
sepsis: a multicenter case‑control study. Pediatrics.
2000;105(1):21–6. 20. Hornik CP, Fort P, Clark RH, Watt K, Benjamin
Jr DK, Smith PB, et al. Early and late onset sepsis
14. Polin RA, Parravicini E, Regan JA. Bacterial sepsis
in very‑low‑birth‑weight infants from a large group
and meningitis. Dalam: Taeusch HW, Ballard
of neonatal intensive care units. Early Hum Dev.
RA, Gleason CA, penyunting. Avery’s diseases
2012;88:S69–74.
of the newborn. Edisi ke 8. Philadelphia: Elsevier
Saunders; 2004.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 591

Humanoid Robot Integration in Rehabilitation of

Musculoskeletal Conditions

Fayz S. Al‑Shahry1, Rayan F. Al‑Shehri2

1Assistant Professor COAMS, KSAU‑HS, Consultant Rehab, KAMC, 2Engineering Student, KSU, Riyadh

Abstract
Robots find numerous applications in medical/health domains and are extensively used in commercial as
well as domestic applications to support daily life activities. Human robot (HR) has widened their wings
to be used in rehabilitation applications. Interest in robots that provide health care is growing as one of the
upcoming fields of next generation. In this study we investigated the Robot ‑patient performance in physical
rehabilitation. A group of musculoskeletal patients diagnosed with pain in muscles or joints or both, aged
20 to 65 years was chosen for the study. The robot was programmed to instruct and guide the patients for
physical rehabilitation activities for three trials of 30 minute sessions on different days. The sessions involved
interaction with a humanoid robot. Robot was programmed for a set of active exercises with a classified
sequences that are time and motion managed. Verbal communication between the robot and patients allowed
for re‑start, stop, resume and replay functions. The whole performance was filmed and reviewed from the
perspectives of the impact on the patient as well as the performance of the robot. The whole process was
validated by performing the same procedure on a trial basis with healthy individuals to ensure the setup is
operated smoothly. The performance of each variable was evaluated in three successive sessions. Evaluated
functions include clarity, therapy sequence, interaction, voice, timing, independency, operation, technical
performance and degree of freedom. Results were computed as percentages by an external assessor. Results
demonstrated dynamic learning in the 1st and 2nd sessions which showed a remarkable improvement in the
3rd, 4th and 5th sessions. The overall average of the performance for the last 3 sessions was 91+%. Referring
to this outcome, it could be concluded that the robot may have the potential to influence the physical therapy
imitation. However,to establish the extent of this influence affirmatively, a bigger sample will be needed
with a wider variety of patients.

Keywords: Humanoidrobot, interaction, integration, rehabilitation, musculoskeletal.

Introduction Advanced humanoid robots are employed in a

variety of applications in medical/health domains and
Robots are being designed to complement human
are also used extensively in commercial establishments
skill sets, reduce workload and enable professionals to
as well as in the home support for daily life activities.
focus on more important activities that have a greater
Beyond the traditional scope, robot can be engaged in
impact on patient care delivery. As this technology
the rehabilitation process and it is poised to become
advances and becomes more affordable, we can expect
one of the most important technological innovations of
more health care institutions to adopt robotics.
the 21st century. Literature showed specific uses with
Robots are still not a replacement for human elderly patients and some pediatric applications.1,2
interaction. Hospital operations are complex and involve
In this article, we offer a trial study on the possible
uncertainty. Robots are good for performing repetitive
uses of robots in rehabilitation, particularly in the
tasks and tracking data, but this technology should only
management of musculoskeletal conditions.
be used to make the clinicians’ workflow easier so that
they may focus on the most critical part of their jobs, Human Robot (HR) has widened their wings to be
which is caring for patients. used in rehabilitation. Interest in health care robots is
592 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
growing as one of the upcoming fields of next generation to 65 years. Other inclusion criteria were no physical
in this smart industry, especially as assistive tools in or mental disability, no hearing and vision deficiency,
rehabilitation1. It is believed that humanoid Robot and a cognitive ability to follow simple commands in
promises excellent experience for CP children to learn English. Signed informed consent was obtained from
motor tasks3. Many studies involving CP children the participants. Five trials, each of 30 minutes session
investigated robotic exoskeletons4 to replace or support were performed on different days. The sessions involved
function. There is still a lack of intervention therapy interaction with humanoid robot. The experiment protocol
which involves complicated functional tasks. was approved by the Occupational Therapy Association
Research Board. The robot was programmed for a set
Some of the robotic technologies were designed of active exercises with a classified sequence managed
to assist the user primarily through social rather than in time and motion. Verbal communication between
physical interaction5. For example, a previous study6 the robot and patients allowed re‑start, stop, resume
has established Kindergarten Assistive Robotics (KAR) and replay functions. The robot was equipped with 4
as a tool for learning and development for normal cameras and programmed to take photos of the patient’s
children in preschool education. KAR has increased face and voice print to enable individual recognition in
children’s motivation and communication during the order to recall the personal therapy program and update
interaction. Robots have been successfully introduced the patient information at the end of the session. The
into physical therapy and rehabilitation of children with whole performance was filmed and reviewed from the
disabilities7,8,. Thus, KAR is suggested to be applied perspectives of both the patient and robot. The whole
for CP children. One of the studies involved KAR process was validated by performing the same procedure
as a Robotics Agent Coach for CP motor Function on a trial basis with healthy individuals to ensure the
(RAC CP FUN)9which is designed to improve their setup is operated smoothly.
motor functions and activities associated to daily
living. Further, anotherstudy10employed a mobile Patients were educated about the robot and the study
robot named “Neptune” and used a toy robot named aim. An introduction session was made to familiarize
“Cosmobot” and the derived results showed that robot the group(robot, patient, operator and the assessor) with
can become a social mediator for learning. The results the study methodology. The study was conducted in a
of a study 11,12that used Lego Mind storms robots13 simple gym, with the exercise mat laid on the floor for
for CP children’s play activities demonstrated that the the patients and the NAO was placed on the non‑slippery
children reacted positively toward the robots, while floor. The performance assessment will use met partially
some children increased their attention span and could me or not met.
be better engaged when they used the robots. However,
most explored robotic systems earlier were mainly in the NAO has 23 degrees of freedom: 2 degrees of
form of toys, and not in humanoid form. Thus, this study freedom for head, 4 degrees of freedom for each arm, 1
is designed to use a humanoid robot to instruct patients degree of freedom for pelvis, and 5 degrees of freedom
in physical therapy sessions with musculoskeletal for each leg.
problems. An expert software programmer and a
physiotherapist jointly developed the therapy program.
Result
Details of the therapy were tailored specifically to meet The aim of this robotic‑patients application is to
the needed conditions, interact with the patients, with instruct patients with musculoskeletal problems for
the mode and specification capable of offering several several pre‑structured and programmed exercises. The
options. overall aim is to measure several factors that govern
the robot‑patient performance, e.g. clarity, sequence,
Methodology interaction, voice, timing, independency, operation,
The intended group is a set of musculoskeletal technical performance, and degree of freedom. The
patients diagnosed and referred for P.T clinic. A assessment is expressed by% of excellence for the three
strengthening exercise was prescribed and endorsed times and then the% average is gathered for all patients.
by a licensed physiotherapist specialized in the The total for each parameter in each session and the total
musculoskeletal disorders, This particular group was for for the five patients for each session is presented. The
improving the back strength, with age range between 20 data in the table below is the grand total for the three
sessions for five patients and expressed in %.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 593
Table 1: The data here is representing the% of performance of each item. The performance of the last
three visits are averaged in the last column and the grand average for the overall performance (91+) is also
presented. The 1st and 2nd sessions were considered as learning sessions.

Trial sessions
Item 3rd session 4th session 5th session Average %
1 st session 2nd session
Clarity 50% 70% 90% 95% 95% 93+
Therapy sequences 30% 60% 90% 90% 100% 93+
Interaction 20% 60% 95% 95% 95% 95
Voice 70% 70% 80% 90% 95% 88+
Timing 40% 60% 100 95% 100% 98+
Independency. 60% 80% 80% 90% 90% 86+
Operation 70% 90% 90% 90% 95% 91+
Technical performance 90% 90% 90% 90% 95% 91+
Grand 91+

Consequently, there are few points to be highlighted recognized in the 3rd session. The overall impression is
and discussed. The data presented represent the external supporting the fast and reliable interaction integration.
assessor evaluation of the performance. It is clear that The total performance related to the robot therapy
the 1st session is a learning step which shows low levels assignment is seen as highly satisfactory and manageable
of performance. Second session showed remarkable with the patient acceptance of the whole process.
improvement and a continuous improvement is

Fig. 1: Shows the representation of various performance parameters. This indicates the average percentage
of the last three sessions.

Fig 2: A, and B, The robot is oppositely facing the time in a steady sequence and follow and repeat for
patient to assure face to face communication, both in several times matching the robot command. The robot
lying position. The robot NAO asks the patient to imitate is watching the patient through the cameras and has the
each movement. NAO starts to perform the exercise and capability to stop, rectify, adjust and resume.
patient is expected to follow, patients should match the
594 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

     
Fig 3: The instructor checks and makes sure that NAOis ready

Discussion Progressing with time is a notable and clear indicator

which means that the patient‑robot relation is supporting
The set up of this robot rehab program was made
the level of confidence of the patient as well as the
to serve patients at the clinic or at home. The overall
therapist, and this matches earlier reported outcomes13.
performance was great,smooth and relatively reliable
This is an improvement of the technology with a friendly
in this small trial group. This work encourages
perspective. The overall satisfaction of the patient and
interest groups to proceed with robot rehab therapy.
the acceptance were high and very promising. The
The available data from this trial study showed the
grand total performance of all eight parameters was very
robot‑patient performance and the technical performance
high(almost 92%) which substantiates its applicability in
as well as the operational performance. The imitation of
the clinical robotic industry in line with the16,17,18.
movement simultaneously with the robot confirmed the
possibility of independent execution of serial therapy This article is meant to cover solutions at different
program in the rehab clinic or at home particularly for stages of applications. Thereafter it is up to the developer
chronic conditions. The total percentages core of the to commercially make it ready and available in the
last three sessions was around 92. However, further market or to look to some alternative or to go for more
optimization of the robot programming and proper phases of research and experimentation. The existing
prescription of exercise program and careful selection data provides examples and pointers to proceed to
of patients could make the work performance highly clinical applications and other major ingredients for the
efficient. Each of the eight parameters of this study were success of these applications as well as the main issues
assessed in five different sessions. These parameters are surrounding their adoption for a wide range of everyday
believed to be the most important factors to govern the physiotherapy use are to be developed further. We have
implementation. Optimizing them will enable the robot examined how robotics could partially fill in some of
to work independently with the patients at the clinic the identified gaps in current telehealth‑care through
or at the home and this will enable to personalize this internet connectivity since the robot is equipped with
technology and the outcomes7,8 are in line with this 4 Cameras and can recognize individuals by face and
result. by voice tone. Introducing a tele control can pave the
way for program modification and alteration based on
It is worth saying that the interaction was very
instantaneous robot‑patient interaction and would bring
successful and the options of stop, resume, restart
in a possibility of remote sharing with a third party or
were used many times to cater to patients’ requests,
more in audio‑visual mode.
and this was considered healthy. The clarity of steps
and voice level was perfect and the patient’s follow‑up We conclude with a brief glimpse at a couple of
on sequence was also maintained to a high level. emerging developments and promising applications in
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 595
this field that are expected to play important roles in the for Children with Cerebral Palsy. The Fourth
future. Readers should note that this paper is intended IEEE RAS/EMBS International Conference on
to be read mainly by non‑roboticists, with little or no Biomedical Robotics and Biomechatronics.2012
background in the field. Specifically, the paper is meant to 3. Marie Fukudome (PY), H.W. A Supportive
ignite the interests of conventional health informatics and System Focusing on the Body Coordination for
telemedicine/telehealthcare specialists and clinicians, Neurocognitive Rehabilitation. The 21st Annual
physiotherapists and rehabilitation professionals into Conference ofthe Japanese Neural Network
such emerging possibilities. It would also be of interest Society.2011.
to experts in robotics who are interested in its potential
4. Montesano, L., Diaz, M., Bhaskar, S. & Minguez,
applications, especially about how robotics may help
J. Towards an Intelligent Wheelchair System for
users in the healthcare and social care sectors. This also
Users With Cerebral Palsy. Neural Systems and
my facilitate investments and businesses in the long‑term
Rehabilitation Engineering, IEEE Transactions on
to commercialize use of robotics in health sectors, both
18, 193‑202, doi:10.1109/TNSRE. 2009.2039592
in health care centers and in homes.
.2010.
Conclusion/Recommendations 5. William OslerS, L. L. a. A, Sigmund Freud and the
evolution of ideas concerning cerebral palsy. Journal
This trial outcome is highly supportive to the use of of Historical Neuroscience 2, 255‑282.1993.
robot in rehabilitation of patients. More focus may be
6. Grigore C, Burdea D.C, Angad Kale, E. Janes
needed to improve the friendly interaction and flexible
William, A. Ross Sandy, R. JackEngsberg. Robotics
sequence between exercises. Logistic support may be
and Gaming to improve ankle strength, motor
included e.g. refreshment time, rest, short breaks may be
control and function in children with cerebral palsy,
considered upon patient request.
Neural Systems and Rehabilitation Engineering,
There is also a need to address some challenges IEEE Transactions on, 21 (2012), pp. 165‑173
encountered in the set up. The degree of freedom for all 7. Murphy C, Y.‑A. M., Decouffle P and Drews.
joints was of acceptable level except the pelvic rotation. Prevalence of Cerebral Palsy among ten year old
There is a need to improve on the robustness of the children in metropolitan Atlanta, 1985 through
pelvic movement. 1987 Journal of Pediatrics 123: S13‑S1.1993.

The issue of the NAO system getting heated up 8. Marie Fukudome (PY), H.W. A Supportive
during the performance causing an interruption in the System Focusing on the Body Coordination for
session needs to be investigated and resolved. Neurocognitive Rehabilitation. The 21st Annual
Conference ofthe Japanese Neural Network
Based on this trial, it is recommended that this work Society.2011.
be continued with a larger sample and varying conditions 9. Montesano, L., Diaz, M., Bhaskar, S. & Minguez,
to ensure consistent approach and reliable outcomes. J. Towards an Intelligent Wheelchair System for
Users With Cerebral Palsy. Neural Systems and
Conflict of Interest: Nil
Rehabilitation Engineering, IEEE Transactions on
Source of Funding: Self 18, 193‑202, doi:10.1109/TNSRE. 2009.2039592
.2010.
Ethical Clearance: Attached
10. Feil‑Seifer, D. & Mataric, M.J. in Rehabilitation
Robotics, 2005. ICORR 2005. 9th International
References
Conference on. 465‑468.2005.
1. TapusA.C. T, and M. Mataric. The Use of Socially 11. Keren, G., A. Ben‑David, and M. Fridin.
Assistive Robots in the Design of Intelligent Kindergarten Assistive Robotics (KAR) As
Cognitive Therapies for People withDementia. a Tool for Spatial Cognition Development in
Proceedings of the International Conference on Pre‑School Education in Intelligent Robots and
Rehabilitation Robotics (ICORR).2009. Systems (IROS), 2012 IEEE/RSJ International
2. Konstantinos P.Michmizos, H. I. K. Assist‑as Conference.2012.
Needed in Lower Extremity Robotic Therapy 12. Amy J. Brisben, A.D. L., Charlotte S. Safos,
596 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Jack M. Vice, Corinna E. Lathan. The Cosmo Conference on Pervasive Technologies Related to
Bot™ System: “Evaluating its Usability in Assistive Environments (PETRA) 2011.
Therapy Sessions with Children Diagnosed with 16. Schulmeister, J., Wiberg, C., Adams, K., Harbottle,
Cerebral Palsy*” in Robot and Human Interactive N., & Cook, A. in Rehabilitation Engineering and
Communication, ROMAN .2005. Assistive Technology Society of North America
13. Corinna E. Lathan, S.M. Development of a New (RESNA).2006.
Robotic Interface for Telerehabilitation. Workshop 17. A. Cook, K. Adams, J. Volden, N. Harbottle,
on Universal Accessibility of Ubiquitous C. Harbottle, L.E.G.O. Using robots to estimate
Computing;1; (WUAUC’01).2001. cognitive ability in children who have severe
14. M. Fridin, S.B.‑H., M. Belokopytov. Robotics physical disabilities Disability & Rehabilitation:
Agent Coacher for CP motor Function (RAC Assistive Technology, 6 (2011), pp. 338‑346.
CP Fun)”. Workshop on Robotic for Neurology 18. Martin Kocanda, B. M. W. a. D. S. B. Using
and Rehabilitation. in Workshop on Robotic for Lego Mindstorm NXT™ Robotics Kits as a
Neurology and Rehabilitation.2011. spectrophometric instrument. International Journal
15. Pavan Kanajar, I.R., Jartuwat Rajruangrabin, Dan on Smart Sensing and Intelligent Systems 3,
O. Popa, Fillia Makedon in The 4th International 400‑410.2010.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 597

Does Give Malnourished Pregnant Mothers with

Supplementary Feeding Biscuit Can affect Pregnancy
Outcomes?

Henrick1, Andi Imam Arundhana Thahir2, Khartini Kaluku3, Elsye Theresia4,

Saifuddin Sirajuddin2, Veni Hadju2, Abdul Razak Thaha2
1FatimaNursing Academy, Pare‑pare, 2Nutrition Department, Faculty of Public Health, Hasanuddin University,
Makassar, 3Health Polytechnic of Maluku, Ministry of Health, Ambon, 4Doctoral students, Faculty of Public
Health, Hasanuddin University, Makassar

Abstract
Objective: Malnutrition in pregnancy is still problematic in the majority of developing countries.
Malnourished pregnant women may result in fetal growth restriction and adverse pregnancy outcomes. This
study examined the impact of nutrition intervention in the forms of biscuit on pregnancy outcomes.

Method: This study was an evaluative study on the supplementation program implemented in Pare‑pare
city, Indonesia. Each package of supplementary feeding biscuit consists of two biscuits (50g) containing
260 kcal of energy, 13g of fat, 8g of protein, 28g of carbs, nine vitamins, and ten minerals. The variables
measured were placental weight and diameter, umbilical cord length and Hb, birth weight and length, head
circumference, and chest circumference. All measurements were done by trained health workers in the
Community Health Service. The analysis of this study was t‑test, ANOVA, and regression linear using SPSS
v. 24.

Result: The result of the study shows no effect of the biscuit dose on pregnancy Hb, MUAC, and gestational
weight among malnourished mother. In comparison between malnourished and healthy mothers, there are
no differences in the pregnancy outcomes. The effect of biscuit dose on the outcomes of pregnancy in
malnourished mother demonstrated no significant difference among doses given on placental weight and
diameter, umbilical cord length and Hb, birth weight and length, head circumference, and chest circumference.

Conclusion: In conclusion, this study demonstrated that given malnourished with a supplementary biscuit
will not provide any improvements on the pregnancy outcomes. A clinical trial design study is necessary to
examine the beneficial effect of complementary foods.

Keywords: Pregnancy, complementary feeding, pregnancy outcome.

Introduction et al., 2016). Women with acute malnutrition are

likely to have stunted children compared to healthy
Malnutrition in pregnancy strongly associated with
pregnant women2 and this associated with the increase
adverse pregnancy outcomes and can affect the health
of noncommunicable diseases risk3. However, recent
of the child early in life. Malnutrition is mainly caused
reports illustrate that majority of children affected
by low dietary intake before and during pregnancy
by stunting were in developing countries where the
influencing the mother’s capacity of storing, utilizing,
population is predominantly with low socio‑economic
and circulating the nutrients to the fetus1. Therefore,
status and exacerbated by intergenerational effects (short
maternal nutritional status is the key to supporting fetal
or malnourished mother)1,4. Several dietary interventions
growth and development, along with other factors,
have been implemented to prevent the negative effect
such as placental, fetal, and genetic factors (Sharma
598 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
of nutrient deficiency experienced by many pregnant biscuit. The design of the study has been described in
women, especially in developing countries. However, the previous publication8. This study has been done in
there was no effect of nutrition interventions on Pare‑Pare City, Indonesia.Malnourished mother was
pregnancy outcomes and only a small effect on the defined as the mother with MUAC measurement at
reduction in the incidence of preterm birth5,6. The result enrolment <23.5cm and healthy mother was otherwise.
of intervention might be varied accordingly the specific Each package of supplementary food consists of two
problem in the population. For instance, the population biscuits (50g) containing 260 kcal of energy, 13g of
with chronic energy malnutrition may be inappropriately fat, 8g of protein, 28g of carbs, nine vitamins, and ten
given with micronutrient interventions. minerals (Table 1).

A recent survey in 2018 shows that the number of Table 1: Nutrient contents of each biscuit package
chronic malnourished pregnant women in Indonesia, (50g; 260 kcal)
defined as mid‑upper arm circumference less than
23.5cm, reached 17.3% 7. In Pare‑pare city, located in Nutrients (g or% RDA) Nutrients (g or% RDA)
South Sulawesi, the prevalence of malnourished mother Fat (13g) Vitamin C (50%)
was 23.2% 8.Nutritional status before and during early Protein (8g) Natrium (16%)
pregnancy is critical, although the result is inconsistent Carbohydrate (28g) Folic acid (50%)
in terms of its effect on pregnancy and pregnancy Vitamin A (50%) Pantothenate acid (55%)
outcomes. A prospective cohort shows that maternal Vitamin D (60%) Selenium (55%)
BMI was not associated with a gestational weight gain Vitamin E (55%) Fluor (60%)
of the mother9. However, the limitation of this study was Vitamin B1 (60%) Iodine (25%)
the malnourished participants were small. A systematic Vitamin B2 (55%) Zinc (25%)
review indicated that maternal nutrition is associated with Vitamin B6 (60%) Iron (25%)
neurocognitive function during childhood, implicating Vitamin B12(60%) Phosphor (15%)
that health pregnancy states may be beneficial in Vitamin B3 (55%) Calcium (15%)
supporting fetal growth and development and child
outcomes10. Another study shows that the nutritional The variables measured were placental weight
status of the pregnancy was positively associated with and diameter, umbilical cord length and Hb, birth
birth weight. Thus, the nutritional status of pregnancy weight and length, head circumference, and chest
should be improved11. circumference. The measurement of the umbilical cord
Hb was performed at birth using HemoCue (Hb 201+
In improving maternal nutritional status during systems).Placenta and baby were weighed using baby
pregnancy, many supplementation programs have been scale meter provided in Community Health Services.
implemented. To date, a supplementation of nutrient‑rich Placental diameter, umbilical cord, head circumference
biscuit, called complementary feeding program or PMT, and chest circumference were measured using tape. All
has been implemented by the government in Pare‑pare measurements were done by trained health workers in
with an intended to support nutrients for the pregnant the Community Health Service. The analysis of this
mothers and their fetus. However, it is not known study was t‑test, ANOVA, and regression linear. All data
yet to what extent the effect of this supplementation analysis was performed using SPSS v. 24 (IBM Corp.).
program on the pregnancy outcomes, specifically for
those with chronic malnutrition. This study aimed to Results
examine the impact of supplementation program given
The results of the changes of hemoglobin, MUAC,
to malnourished pregnant women on the pregnancy
and gestational weight gain of pregnant women after
outcomes.
given supplementation have been previously published,
Material and Method but the effect of biscuit dose is still presented. Table 2
shows no effect of the biscuit dose on pregnancy Hb,
This study was an evaluation program observing MUAC, and gestational weight among malnourished
the pregnancy outcomes of the mother received mother.
complementary feeding program in the form of a
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 599
Table 2: Dose effect of complementary biscuit on Hb, gestational weight, and MUAC changes during
pregnancy

Dose
Changes (n=49) p
< 1 biscuit (n=33) > 1–2 biscuits (n=13) > 3 biscuits (n=3)
DHb1 – Hb2 ‑0,25±1,82 ‑0,54±1,31 ‑0,63±0,40 0.776
DHb1 – Hb3 ‑0,25±1,80 ‑0,16±1,68 ‑0,73±1,90 0.865
DHb2 – Hb3 ‑0,01±1,24 0,38±1,92 ‑0,10±1,80 0.431
DGestational weight 5,03±1,46 5,00±1,83 5,83±1,89 0.875
DMaternal MUAC 1,84±0,89 1,82±1,00 2,67±1,04 0.297

Table 3 shows the difference in the pregnancy women. Between the two groups, there are no differences
outcomes between malnourished and healthy pregnant in the outcomes.

Table 3: Differences of pregnancy outcomes between malnourished and healthy pregnant women

Variables Malnourished (n=49) Healthy (n=162) Total (N=211) p

Placental weight 541.53±175.01 542.685±187.22 542.42±184.05 0.969
Placental diameter 19.13±2.23 19.41±2.12 19.35±2.14 0.429
Umbilical cord length 43.71±9.70 45.25±8.81 44.89±9.02 0.298
Umbilical cord Hb 13.42±2.87 13.37±2.35 13.38±2.47 0.890
Birth weight 3,033.04±367.47 3,036.17±367.26 3,035.45±366.44 0.958
Birth length 47.74±2.00 47.85±1.69 47.82±1.76 0.700
Birth head circumference 32.74±1.34 32.56±1.72 32.60±1.64 0.518
Birth chest circumference 31.96±1.44 31.80±1.68 31.84±1.62 0.544

The effect of biscuit dose on the outcomes of doses given on placental weight and diameter, umbilical
pregnancy in malnourished mother is demonstrated in cord length and Hb, birth weight and length, head
Table 4. There was no significant difference among circumference, and chest circumference.

Table 4: Dose effect of biscuit supplementation on various outcomes of pregnancy among malnourished
women

Biscuit Dose
Variable (n=49) p
<1 Biscuit (n=33) >1–2 Biscuits (n=13) >2 Biscuit (n=3)
Placental weight 559.39±200.67 495.77±105.10 543.33±75.06 0.547
Placental diameter 19.52±2.41 18.12±1.58 19.33±1.53 0.119
Umbilical cord length 43.76±10.08 43.92±9.72 42.33±8.02 0.991
Umbilical cord Hb 13.72±2.99 13.12±2.14 11.50±4.35 0.310
Birth weight 3,029.52±406.05 3,053.08±313.38 2,985.00±85.00 0.935
Birth length 47.58±2.28 48.15±1.34 47.68±0.58 0.813
Birth head circumference 32.67±1.25 33.08±1.61 32.00±1.00 0.483
Birth chest circumference 31.89±1.41 32.15±1.48 32.00±2.00 0.877
600 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Discussion weight is one of the determinant factors causing stunting

in children under five16. Whereas the placenta is the
The main finding of this study reveals that there
supportive feature for maternal‑fetal oxygen transport
was no difference in terms of pregnancy outcomes
and nutrient exchange which affects birth weight.
of malnourished women by the dose of energy‑dense
Placental weight is the manifestation of fetal growth in
biscuits. The complexity of the metabolic process during
utero characterized by many dimensions of growth17.
pregnancy mainly affects fetal growth and developments,
One of the dimensions is umbilical cord length. In this
determining pregnancy outcomes. Intrauterine growth
study, malnourished women have similar cord length to
retardation (IUGR),one of the common forms of
healthy pregnant women (43.71±9.70 vs 45.25±8.81,
complications during pregnancy,is associated with
p=0.298), indicating that the growth of fetus established.
the oxidative stress caused by exceeding of pregnancy
Therefore, it can be fairly stated that the supplementation
complexity end products, called reactive oxygen
of biscuit along with iron‑folic acid may be effective
species (ROS)12. However, to what extent the impact of
in reducing the risk of adverse pregnancy outcomes
oxidative stress on the specific outcome of pregnancy
in malnourished women. However, this study did not
is poorly understood. A prospective cohort study shows
measure the impact of biscuit supplementation in healthy
that oxidative stress biomarker is associated with adverse
pregnant women which may reveal other mechanisms
pregnancy outcomes, although the age of participants of
involved in metabolic pathways during pregnancy.
the study was in the risk (>30 years) that probably affect
the metabolic process during pregnancy13. The limitation of this study was that the dietary
intakes were not observed. Dietary intake can potentially
Most studies correlate oxidative stress during
justify the explanation to what extent the contribution
pregnancy to antioxidant‑functioned micronutrients, such
of those supplementations to meet the nutrient
as iron, copper, zinc, and manganese14,15.Casanueva and
requirements of malnourished pregnancy. Second, the
Viteri suggested that iron intake is critical determining
number of pregnant women who consumedbiscuits as
balance oxidative stress in thehuman body. A proper
recommended (two biscuits per day) was underestimated
dose and timing of iron supplementation potentially
(only three mothers). However, since this is a study which
cause the reduction of oxidative stress. Conversely, iron
was observed nutritional program of the government, it
overload may induce oxidative stress15. In the present
then describedthe real setting that a real challenge in the
study, malnourished participants received iron‑folic acid
population. Hence, the government understands which
supplementation. This supplementation may correct the
has to be improved in order to support maternal and child
nutrient status of the participants, resulting in a positive
health.This study also did not measure the impact of the
result in fetal growth which is manifested in pregnancy
biscuit supplementation on the healthy pregnancy as the
outcomes. Energy‑dense biscuits supplement given to
program only be given to those malnourished women.
the participants may successfully support the nutrient
The strength of this study was in the outcomes of the
supply for the mother and fetus and complement the
pregnancy measured. Measuring placenta, umbilical
role of iron‑folic acid supplement in various metabolic
cord, and birth weight may give a comprehensive
mechanisms during pregnancy. Hence, the dose of
explanation of the supplementation effect during
the biscuits could not be seen explicitly in this study.
pregnancy.
This finding is supported by the result in which the
outcomes of pregnancy between malnourished and
Conclusion
healthy pregnant women were not statistically different.
Supported by a previous study8, it can be assumedthat In conclusion, this study demonstrated that given
the nutrients status in the malnourished body, both malnourished with a supplementary biscuit will not
macro and micronutrients, potentially resemble those provide any improvements on the pregnancy outcomes.
healthy pregnant women. The government should review the program of biscuit
supplementation in order to improve pregnancy
The interesting finding of this study was that the outcomes. Further research is necessary using
placenta and birth weight outcomes in malnourished clinical trial design to examine the beneficial effect of
women are similar to health pregnancy women. Given complementary foods.
that this finding implicates for the potential treatment
of minimizing the risk factor of stunting. Low birth Acknowledgement:
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 601
Ethics Approval: This study approved an ethical 9. Muqni AD., Arundhana AI., Thaha AR., Hadju V.,
clearance. Jafar N. Maternal preconception body mass index
and gestational weight gain: A prospective cohort
Source of Funding: This study was obtained a study potentially to prevent low birth weight.
financial support from Directorate of Higher Education, Indian J Public Heal Res Dev. 2017;8(4), doi:
Ministry of Research, Technology and Higher Education 10.5958/0976‑5506.2017.00377.1.
of Indonesia.
10. Veena SR., Gale CR., Krishnaveni G V., Kehoe
Conflict of Interest: All authors declared no conflict SH., Srinivasan K., Fall CHD. Association
of interest within this study. between maternal nutritional status in pregnancy
and offspring cognitive function during childhood
References and adolescence; a systematic review. BMC
Pregnancy Childbirth. 2016;16(1), doi: 10.1186/
1. Abu‑Saad K., Fraser D. Maternal nutrition and
s12884‑016‑1011‑z.
birth outcomes. Epidemiol Rev. 2010;32(1):5‑25,
doi: 10.1093/epirev/mxq001. 11. Woldeamanuel GG., Geta TG., Mohammed TP.,
Shuba MB., Bafa TA. Effect of nutritional status
2. Bhutta ZA., Das JK., Rizvi A., Gaffey MF.,
of pregnant women on birth weight of newborns
Walker N., Horton S., et al. Evidence‑based
at Butajira Referral Hospital, Butajira, Ethiopia.
interventions for improvement of maternal and
SAGE Open Med. 2019;7:205031211982709, doi:
child nutrition: What can be done and at what cost?
10.1177/2050312119827096.
Lancet. 2013;382(9890):452‑77, doi: 10.1016/
S0140‑6736(13)60996‑4. 12. Rashid CS., Bansal A., Simmons RA. Oxidative
Stress, Intrauterine Growth Restriction, and
3. Sharma D., Shastri S., Sharma P. Intrauterine
Developmental Programming of Type 2 Diabetes.
Growth Restriction: Antenatal and Postnatal
Physiology (Bethesda). 2018;33(5):348‑59, doi:
Aspects. Clin Med Insights Pediatr. 2016;10:67‑83,
10.1152/physiol.00023.2018.
doi: 10.4137/CMPed.S40070.TYPE.
13. Anto EO., Owiredu WKBA., Sakyi SA., Turpin
4. De Onis M., Borghi E., Arimond M., Webb P.,
CA., Ephraim RKD., Fondjo LA., et al. Adverse
Croft T., Saha K., et al. Prevalence thresholds for
pregnancy outcomes and imbalance in angiogenic
wasting, overweight and stunting in children under
growth mediators and oxidative stress biomarkers
5 years. Public Health Nutr. 2018;22(1):175‑9, doi:
is associated with advanced maternal age births:
10.1017/S1368980018002434.
A prospective cohort study in Ghana. PLoS
5. Gresham E., Byles JE., Bisquera A., Hure AJ. Effects One. 2018;13(7):1‑12, doi: 10.1371/journal.
of dietary interventions on neonatal and infant pone.0200581.
outcomes: a systematic review and meta‑analysis.
14. Mistry HD., Williams PJ. The importance of
Am J Clin Nutr. 2014;100:1298‑321, doi: 10.3945/
antioxidant micronutrients in pregnancy. Oxid Med
ajcn.113.080655.Nutrition.
Cell Longev. 2011;2011, doi: 10.1155/2011/841749.
6. Gresham E., Bisquera A., Byles JE., Hure AJ.
15. Casanueva E., Viteri FE. Iron and Oxidative Stress
Effects of dietary interventions on pregnancy
in Pregnancy. J Nutr. 2003;133(5):1700S‑1708S,
outcomes: a systematic review and meta‑analysis.
doi: 10.1093/jn/133.5.1700s.
Matern Child Nutr. 2016;12(1):5‑23, doi: 10.1111/
mcn.12142. 16. Abeway S., Gebremichael B., Murugan R., Assefa
M., Adinew YM. Stunting and its determinants
7. MoH. Laporan Nasional Riset Kesehatan Dasar
among children aged 6‑59 Months in Northern
(Riskesdas) tahun 2018. Jakarta, Indonesia; 2019.
Ethiopia: A cross‑sectional study. J Nutr Metab.
8. Sampeangin H., Hadju V., Sirajuddin S., Thahir 2018;2018, doi: 10.1155/2018/1078480.
AIA., Thaha AR. The effect of supplementary
17. Salafia C., Charles A., Maas E. Placenta and
feeding program for chronic energy deficiency
fetal growth restriction. Clin Obs Gynecol.
pregnant women on Hb concentration, MUAC,
2006;49(2):236‑56, doi: 10.1097/00003081‑20060
and gestational weight gain in Indonesia. Indian
6000‑00007.
J Public Heal Res Dev. 2018;9(8):306‑12, doi:
10.5958/0976‑5506.2018.00738.6.
602 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Heavy Metals Concentration and Biochemical Parameters in

the Blood and Nails of Industrial Workers

Kameran Sh. Husien1, Mohsin O. Mohammed2, Tamara N. Ahmed2

1Professor, College of Nursing, 2Assistant Professor, College of Science, Kirkuk University‑Kirkuk, Iraq

Abstract
This study amied to measure the concentration of heavy metals (Pb, Cd) and certain biochemical variables in
blood and nails of(50) samples(male and female) of workers (who were in risk of exposition to these heavy
metals) from Northern Gas Company in Kirkuk city/Iraq. Flame atomic absorption spectrometer was used
for measuring these elements. The results showed significant differences (P < 0.01) in the concentration of
lead and cadmium in the studied samples (whole blood and nails) of workers compared to the control group.
The concentration of lead and cadmium were higher in blood and Nails. As of the biochemical variables,
significant differences (P < 0.05) showed in the concentration of antioxidant enzyme (SOD) in serum. As
of oxidative stress (MDA), results showed significant differences (P < 0.05) in serum, the highest value of
(MDA) was recorded in serum samples.

Keywords: Heavy metals, Antioxidant, Oxidative stress.

Introduction fatty acids, which is an indicator for estimating oxidative

stress.9 Antioxidants are of great importance as they
Heavy metals have found as natural constituents
are the first line of defence against free radicals, and
of the Earth’s crust and are non‑degradable in nature
the need for antioxidants becomes more critical with
and tend to form pollutants of living organisms in
increasing exposure to free radicals.10 The human
the environment,1 and living organisms inhabiting
antioxidant defence system consists of enzymatic and
contaminated sites may be exposed to very high amounts
non – enzymatic systems. Many enzymatic systems
of heavy metals as they are toxic and may cause adverse
are stimulatingreactions to neutralise free radicals.
effects, even if in small concentrations.2‑3
These enzymes include Superoxide Dismutases (SOD),
Different sources of heavy metals were found in the Catalases (CAT), Glutathione Peroxidases (GPX),
environment (natural and industrial). Natural sources Glutathione Reductases (GRX), and these mechanisms
such as weathering and volcanic eruption contribute form the internal defence mechanisms of the body to help
significantly to the pollution of heavy metals,4‑6 and protect against cell damage caused by free radicals.11
industrial sources such as; mineral processing in These enzymes also require co‑factors such as copper,
refineries, power plants, coal combustion, oil combustion, zinc, and selenium as a stimulant to activate enzymes to
nuclear power plants, chemical and metal industries, in maintain functions and prevent oxidation in human cells,
addition to the plants of wood preservation, and paper and the need for antioxidants has become very important
processing.7,8 with increased exposure to free radicals.

Malondialdehyde (MDA), one type of oxidant, is Materials and Method

the final product for the oxidation of polyunsaturated
The samples of blood and nails were collected
from 50 employees (males and females) aged between
Corresponding Author: 20‑65 years of the Northern Gas Company in Kirkuk
Kameran Sh. Husien governorate, while the duration of exposure or years of
Professor, College of Nursing, Kirkuk work ranged between (1‑30) years. The control group
University‑Kirkuk, Iraq was selected from 20 people outside the North Gas
e‑mail: [email protected] Company, which did not work in the industrial sector.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 603
The samples were collected in January 2019. The was (25.40 ± 4.20) and control (13.91 ± 2.02), respectively
elements were estimated in all studied samples by an (Figure 1). Statistically significant differences were
atomic absorption device (ASS), where the lead element found (P<0.01) between the concentration of the lead in
was measured by the flame atomic absorption device the whole blood of workers and the control group, that
(FAAS), while the Cd element by non‑flammable atomic it was found to be higher than the control group. The
absorption device (GFAAS).12 reason for the high concentration of lead in the workers
could be attributed to the tetraethyl lead, chemicals that
Preparation and Sating Samples: emitted from North Gas Company. Furthermore, a study
1. Blood: 10 ml of blood was collected from each has shown that high concentrations of lead in industrial
person; blood samples were divided into two atmospheres are humanmade, as it is almost 100 times
parts; in the first part, (5 ml) was placed in an higher in industrial atmospheres compared to natural
anticoagulant tube and kept at room temperature to atmospheres 15. Increasing the concentration of lead in
measure lead and cadmium. In the second part, (5 the whole blood leads to many adverse consequences
ml) was placed in plastic tubes with tight lids and such as hypertension, renal failure, and brain damage.16
free from any anticoagulant (Plain tube), and was These findings are consistent with those reported by
left at room temperature (25 C) until coagulated, others 17, 18.
and then placed in the centrifuge for 10 minutes at a
Table (1): Concentration of heavy metals (Pbµg/dl,
speed of 3000 rpm, afterword serum was collected
Cdµg/dl) inworkers’ whole blood and control group
by micropipette to measure biochemical tests. It was
then transferred to dry plastic tubes and kept at 10° Elements Groups Mean±SD P‑Value
C using Deep Freezer 13 until tests were carried out. Workers 25.40±4.20
The concentration of lead and cadmium in the blood Pb P<0.01
Control 13.91±2.02
of the workers was estimated by Haswell method.13 Workers 1.0904±0.0416
Cd P<0.01
2. Nails: Each person’s nails were trimmed with Control 0.2782±0.0291
clean, sterile scissors, and then placed in sealed
Cadmium‑(Cd): The results of table (1)
plastic bags. Nails were then washed with non‑ionic
showed different concentrations of the Cadmium; the
cleaners. After a standard wash, the nail samples
concentration of the Cadmium in whole blood of workers
were soaked in acetone. Finally, the samples are
during the study period was (1.0904±0.0416) and
rinsed five times with deionised water and then
control group (0.2782±0.0291), respectively (Figure 1).
dried in the oven at 110 c̊ and stored in the desiccant
Statistically significant differences were found (P<0.01)
pending analysis. The samples were divided into two
between the concentration of the lead in the whole blood
parts, the first part for measuring the heavy elements
of workers and the control group, that it was found to be
and the second part for measuring the biochemical
higher than the control group. The high concentration
variables. The heavy elements in the nail samples
of cadmium in workers was attributed to industrial
were estimated, according to Abdul‑Rahman et al.14
emissions, especially the mining and mineral refining
method.
industry. Also, cadmium occurs naturally with zinc and
Statistical analysis: Results were statistically lead in sulfide ores. Cadmium has a direct relationship
analysed using ANOVA test and the results obtained with some chronic diseases, such as hypertension, which
were described in the tables as (mean and standard is an excellent indicator of exposure to cadmium in
deviation) and with a probability level (P <0.05) and P occupationally exposed individuals.Cadmium leads to
<0.01). an increase in systolic and diastolic blood pressure, and
thus an increase in high blood pressure.19
Results and Discussion
The results obtained were mostly consistent with
1. Heavy Metals: studies conducted on gas station workers in Babil17 and
Estimation of heavy metals in whole blood: Basrah18 governorates, where there was a decrease in
the concentration of (Cu, Zn, Mg) and an increase in
Lead‑(Pb): The results of table (1) showed different the concentration of (Cd, Pb) in the blood of gas station
concentrations of the lead element; the concentration of workers compared to the control group.
the lead in whole blood of workers during the study period
604 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
2.50), and in the control group (9.11 ± 1.60), (Figure
3). Statistically, there were significant differences
(P <0.01) for the average concentration of lead in
workers’ nails compared to the control group.This is
due to occupational exposure, which contributes to the
absorption of minerals, and these results are like those
reported by others.21, 22

Cadmium‑(Cd): The results obtained, shown in

Table (3), showed the concentration of cadmium in
workers ‘nails compared with the control group, where
the concentration of cadmium in workers’ nails was
Figure 1: Concentration of Heavy Metals (Pbµg/dl,
0.1362 ± 0.0217), and in the control group (0.0925 ±
Cdµg/dl) in workers’ Whole Blood and control group
0.0189), (Figure 2).Statistically, there were significant
Estimation of heavy metals in workers’ hair differences (P <0.01) on the average concentration of
compared to the control group cadmium in workers’ nails compared to the control
group. The reason for the high concentration of cadmium
Table (2): Concentration of heavy metals (Pbµg/dl, is due to the complex occupational exposure of the
Cdµg/dl) in workers’ hair and control group. elements, and the results obtained are consistent with
the findings.21, 22
Elements Groups Mean±SD P‑Value
Workers 15.70±2.18
Pb P<0.01
Control 7.75±1.29
Workers 0.1330±0.0264
Cd P<0.01
Control 0.0820±0.0194

Lead‑(Pb): The lead element poses a real concern

among heavy metals because of its toxicity, and there is
no primary function in the human body, the damage can
occur only after its absorption from air or water 20.

The results of table (2) showed different

concentrations of the lead element; the concentration
of the lead in whole blood of workers during the study Figure 2. The concentration of heavy metals (Pbµg/dl,
period was (15.70±2.18) and control (7.75±1.29), Cdµg/dl) in workers’ nail and control group.
respectively (Figure 2). Biochemical Variables:
Estimation of heavy metals in workers’ Estimation of oxidative and antioxidant
nailcompared to the control group: concentrations in blood serum:
Table (3): Concentration of heavy metals (Pbµg/dl, Table (4): Concentration of Enzymes (SOD U/ML,
Cdµg/dl) in workers’ nail and control group MDA µmol/L) in the blood serum of workers and
Elements Groups Mean±SD P‑Value
control group
Workers 14.57±2.50 Variables Groups Mean±SD P‑Value
Pb P<0.01
Control 9.11±1.60
Workers 30.7±3.1
Workers 0.1362±0.0217 SOD P<0.05
Cd P<0.01 Control 49.3±10.5
Control 0.0925±0.0189 Workers 123.6±16.9
MDA P<0.05
Control 70.0±13.7
Lead‑(Pb): The results obtained, shown in Table
(3), indicate the concentration of the lead element in The concentration of Superoxide dismutase (SOD)
workers’ nails compared to the control group, where enzyme: The results of table (4) show the concentration
the concentration of lead in workers’ nails was 14.57 ± of enzyme (SOD) in the serum of workers and the control
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 605
group, where the concentration of enzyme in the serum all samples of studied workers.
of workers was (30.7 ± 3.1) which was lower than the
control group was (49.3 ± 10.5),(Figure 4).Statistically, Conflict of Interest: None of the authors have any
there were significant differences between the workers conflicts of interest to declare.
and the control group (p <0.05). The reason for the Source of Funding: The research was performed
decrease in the concentration of the enzyme SOD is that independently, there is no funding
it is common in contaminated environments because this
enzyme is necessary to protect the body’s cells from free Ethical Clearance: The project was approved by
radicals and excessive oxygen that promote ageing or the local ethical committee in University of Kirkuk.
cell death.23 Moreover, trace elements (Zn, Cu, Mg) are
SOD components and are associated with antioxidant References
functions, so their deficiency may lead to poor control 1. Bhagure, G. R. a Mirgane, S. R. Heavy Metals
of free radicals, and all these elements are replaced by Contaminations in groundwater and soils of Thane
lead, which reduces the activity of (SOD).24 The results Region of Maharashtra, India, Environ Mot Assess,
obtained were in contrast with that reported in another 2010; 1‑10.
study 25 and coincide with the others.17, 18, 26, 27
2. Aderinola, O.J., E. O.Clarke, O. M.Olarinmoya,
Concentration Serum lipid peroxidation (MDA): V.Kusemiju and M. A. Anatekhai. Heavy Metals in
The results are shown in Table (4) indicate that the Surface Water, Sediments, Fish and Perwinkles of
concentration of MDA in the serum of the workers Lagos. Lagoon. American‑Eurasian J. & Environ.
(123.6 ± 16.9) was high in comparison to the control Sci., 2009; 5(5), 609‑617.
group (70.0 ± 13.7),(Figure 4). Statistically, there were 3. Yahaya A., AdegbeA..and EmurotuJ. E. Assessment
significant differences between the workers and the of Heavy Metals content in the Surface Water of
control group (p<0.05). The reason for this is that the Oke‑Afa Canal Lsola Lagos, Nigeria. Archives of
rise in the level of heavy metals leads to the destruction Applied Science Research, 2012; 4(6), 2322‑2326.
of oxidative stress by increasing the production of free 4. Skaldina, O., & Sorvari, J. Ecotoxicological
radicals (ROS), which reduces the system of antioxidant Effects of Heavy Metal Pollution on Economically
defence in cells and increase the concentration MDA.28,29 Important Terrestrial Insects. In Networking
These results are consistent with other findings.17,18,26,30 of Mutagens in Environmental Toxicology,
2019;137‑144. Springer, Cham.
5. Odum, H. T. Heavy metals in the environment:
using wetlands for their removal, 2016. CRC Press.
6. NriaguJO.(1989). A global assessment of natural
sources of atmospheric trace metals. Nature, 1989;
338:47‑49.
7. ArrutiA,Fernandez‑Olmo I, Irabien A, Evaluation
of the contribution of local sources to trace metals
level in urban PM2.5 and PM10 in the Cantabria
region (Northern Spain) J Environ Monti,
2010;12(7):1451‑1458.
Figure 4: The concentration of Enzymes (SOD U/
8. Joshi, N. C. Biosorption: Agreen approach for
ML, MDA µmol/L) in the blood serum of workers and
control group heavy metals removal from water and waste waters.
RJLBPCS, 2018; 4(1), 1‑59.
Conclusion 9. Bae S., Pan X., Kim S. et al. Exposures to
particulate and polycyclic aromatic hydrocarbons
The results of this study concluded that the
and oxidative stress in school children, Environ
concentration of heavy metals (Pb, Cd) was high in the
Health Perspect, 2010; 118(4), 579‑583 .
whole blood and nails of the workers in the North Gas
Company. Moreover, the concentration of SOD enzyme 10. K. Bagchi. And S. Puri.Free radiacals
in the blood and samples was low;the MDA was high in and antioxidants in healthy and diasease.
606 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Estranmediterrean health J., 1998; 4(2),pp: 350 Determination of heavy metal concentration in nail
‑360. of car workshops workers in Baghdad. Journal of
11. Burtis CA. and Ashwood ER. Tietz textbook of American Science, 2017; 13(6), 1‑8 .
clinical chemistry 3rd ed. W.B. Saunders comp., 22. Krishnamurthy, P., & Wadhwani, A. Antioxidant
1999; Tokyo, 1034‑1054. enzymes and human health. Antioxidant enzyme,
12. Haswell, S. J. Atomic absorption spectrometry 2012; 1‑17.
Theory, Design And Application. 1991, Elsevier, 23. Negi, R., Pande, D., Karki, K., Kumar, A.,
Tokyo. Khanna, R. S., & Khanna, H. D. Trace elements
13. Wilson, S. S., Guillan, R. A., & Hocker, E. V. and antioxidant enzymes associated with oxidative
Studies of the stability of 18 chemical constituents stress in the pre‑eclamptic/eclamptic mothers
of human serum. Clinical chemistry, 1972; 18(12), during fetal circulation. Clinical nutrition, 2012;
1498‑1503. 31(6), 946‑950.
14. Abdulrahman, F. I., Akan, J. C., Chellube, Z. M., 24. Gerli, G., Locatelli, G. F., Mongiat, R., Zenoni,
& Waziri, M. Levels of heavy metals in human L., Agostoni, A., Moschini, G., ... & Tarolo,
hair and nail samples from Maiduguri Metropolis, G. Erythrocyte antioxidant activity, serum
Borno State, Nigeria. World Environ, 2012; 2(4), ceruloplasmin, and trace element levels in subjects
81‑89. 159. with alcoholic liver disease. American journal of
clinical pathology, 1992; 97(5), 614‑618.
15. Bradl, H., Kim, C.,Kramar, U., & Stüben, D.
Interactions of heavy metals. In Interface science 25. Al‑Fartosy, A. J., Awad, N. A., & Shanan, S. K.
and technology, 2005;6, 28‑164. Biochemical correlation between some heavy
metals, malondialdehyde and total antioxidant
16. Tiwari, S., Tripathi, I. P., & Tiwari, H. L. Effects
capacity in blood of gasoline station workers. Int
of lead onEnvironment. International Journal of
Res J Environment Sci, 2014; 3(9), 56‑60.
Emerging Research in Management & Technology,
2013; 2(6). 26. Dewi, N. K., & Yuniastuti, A. Superoxide
Dismutase Levels of Operator Gas Stations in
17. Azize S.Study of Heavy Metals and their effects
Semarang, Central Java, Indonesia. KnE Life
on Oxidant/Antioxidant Status in Workers of fuel
Sciences, 2017; 3(5), 167‑172.
Station in Hilla city‑ Iraq . Research J. Pharm . and
Tech, 2018; 11(1), 1‑5 . 27. Hussain S., Atkinson A., Thompson S.J. and Khan
A.T. Accumulation of mercury and its effect on
18. Al‑Fartosy, A. J., Awad, N. A., & Shanan, S. K.
antioxidant enzymes in brain, liver and kidneys of
Biochemical Study of the Effects of Some Heavy
mice, J. Environ. Sci. Heal. B, 1999;34(4), 645‑660
Metals on Oxidant/Antioxidant Status in Gasoline
.
Station Workers/Basra‑Iraq . Intarnational Journal
of Scientific and Research, 2017; 2(7), 83‑88. 28. Whaley‑Connell A., McCullough P.A. and Sowers
J.R. The role of oxidative stress in the metabolic
19. Chen, G. C., Shan, X. Q., Wang, Y. S., Pei, Z.
syndrome, Rev. Cardiovasc. Med.,2011; 12, 21‑29.
G., Shen, X. E., Wen, B., & Owens, G. Effects
of copper, lead, and cadmium on the sorption 29. Al‑Fartosy, A. J., Awad, N. A., & Shanan, S. K.
and desorption of atrazine onto and from carbon Biochemical correlation between some heavy
nanotubes. Environmental science & technology, metals, malondialdehyde and total antioxidant
2008; 42(22), 8297‑8302. capacity in blood of gasoline station workers. Int
Res J Environment Sci, 2014; 3(9), 56‑60.
20. Pirsaraei, S. R. A. Lead exposure and hair lead
level of workers in a lead refinery industry in Iran. 30. Signori, V. Review of the current understanding of
Indian journal of occupational and environmental the effect of ultraviolet and visible radiation on hair
medicine, 2007; 11(1), 6. structure and options for photoprotection, Cosmet.
Sci, 2004; 55,95–113.
21. Al‑Easawi N, Mahmood M, Hassoon H.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 607

Impact of Workplace Violence Educational Program on Self

Confidence for Nursing Staff Working in Psychiatric Hospital

Mohga Fathy Abd Elmoteleb Ali Hamza1, Afaf Abd Elhamed Abd Elrahman2
1Assistant Lecturer, 2Professor, Psychiatric Mental Health Nursing, Faculty of Nursing‑Cairo University‑Egypt

Abstract
Inpatient mental health clinicians need to feel safe in the workplace. They require confidence in their
ability to work with aggressive patients, allowing the provision of therapeutic care while protecting
themselves and other patients from psychological and physical harm. The aim of this study is to evaluate
the impact of educational training program on self‑ confidence for nursing staff working in psychiatric
hospital. Design: A quasi‑experimental design” pre‑posttest assessment” was utilized for the current study.
A sample of convenience of 45 psychiatric nurses who agree to participate and were in Al‑Abbassia mental
health hospital were included. Two tools were utilized in the current study including Socio‑ Demographic
including Department Data Sheet, Confidence in Managing Service user Aggression. The results showed
that: there was a highly statistically significant difference was found for all items in nurses’ pre versus
post self‑ confidence assessment. Also there was a positive significant correlation between nurses’ level of
self‑confidence and the frequency of isolation for the patients & nurses’ years of experience in pre & post
assessment, while there is no significance correlation between nurses’ level of self‑confidence and their age,
gender, or duration of patient’s isolation. To conclude that, nurses who received the educational training
program about workplace violence showed higher score in their post assessment of self‑ confidence than
before receiving the program. So the research hypotheses was accepted. Further studies was recommended
in addressing the effect of training on staff behavior to be measured through direct observation.

Keywords: Workplace Violence, self‑confidence, Psychiatric Nursing Staff.

Introduction According to2, professional quality of life reflects

how individuals feel about their work as helpers. A
Workplace violence (WPV) toward nurses
crucial factor in improving the delivery of service to
working in the hospital environment is a well‑known
patients in acute care psychiatric units appears to be the
issue worldwide. It compromises not only health
confidence level of staff to deal with aggression both
care professionals’ physical well‑being but also their
in the antecedent stages and when physical aggression
psychological well‑being. The victims may suffer
occurs.
physical and mental stress and a high degree of anxiety,
nurses are one of the professional groups most exposed 2
added that,a crucial factor in improving the
to physical aggression, verbal abuse, and threats because delivery of service to patients in acute care psychiatric
nurses have more frequent and longer contacts with units appears to be the confidence level of staff to deal
patients or families and are responsible for providing with aggression both in the antecedent stages and when
direct care.1 physical aggression occurs. There are many factors
that impacted on clinicians’ confidence to manage
aggression as colleagues’ knowledge, experience and
Corresponding Author: skill, management of aggression, use of prevention and
intervention strategies, teamwork and the staff profile.
Mohga Fathy Abd Elmoteleb Ali Hamza
Assistant Lecturer, Psychiatric Mental Health Nursing
Subject and Method
e‑mail: [email protected]
Mobile Phone: 01022894779 Aim of the study: The current study is to evaluate
608 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
the impact of educational training program on self‑ at the upper end of the scale if their response to a
confidence for nursing staff working in psychiatric question was very positive, or the number 1 if their
hospital. response was very negative. If the response was
somewhat positive respondents were asked to circle
Research Hypothesis: Nurses who will receive the 5 or 6 and if they was somewhat negative to circle
educational training program about workplace violence 2 or 3. Where they were unsure or undecided they
will show higher score in their post assessment of self‑ were asked to circle the number 4.
confidence than before receiving the program.
Procedure:
Sample: A sample of convenience of 45 psychiatric
1. Obtaining required tools and designing the
nurses who agree to participate and were in Al‑Abbassia
program: A review of related literatures was done
mental health hospital were included.
using available books, articles, and journals, to
Tools of Data Collection: cover various aspects of nurse’s self‑confidence in
managing aggressive patients and their relatives, and
1. Socio‑Demographic & Department Data Sheet:
also to obtain the relevant standardized tools and to
It was developed by the researcher. It was divided
develop workplace violence prevention program.
into two parts, first part was about nursing staff
Scio‑demographics included gender, education 2. Recruitment and interviewing: An official
level, and years of experience etc.... The second part permission from the research ethics committee in the
was about the department’s data such as department faculty of nursing was obtained upon the feasibility
type (in‑patient or out‑ patient), the approximate of the research tools and study. There searcher met
number & duration of using seclusion & or restraints with the responsible about training department at
in the section per year etc.... El Abbassia Mental Health Hospital after receiving
the permeation from the hospital manager in order
2. Confidence in Managing Service user Aggression:
to recruit staff nurses for participation in the study
The questionnaire was developed by3 & was selected
according to inclusion criteria. Written informed
as suitable for measuring confidence in coping with
consents were obtained from each participant after
patient aggression. But it was modified & adopted
complete description of the purpose and nature of
from4 to assess nurse’s self‑ confidence in managing
the study, all participants were assured and informed
service user aggression and their ability to deal with
that participation in the study is voluntary.
violent situations. It consists of a 7 items rating scale
ranged from (1‑7) and one qualitative (open ended 3. Intervention: Figure (1), represents the researcher’s
question). In the rating scale, respondents were own interpretation about the information map and
asked to indicate their degree of confidence to the skills that each member of the nursing staff must
questions using a 7 point rating scale with verbal have and mastering in order to enabling them
descriptors at each end, e.g. 7 = very sure/very able/ limiting, intervening & managing the in ‑patient’s
very save, and 1 = very unsure/very unable/safe. aggression continuum.
Respondents were asked to circle the number 7

Preventive Strategies Anticipatory Strategies Containment Strategies

• Warning Signs • Escaping from Holds & Grabs

• Awareness & understanding • Violence assessment
• Seclusion
• Self‑ awareness • De‑escalation Strategies
• Restraints
• Assertiveness training • Communication Strategies
• Behavioral actions • Reporting & Recording
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 609
4. Evaluation: All participants recruited in the study Results
who receive the program were evaluated for the
Socio‑ demographic Characteristics & workplace
benefits of the workplace violence prevention
information of the study sample (n=45):
program by using the study tools.
Ethical consideration: Written informed consent Table (1) shows that, more than half of nurses
was taken from each participant who was willing (53.3%) were male. More than two thirds (62.2%) were
to participate in the research. All participants were aged from 19<30 years old with mean age (X 30.18±9.1
informed that, participation in the research is voluntary years). As for years of experience, 46.7% of them have
and any one can withdraw from this study at any time experience 10<25 years with a mean =9.6±8.8 while
without giving any reason. Confidentiality of the 22.2% have less than 10 years of experience.
participants were assured through coding the data; Table (2) shows that, regarding to frequency of
a unique identifying number was assigned to the data using isolation within a year 53.3% of nurses reported
collected for each participant. Only the researcher had that it was ranged from once to less than 20 time/year
access to these information in the database. with mean 16.1±13.4, Regarding to isolation duration,
Pilot Study: A pilot study was conducted at the 71.1% of nurses mentioned that it was from one to less
beginning of the study. It included 5 psychiatric nurses. than 6 hours with mean 3.5±3.7.
The designed tools were tested on those subjects who Table (3) revealed that it was a highly statistically
were three male and 2 female staff nurses. significant difference was found for all items in nurses’
Statistical Analysis: Data were analyzed using pre versus post self‑ confidence assessment (p<0.0001)
Statistical Package for Social Sciences (SPSS) version except for question 7 (p>0.05)
20. Numerical data were expressed as a mean and Table (4) showed that there was a positive significant
standard deviation. Qualitative data were expressed correlation between nurses’ level of self‑confidence
as frequency and percentage. Probability (p‑value)> and years of experience & the frequency of isolation
0.05 indicates non‑significant result, p‑value< 0.05 is for the patients in pre & post assessment .While there
considered a significant result and p‑value <0.001 is is no significance correlation between nurses’ level of
considered highly significant result. self‑confidence and their age, gender, or duration of
patient’s isolation.

Table 1: Socio‑demographic characteristics of the study sample (n = 45)

Items No. Percent Range/Mean±SD

Gender
• Male 24 53.3%
• Female 21 46.7%
Age
• 19<30 28 62.2%
• 30<45 10 22.2% 30.18±9.1
• 45‑60 7 15.6%
Years of Experience
• 0<10 10 22.2%
• 10<25 21 46.7% 9.6±8.8
• ≥25 14 31.1%
610 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 2:Work place information of the study sample (n = 45)

Items No. Percent Range/Mean±SD

Duration of Patient’s Stay (Month)
• Zero for out patient 4 8.9%
• 1<6 28 62.2%
1.3±0.79
• 6<12 8 17.8%
• ≥12 5 11.1%
Frequency of Using Isolation within a Year
• No time 4 8.9%
• 1<20 24 53.3%
16.1±13.4
• 21<40 12 26.7%
• ≥40 5 11.1
Duration of Isolation
• Zero time 4 8.9%
• 1<6 32 71.1%
• 6<12 8 17.8% 3.5±3.7
• 12‑24 1 2.2
• >24 0 0.0%

Table 3: Nurses’ pre versus post self‑ confidance assessment regarding managing aggressive patients (n = 45)

Items Mean±SD t p
1. How confident are you in your work with hostile and aggressive service users? 1.4±1.5 6.24 0.000**
2. How safe do you feel around aggressive and aggressive service users? 0.3±1.4 1.26 0.215
3. How able are you to de-escalate an aggressive service user? 1.5±1.4 7.26 0.000**
4. How able are you to contribute to the restraint of an aggressive service user? 1.1±1.5 4.93 0.000**
5. How able are you to maintain your own safety in the presence of an aggressive service user? 1.2±1.5 5.42 0.000**
6. How confident are you in the ability of your colleagues’ ability to maintain your safety and
0.8±1.0 5.36 0.000**
manage an aggressive service users?
7. How safe do you feel the environment in El Abbasiamental health hospital? 0.3±1.6 1.37 0.179

** Highly statistically significant difference at p<0.0001

Table 4: correlation analysis of nurses’ self confedance assessment and the sociodemografic data (n= 45)

Pre Post
r p r p
Age 0.13 0.36 0.06 0.72
Gender 0.10 0.51 0.06 0.72
Years of experience 0.18 0.24 0.33 0.03*
Frequency of isolation 0.33 0.03* 0.31 0.04*
Duration of isolation 0..22 0.15 0.07 0.64

Discussion The greatest area of improvement was in question

three “how able are you to de‑escalate an aggressive
The findings of the current study showed a highly
user?” followed by question one “how confident are
significant improvement for all items in nurses’ pre
you in your work with hostile and aggressive service
versus post self‑confidence assessment. And it’s also
users?” this results are in congruent with6 who stated that
clear that there was an increase in the total weighted
verbal de‑escalation training improves confidence of all
mean of the scale in post assessment than the pre. On the
participants after they provided the training program.
same line5 concluded that there was an overall increase
in the nurses’ confidence in post assessment.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 611
From the researcher’s own point of view the overall 2. The effect of training on staff behavior measured
improvement in the staff confidence is open to at least two through direct observation should also be addressed.
interpretations. First, the course specifically focused on
Source of Funding: Self‑funding.
teaching staff strategies to deal with aggressive behavior
in a more confident manner and directly focused on staff Conflict of Interest: The authors declare that there
fears when managing challenging behaviors. Second, is no conflict of interest.
this particular form of staff training may have a relatively
specific effect on staff confidence because prior to this References
experience, the majority of these participants had not
1. Martin, T., and M. Daffern. “Clinician perceptions
received a theoretical content about how to interact with
of personal safety and confidence to manage
aggressive patients confidently many years ago.
inpatient aggression in a forensic psychiatric
The current result revealed that, there is no setting.” Journal of psychiatric and mental health
significance correlation between nurses’ level of nursing 13.1 (2006): 90‑99.
self‑confidence and their age, gender, or duration 2. Itzhaki, Michal, et al. “Mental health nurse’s
of patient’s isolation. This not in the same line with exposure to workplace violence leads to job stress,
7
who stated that nurses those are older, had more which leads to reduced professional quality of life.”
self‑confidence as compared to others. Frontiers in psychiatry 9 (2018): 59.
3. Shimizu, Takashi, et al. Relationship between
Furthermore, there was a positive significant
burnout and communication skill training among
correlation between nurses’ level of self‑confidence and
Japanese hospital nurses: a pilot study. Journal of
there years of experience & the frequency of isolation.
occupational health 45.3 (2003): 185‑190.
This is not in the same line with 7who concluded that
there was no significant correlation between the lengths 4. Mc Carron, Francis. An Evaluation of the Impact
of mental health practice with any of the confidence of the Talk downs Model on~ Self‑perceived
ratings. This was in congruent with 8 who added that, age Confidence of Nurses for Deescalating Potential
maturity and increase numbers of years of experience Aggressive Episodes. (2016).
are important in development of assertiveness and as 5. Healea, Bryan. Off the Verge: Teaching
regard development of self‑confidence, because the old De‑escalation through Simulation. (2017).
nurses had ability to solve problem and negotiate work 6. Özdemir, Leyla, and Erdem Karabulut. Nurse
situations. education regarding agitated patients and its effects
on clinical practice. Contemporary nurse 34.1
Conclusion (2010): 119‑128.
Nurses who received the educational training 7. Maheshwari, S. K., and Kanwaljit Kaur Gill.
program about workplace violence showed higher score Relationship of assertiveness and self‑esteem
in their post assessment of self‑ confidence than before among nurses. International Journal of Health
receiving the program.So the research hypotheses was Sciences and Research 5.6 (2015): 440‑449.
accepted. 8. Mohamed, H. Assertiveness among nursing
Recommendations: personal working at Ain Shams University
Hospitals. Unpublished Master thesis, High
1. Variables that mediate staff confidence, such as staff Institute of Nursing, Ain Shams University, Cairo,
fear and anger may be useful to consider infuture Egypt (1999).
studies.
612 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

The Association of Glutathion Peroxydase‑1 Serum and

Sensorineural Hearing Lossin MDR TB Patients with
Kanamycin Therapy

Ratna Anggraeni1, Arif Darmawan1, Febri Wisudawan F.1

1Department of Otorhinolaryngology‑Head and Neck, Faculty of Medicine, Universitas Padjajaran

Abstract
Introduction: Kanamycin therapy in Multi‑Drug Resistance Tuberculosis (MDR‑TB) patients increases
the possibility of sensorineural hearing loss through increasing the level of Reactive Oxygen Species
(ROS) production in cochlea, particularly in hair cells. In normal state, ROS is detoxicated by numerous
antioxidant enzymes, including glutathione peroksidase‑1 (GPx‑1). Imbalance of antioxidant enzymes and
ROS production leads to death of hair cells and eventually sensorineural hearing loss.

Objective: This study aimed to observe the association of GPx‑1 level and sensorineural hearing loss in
MDR‑TB patients with Kanamycin therapy.

Method: This study was a prospective observational study conducted at Dr. Hasan Sadikin General Hospital,
Bandung, Indonesia, between February to April 2017. 17 patients were included into the study with pre‑ and
post‑kanamycin therapy examination within 3 weeks duration using pure tone audiometry and serum level
of GPx‑1. Statistic analysis was done using Man Whitney test with significant level of p < 0.05.

Result: A significant reduction of GPx‑1 level in 3 weeks period after the initial Kanamycin administration
was found in the study; p <0.001. Furthermore, there was a significant alteration in the hearing threshold
on frequency of 500‑800 Hz after Kanamycin administration; p < 0.05. There was a significant association
between GPx‑1 level and sensorineural hearing loss in Kanamycin therapy; p < 0.05.

Conclusion: Sensorineural hearing loss in patient with history of Kanamycin therapy was associated with
level of GPx‑1 degradation.

Keywords: GPx‑1, Kanamycin, MDR TB, Sensorineural hearing loss.

Introduction almost in all cells’ organ (cytosol, mitochondria, and

peroxisome).15,16 Furthermore, in cochlea, GPx‑1 has
Tuberculosis (TB) remains a concern among global
a higher enzymatic activity in organ of corti, spiral
health problem with a high mortality and morbidity
ganglion, stria vascularis, spiral ligament, and another
rate.1 WHO also stated that Indonesia had approximately
supporting cell.17,18,19 Higher activity of SOD and CAT
6,800 new Multi Drug Resistance TB (MDR TB)
are also found in stria vascularis and organ of corti. GSH
annually with approximately 2% of new cases and
and GPx are the main antioxidants in those areas.14
12% of re‑treatment TB were MDR TB.2,3,4 Among all
injection drugs for MDR TB, Kanamycin is widely used Study conducted by Alli, et al. in 2014 on 83
as stated in WHO’s recent MDR TB guideline due to its MDR TB patients showed that there was a significant
wide distribution area and affordable price.5,6,7,8 degradation of antioxidant enzyme activity, including
glutathione transferase and glutathione peroxide.20 It
In general, three types of antioxidant present in
was strengthened by Madebo et al who also showed a
human body.14 Among all GPx, Glutathione peroxide‑1
significant decrease in glutathione peroxide level in TB
(GPx‑1) is the main glutathione peroxide enzyme family;
MDR patients.20,22
mainly found in erythrocyte, liver, lungs, kidney, and
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 613
Rakhmawati in her study found sensorineural DPOAE examination and audiometry. Exclusion criteria
hearing loss, particularly in high frequencies, 4000‑8000 for the study were patient with history of treatment using
Hz, in MDR TB patient treated using Kanamycin within ototoxic drugs except TB‑MDR treatment, had a history
the 19th to 22nd day of therapy, affecting high frequency of another diseases, including renal failure, diabetes
hearing ability to lower frequency.8 Study conducted mellitus, liver diseases, systemic lupus erythematosus
by Jiang et al in 2006 found that there was a shift in (SLE), and cardiovascular diseases. Intervention.
auditory brain stem response (ABR) by 45‑50 dB in the Data was collected from physical examination and
14th day that was remained for 5 weeks also showed laboratories data of already diagnosed MDR TB patients
that the death of hair cells happened in the 11th day and and planned for kanamycin therapy. Data before and 3
30% of the superficial hair cells died after 14 days.24 It is weeks after treatment consist of personal data collection,
proposed that hearing loss due to Kanamycin’s toxicity physical exam of ENT, tympanometry, pure tone
mostly started on higher frequency tone as it is located audiometry, DPOAE, and blood sample collection for
on the basal of cochlea; this progressivity happens due glutation peroksidase‑1 (GPx‑1) serum. Outcome.The
to difference of survival ability among the hair cells on data then analyzed for comparison of subject group
basal and apex cochlea; as explained by the lower level characteristic using paired t‑test if the data is normally
of GPx‑1 in basal hair cell in comparison with apex of distribute, and using Wilcoxon if the data is abnormally
cochlea.25 distribute. The data is also analyzed for GPx‑1 level
correlation with SNHL using Mann‑Whitney test. The
This study aims to observe the association between result is statistically significant if p≤0,05.
GPx‑1 level and SNHL in MDR TB patients treated
using Kanamycin. Findings: This study was held from February 2017
to April 2017, using 17 subject that fulfill the inclusion
Material and Method criteria. All subject received same test for pre and post
This study was an analytic prospective observational Kanamycin therapy, which includes tympanometry,
study with pre‑ and post‑ intervention examination for pure tone audiometry, DPOAE, and GPx‑1 level.
association between variables, which had been ethically Table 1: Subject Characteristic
legalized before. Participants. Patients with MDR TB
at MDR TB Policlinic of Internal Medicine Department Characteristics n=17
of Dr. Hasan Sadikin General Hospital, Bandung Gender, n (%)
between February to April 2017. The inclusion criteria Male 7 (41,2)
for the study were patients with MDR TB with plan for Female 10 (58,8)
Kanamycin therapy, aged 20‑50 years old, had intact Age (Years)
tympanic membrane in both ears, had type A result on Mean ± SD 36 ± 8
tympanometry examination, normal hearing threshold on Range 23 – 46

Table 2. GPx‑1 Level Before and After Kanamycin Therapy

Measurement
Decendants (%) p‑value
Before therapy (u/l) After 3 weeks therapy (u/l)
GPx‑1
Mean ± SD 4,49 ± 3,12 1,2 ± 1,0 70.42 ± 20,94 <0,001*
Range 1,01 – 14,01 0,07 – 5,15 18.81 – 98,54

Analysis using paired‑t test. *significant if p ≤ 0.05

Based on these table GPx‑1 level before therapy with range 1,01‑14,01 (4,49 ± 3,12) and GPx‑1 level after
therapy (1,2 ± 1,0) with range 0,07 – 5,15.
614 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
Table 3. Correlation between GPx‑1 level and DPOAE value

DPOAE test (Dp‑NF)

p‑value
Pass n=4 (23,5%) Refer n=13 (76,5%)
GPx‑1
Mean ± SD 66,60 ± 21,02 84,59 ± 14,86 0,062*
Range 18,81 – 92,36 64,40 – 98,54

Analysis using paired‑t test. *significant if p ≤ 0.05

From the analysis above, GPx‑1 median value at ear that having DPOAE test a “refer” value is higher (84,59 ±
14,86) compared to those who have DPOAE test a “pass” value (66,60 ±21,02), but it’s not significant statistically
(p=0,062).

Table 4. Audiometry examination before and after Kanamycin therapy

Threshold (dB)
Frequency Ear p‑value
Before Therapy Mean ± SD After Therapy Mean ± SD
AD 20,6 ± 5,6 23,7 ± 5,3 0,002
500 Hz
AS 21,2 ± 4,5 24,7 ± 4,1 0,020
AD 18,8 ± 3,3 19,4 ± 5,0 0,041
1.000 Hz
AS 18,2 ± 5,0 21,8 ± 3,5 0,048
AD 14,4 ± 3,6 17,7 ± 3,3 0,045
2.000 Hz
AS 14,4 ± 3,9 18,5 ± 5,8 0,016
AD 16,8 ± 5,6 20,9 ± 4,4 0,050
4.000 Hz
AS 15,3 ± 6,0 21,8 ± 6,4 0,020
AD 19,1 ± 7,3 24,4 ± 6,6 0,003
8.000 Hz
AS 18,0 ± 7,7 25,9 ± 10,3 0,004

Analysis using paired‑t test. *significant if p ≤ 0.05

There’s a significant increase in hearing threshold on both ear from pre to post Kanamycin therapy using
audiometry each frequency.

Table 5. Correlation between GPx‑1 Level and Sensorineural Hearing Loss

SNHL
P value
Yes n=13 (76,5%) No n=4 (23,5%)
GPx‑1 Pre Therapy
Mean ± SD 3,68 ± 1,99 7,13 ± 4,88
Median 3,73 5,88 0,049
Range 1,01 – 6,32 2,75 – 14,01
GPx‑1 Post Therapy
Mean ± SD 0,95 ± 0,71 1,99 ± 2,17
Median 0,82 1,30 0,013
Range 0,07 – 2,59 0,21 – 5,15

Analysis using Mann‑Whitney test. *significant if p ≤ 0.05

There’s a significant correlation between GPx‑1 level and SNHL condition.

 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 615

Discussions protein damage. DNA damage can be repaired by Base

Excision Repair (BER) mechanism, but if the damage
This study conclude MDR TB is mostly suffered
exceeded BER capability, the cell will activate protein
by female (58.2%) compared with male (41,8%). Liu
P53 and result in apoptosis.27 GPx‑1 level is determined
et.al hypothesized that female mostly spend their day
by many factor, such as inflammation process, inadequate
taking care of their family who has MDR TB, compared
nutritional intake, and low social economy condition.20
to male, so the risk of bacterial infection transmission
is higher in female.28 This result also found in Pelaquin Pure tone audiometry testing is used to monitor
et.al study and WHO data survey on 2015.2,29 Pelaquin the change of hearing threshold due to Kanamycin
study stated that gender does not affect the ototoxic effect therapy. A study conducted by Rakhmawati also shows
of Kanamycin in MDR TB therapy and there is no direct a decrease on sensorineural hearing function from
correlation between MDR TB incidence and gender.29 frequency 4.000 Hz to 8.000 Hz.7 Other study conducted
by Mustikaningtyas shows that SNHL after Kanamycin
Based on age group, this study conclude that MDR
therapy happens in several level (48% mild, 24%
TB cases occur mostly on productive age (23 – 46 years
moderate, 4% moderate‑severe, 1% severe and 15%
old). This result was supported by Rakhmawati and
very severe).30
Reviono et.al study that also found that MDR TB cases
most likely occur on age 20 – 50 years.7,8 Medical record Baseline data, consist of HFA, tympanometry,
data at Dr. Hasan Sadikin General Hospital, Bandung, speech audiometry, and OAE, should be recorded before
Indonesia on 2016 stated that MDR TB mostly happen administration of ototoxic therapy to determine the
in age group 25‑54 years.4 Productive age have higher hearing threshold. Pure tone audiometry is the only exam
working time than other age group, which may affect that still used before administering ototoxic therapy.26
the obedience for taking medicine, which then lead to
drug resistance. Productive age also has more contact Early stage of Kanamycin therapy does not exhibit
to different people in work, school, or other activity, so hearing problem on speech frequency (500 – 4.000 Hz),
the risk of bacterial transmission is higher and could so not many patient realized that hearing problem is
influence the incidence of MDR TB.28 already happened. HFA exam can be useful for early
detection of hearing problem, so further and more severe
Kanamycin is known for its side effect damaging condition can be prevented.14
outer hair cell of cochlea. This study used DPOAE on
frequency ranged 1,500 Hz to 8,000 Hz which was Table 3 showed a tendency of diminishing level of
tested prior and 3 weeks after the therapy begin. The GPx‑1 level after Kanamycin therapy, although it is not
result was most of the study subject exhibit “refer” statistically significant. This may result from a minimal
value, which indicates damage at cochlear cell hair. number of samples. On this study, decreasing level of
Other study by Mustikaningtyas also exhibit the same GPx‑1 level is more likely to be lower on “refer” value
result.25,30 DPOAE test could provide initial data of ear compared to “pass” value ear after therapy, whereas
hearing condition and early detection of ototoxicity. GPx‑1 level is higher on “refer” value ear compared to
Reavis et.al stated that DPOAE could detect around “pass” value ear before therapy. This may result from
78% of hearing problem cases, which then confirmed higher exposure of ROS on “refer” value ear cochlea
using HFA. Other study also stated that DPOAE test is as an effect of intracellular defense, which then lead to
sensitive in monitoring of ototoxicity caused by drugs.28 an increase in GPx‑1 level at the beginning to balance
ROS level. This mechanism will end at some point due
MDR TB infection is a chronic infection, marked by a to maximal compensatory effect of GPx‑1 enzyme, so
decrease in one of antioxidant enzyme. Study of Alli et.al the imbalance of ROS and antioxidant enzyme is no
and Madebo stated that the antioxidant enzyme known more tolerable, which lead to the damage of cochlear
to be decreased by chronic infection is GPx‑1.16,17 This hair cell.14,23
study found that GPx‑1 level is significantly decrease
after 3 weeks therapy of Kanamycin. ROS production Table 5 shows that GPx‑1 level is significantly
happens continuously inside the cell, together with a related to SNHL. Low GPx‑1 level decreasing the
decrease in antioxidant production, which results an capability of this enzyme to eliminate ROS, especially
imbalance level of antioxidant and ROS. This imbalance in basal area of cochlea.31 This phenomenon is because
leads to DNA, cell membrane, cell protein and kinase GPx‑1 level in basal area of cochlea is lower than in
616 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
apex area, causing basal area to be more vulnerable.15 7. Caminero J, Sotgiu G, Zumla A, Migliori G. 2010.
Study conducted by Sharma et.al showed that 18 MDR Best‑drug Treatment for multidrug‑resistant and
TB patient that is given Kanamycin therapy for 6 weeks, extensively drug‑resistant tuberculosis. Lancet
develop sensorineural hearing problem, 2% on the first Infect Dis. 2010;10:621−9.
week and 12% after 6th week. Mostly having bilateral 8. Shim Ts, Jo Kw. Medical treatment of pulmonary
hearing problem.25 multidrugs‑resistant tuberculosis. Infect Chemoter.
2013; 45(4):367−74.
The limitations of this study were the fact that
GPx‑1 examination performed with ELISA which only 9. Liu H, Ding D, Jiang H, Wu X, Salvi R. Ototoxic
saw serum levels or amount of the enzyme, but not the destruction by Co‑administration of Kanamisin and
activity of the enzyme. Ethacrynic acid In Rats. Jzus. 2011;12:853−61.
10. Huth ME, Ricci AJ, Cheng AG. Mechanism of
Conclusion Aminoglycoside Ototoxicity and Targets of Hair
There is a significant correlation between GPx‑1 Cell Protection. Int J Otolaryngol. 2011;14:314−55.
level and SNHL condition proceeding Kanamycin 11. Lubos E, Loscalzo J, Handy D. Glutathione
therapy on MDR TB patient, characterized by a decrease Peroxidase‑1 in Health and disease: From
in GPx‑1 level and an increase in hearing threshold on Molecular to Therapuetic Opportunities. Antioxid
subjects after administration of Kanamycin therapy. Redox Signal. 2011;15:1957−69.
12. Margis R, Dunand C, Texeira FK, Pinheiro MM.
Conflict of Interest: There was no conflict of
Glutathione peroxidase family ‑ an evolutionary
interest in this study.
overview. FEBS J. 2008;275:3959−70.
Ethical Clearance: The ethical clearance is granted 13. Ohlemiller K, Macfaden S, Ding D. Targeted
from KEPK, Dr Hasan Sadikin General Hospital, Mutation Gene for Glutathione Peroxidase Increase
Bandung no.LB.04.01/A05/EC/033/II/2017. Noise Induced Hearing Loss in Mice. JARO.
2000;1:243−54.
Source of Funding: This study was supported by
14. McFadden Sl, Ohlemiller K. The influence of
the authors.
Superoxide Dismutase & Glutathione Peroxidase
References Deficiency on Noise induce Hearing Loss in Mice.
Noice Health. 2001;3:49−64.
1. Sharma R, Yadav R, Sharma M, Saini V. Quality of
15. Kil J, Pierce C, Tran H, Gu R. Ebselen treatment
Life of Multi Drug Resistant Tuberculosis Patients:
reduces noise induced hearing loss via the mimicry
a Study Of North India. Acta Medica Iranica. 2014;
and induction of glutathione peroxidase. Hear Res.
52:448−53.
2006:44−51.
2. World Health Organization. Global Tuberculosis
16. Alli J, Kehinde A, Kosoko A, Adenowo O.
Report. Geneva. WHO. Switzerland.2015.
Oxidative Stress and reduced vitamin C and E level
3. Pusat Data dan Informasi Kementrian Kesehatan associated with Multi drugs Resistant Tuberculosis.
RI. Tuberkulosis. 2015. Jakarta. Kemenkes RI. JTR. 2014;2:52−8.
2015.
17. Madebo T. 2003. Circulating antioxidants and lipid
4. Unit Rawat Jalan Rumah Sakit Hasan Sadikin. peroxidation product in untreated tuberculosis in
2016.Data Rekam Medis. RS.Hasan Sadikin Ethiopia. Am J Clin Nutr;78:117−22
Bandung.RSHS.
18. Le Prell C. G DC, Rudnick E.W, Nelson M.A,
5. Rakhmawati L, Agustian R.A, Wijana. Peluang Deremer J.S, Prieskorn DM, Miller J.M. Assessment
Kejadian ototoksisitas pada penggunaan kanamisin of Nutrient Supplement to Reduce Gentamisin −
dalam pengobatan tuberkulosis resisten obat ganda Induced Ototoxicity. JARO. 2014;15:375−93.
selama 1 bulan. MKB. 2015;47(4):224−30.
19. Jiang H, Sha S, Forge A, Schact J.
6. Sub Direktorat Tuberkulosis Direktorat Caspase‑Independent Pathway of Hair cell death
Jenderal Pengendalian Penyakit dan Penyehatan induced by Kanamycin In vivo. cell death differ.
Lingkungan. Pengendalian TB resisten Obat. 2006;13:20−30.
Jakarta. Depkes RI.2011.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 617
20. Dugal P, Sarkar M. Audiologic monitoring of Ototoxicity monitoring. Am Ad Audiol. 2009:1−25.
Multi Drug Resistant Tuberculosis Patients on 26. Deaval G, Martin E, Horner J, Roberts R.
Aminoglycoside Treatment with Long Term Drug‑induced Oxidative Stress and Toxicity. J
Follow Up. BMC ENT Dis. 2007;7:1−7. Toxicol. 2012;12:1−13.
21. Erlinda E, Purnami N, Supriyadi. Correlation 27. Liu Q, Shao Y, Song H, Li G. 2013. Rates and risk
between superoxide dismutase serum and factors for drug resistance tuberculosis in Nothern
sensoryneural hearing disorder in patient with China. BMC pub health. 2013;13:1−7.
multi drug resistance tuberculosis. Folia Medica
28. Peloquin C BS, Nitta A, Simone P, Goble M.
Indonesiana. 2013;49:42−50.
Aminoglycoside Toxicity: daily versus Thrice
22. Sagwa E, Ruswa N, Mavhunga F, Renie T, Leufkens Weekly Dosing for Treatment of Mycobacterial
H. Comparing amikacin and kanamycin‑induced Disease. Clin Infect Dis. 2004;11:1538−44.
hearing loss in multidrugs ‑resistant tuberculosis
29. Mustikaningtyas E, Purnami N. Hearing disorder
treatment under programmatic conditions in
in multidrug‑ resistant tuberculosis patients at
Namibian retrospective cohort. BMC Pharmacol
the outpatients unit, pulmonary departement,
Toxicol. 2015;16:36‑45.
DR Soetomo Hospital Surabaya. Folia Medica
23. Sharma V, Bhagat S, Verma B, Singh R. Indonesiana. 2013;49(4):263−7.
Audiological Evaluation of Patients Taking
30. Klemens J M, Hughes LF, Somani S, Campbel K.
Kanamycin for Multidrug Resistant Tuberculosis.
Antioxidant Enzyme Levels Inversely Covary with
Iran J Otol. 2016;28(3):203−8.
Hearing Loss after Amikacin treatment. J Am Acad
24. Durrant JD, Campbel K. Ototoxicity monitoring. J Audiol. 2006;43:134−42.
Am Acad Audiol. 2009:1­−25.
31. Kohza S. Ototoxicity in Tuberculosis treatment in
25. American Academy of Audiology. Position South Africa: Exploring the current status. Afr J
Statement and Clinical Practice Guidelines: Pharm Pharmacol. 2013;7:2140−5.
618 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01

Post‑Traumatic Growth with Police Officer: System Review

(Focused on Korean and Foreign Studies)

Seung Woo Han1

1College of Emergency Medical Technology, Kyungil University

Abstract
Purpose: The purpose of this study was to analyze literature related to post‑traumatic growth with police
officer. Method: Systematic review of studies published were conducted through a vatiety of databases such
as Ovid‑Embase, Ovid‑Medline, The cochrane library, Pubmed, RISS. The research terms included Police
officers, Police, Trauma, Posttraumatic growth, Growth. Results: All studies were correlation analysis. In
the Korean researches, PTG was positively correlated with self‑esteem, problem focused coping, emotion
focused coping, social support, self‑disclosure and deliberate rumination. In the foreign researches, PTG
was correlated with thriving, resilience, events involving threat, personal relationship stress, trauma severity,
life stress, and gratitude. Demographic variables such as Female, White were also associated with PTG.
Conclusion: To improve post‑traumatic growth of police officers, strategies to increase stress coping, social
support, are needed. Strategies to decrease stress, trauma and PTSD symptoms should be developed.

Keywords: Police officers, Police, Post‑traumatic, Growth, Review literature as topic.

Introduction by traumatic events, such as depression, anxiety.3

However, not all people will be led to the post‑traumatic
The increases in crime and violence in Korea may
stress after experiencing traumatic events, and even
have a great impact on the life and safety of police
if they experience the same trauma, most people will
officers, and according to the statistics of the National
overcome it well, sometimes experiencing physical and
Police Agency, of 9,552 on‑duty‑injured people for the
mental growth.4 In other words, they may experience
last five years, the assaulted injuries, traffic accidents,
positive psychological changes that would be perceived
and negligent accidents accounted for 97% of the total
after the traumatic event or crisis, and such changes
number of on‑duty‑injured people.1 Particularly, these
are called as the posttraumatic growth (PTG).5 The
traumatic events will be directly linked not only to the
positive psychological change, mentioned here, may
police officers’ lives but also to the protection for the
mean a genuine positive change that transcends the
lives of the people. In DSM‑IV (1994) of the American
psychological functioning level and the self‑awareness
Psychiatric Association, the trauma cases were extended
level of life – simply beyond physical and psychological
to direct or indirect experiences that may threaten
functioning levels prior to trauma.6 Further, rather than
physical well‑being, including life threats, serious
the focus on the physical and pathological symptoms
injuries, striking events and so on.2The experiences
which have been induced by the event itself, mentioned
of various traumatic events, such as witnessing of the
in PTSD, the posttraumatic growth implies a more
murder scene, usage of guns, and violence during the
comprehensive concept focusing on the psychological
suppression process, which should be undergone on
and subjective response, the individual internal‑strengths
duty, cause the anxiety, pain, and trauma to the relevant
and adaptive aspects, which would be experienced in the
event. These various traumatic experiences lead to
event experiences.7
Posttraumatic Stress Disorder (PTSD).
These positive changes had been diversely interpreted
Accordingly, in the meantime, the studies on
by each scholar, which had been used in various terms,
post‑traumatic stress have been actively conducted,
such as discovery of benefits, stress‑related growth, etc.,
which have focused on negative physical and
by the 1990s, but Calhoun and Tedechi suggested the
psychological experiences and symptoms, accompanied
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 619
terminology of ‘Posttraumatic Growth’, different from As all the primary studies included in the literature
their concept.8,9 Examining the research trend on the review of this study are the study analyzing correlations,
posttraumatic growth in the meantime, the initial studies the quality evaluation on the literature was conducted
on posttraumatic growth have been performed in the by utilizing the ‘Quality Assessment and Validity Tool
field of psychology, but in recent years, the research has for Correlational Studies’ which was used in the existing
been actively conducted in nursing, medicine, etc., as the study of Wong and Cummings.10
interest in prevention of diseases and health promotion
increases.3 In most precedent studies, the studies Results
concentrating on the posttraumatic growth for specific Based on the literature search criteria of this study,
disease subjects including cancer patients, women the total number of retrieved literature was 2683 units,
experiencing physical violence, the subjects who have and of these, 420 duplicate literature units were excluded.
experienced war have been conducted. However, the Among 2263 theses by excluding 420 theses, 351 theses
posttraumatic growth studies for high‑risk occupational related to PTSD and 407 literature units were left by
groups experiencing various traumatic events, like excluding 505 literature units which were not related to
police officers, fire‑fighting officers, and prison officers, the subject, after reviewing abstract, titles and contents.
are in very short. Of them, in the posttraumatic growth, by excluding 322
Thus, this study is going to search for and then, theses which were studied on the samples not related
systemically investigate various variables related to the to police officers of the subject of this study, 8 review
posttraumatic growth of police officers. theses, 18 qualitative research theses, 23 experimental
theses, 4 non‑English theses, and lastly, 11 literature
Study Method units which were retrieved as the poster‑presented
literature, the final 24 theses were selected. 24 literature
Selection of Searching Database: In terms of units were systematically analyzed by 2 researchers, and
searching, the literature search started from 1996, when if the exclusion was not identical, they discussed it until
the posttraumatic growth was developed and the term they reached the agreement.
of the original author began to be used, and all the
literature associated with the related keywords and the Discussion
like were searched by January 2018 based on the search
date. In order to conduct the systematic literature review In this study, with respect to the correlations between
of this study, researcher collected studies focusing variables related to posttraumatic growth of police
on the posttraumatic growth aimed at police officers. officers, it was found in Koreanstudies that self‑esteem,
In this study, Pubmed, Ovid‑medline, Ovid‑Embase problem‑centered coping, emotion‑centered coping,
and The cochrane library were used as the overseas self‑exposure, social support, and intentional rumination
database and RISS (Korean/English) as the Korean one. had a significant correlation with posttraumatic growth.
The research objects included Police officers, Police, These results are in agreement with the study21 that the
Trauma, Posttraumatic growth, and Growth. In addition, higher self‑esteem becomes, the higher posttraumatic
the literature search was limited to articles providing growth is, and since self‑esteem correlates with positive
abstract and full text. cognition control strategies, it is considered that it has
the significant correlation with posttraumatic growth,
Literature Screening and Quality Assessment: as a factor of protection and internal growth to control
Based on the literature search strategy, all literature negative emotions in the process of accepting events
retrieved by each database was merged and then, the after experiencing traumatic events. In other correlation
duplicate literature was removed. After the elimination studies, problem‑centered coping and emotional‑centered
of duplicate literature, the studies that did not satisfy the coping also showed a significant correlation with
core questions of this study were excluded through the posttraumatic growth of police officers. This suggests
titles and abstracts of the primary study. The primary that the adaptive mechanisms and responses will vary
study, which was unclear to judge whether it might be depending on the stress coping strategies used by
selected or excluded or which fully met the selection individuals, even if they may experience the same trauma.
criteria, based on the title and abstract, was judged by In the precedent study22, they stated that if the negative
securing the full text. emotions, such as trauma and stress, was controlled
620 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
well, and the emotion‑centered coping was well exerted It suggested that in overseas studies, Positive variables,
after the traumatic experience, so that problem‑centered such as prosperity and resilience, and negative variables,
coping, one of the active coping strategies, was utilized like stress and trauma, were found to be more variously
more, it would be in charge of the responses for related to posttraumatic growth than in domestic ones,
well‑understanding of their own psychological emotions as a variable related to posttraumatic growth of police
and expression of their emotions. Therefore, the stress officers. Prosperity and resilience were found to be
coping strategies, such as problem‑centered coping and significantly correlated with posttraumatic growth
emotional‑centered coping, after traumatic events, will be in the precedent theses. In the positive psychology,
served as important variables to induce the posttraumatic the constructively adaptive ability, well‑being, and
growth. Self‑exposures were also established to have a individual strengths focused on the prosperity of
significant correlation with posttraumatic growth, and humans, and in the self‑formation and prosperity theory,
in the precedent study15, it was said that those who Frederikson24 argued that the positive emotions, such
actively engaged in self‑disclosure were more likely to as prosperity, would undergo a process to promote
participate in cognitive processes related to growth than posttraumatic growth. In addition, referring to resilience
those who did not. It was confirmed that self‑exposure as one of coping abilities when confronting a crisis after
was statistically related to posttraumatic growth as an generally experiencing a traumatic event, he stated that
important factor of psychological recovery in the growth this had a static correlation with posttraumatic growth
of trauma experience. In the precedent studies15,16,17, causing less psychological trauma in crisis. Finally, the
social support and intentional relativity also showed a appreciation, as a positive variable, corresponded to the
significant correlation with posttraumatic emotions. study results25suggesting that the higher the appreciation
In precedent research23, when social support was well tendency, the higher the posttraumatic growth.
supported after experiencing the traumatic event, it was
considered to be an important factor in well coping with Conclusion
stress situations and functioning for the psychological The purpose of this study was to investigate and
adjustment in adverse situations, which was regarded as explore the precedent literature on posttraumatic growth
an important parameter to induce posttraumatic growth aimed at police officers, to establish the variables related
after experiencing the traumatic event. Finally, intentional to the posttraumatic growth of Korean and abroad police
rumination was found to have a significant correlation officers, and at the same time, to provide baseline data
with posttraumatic growth, which was considered as an for the development of programs that can promote
important parameter to promote posttraumatic growth to posttraumatic growth. In the present study, as a result
bythinking carefully about the cast through that event of investigating the literature that have been created
and discovering the positive meanings or benefits from since 1996 when the term of posttraumatic growth
that case, rather than that the trauma experience was was firstly used, in the Korean theses, self‑esteem,
not just regarded as a negative event23. As a result of problem‑centered coping, emotion‑centered coping,
precedent studies of such Koreanstudies, the valuables self‑exposure, social support, and intentional rumination
significantly correlated with posttraumatic growth was were identified and in overseas theses, prosperity and
found to be self‑esteem, problem‑centered coping, resilience, appreciation, stress caused by traumatic events
emotion‑centered coping, self‑exposure, social support, threatening the individual live and human relationships,
and intentional rumination. By getting out of these severity of trauma and PTSD symptoms, relation stress,
phases to explore the relations with valuables, the future work stress, and depression were confirmed.
research will provide the baseline data for developing
programs to promote a positive and healthy direction Conflict of Interest: The author(s) declared no
and posttraumatic growth of police officers, and be potential conflicts of interest with respect to the research,
helpful as an important factor in conducting a more authorship, and/or publication of this article.
realistic and multifaceted research. In overseas theses,
as the posttraumatic growth‑related variables, prosperity Source of Funding and Ethical Clearance: The
and resilience, appreciation, traumatic event threatening researchers received no financial support for this paper.
the personal life, stress induced from human relations, This study was a literature study using secondary data,
severity of trauma, PTSD symptoms, relationship and did not harm the subject ethically.
stress, working stress, and depression were identified.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 621

References 12. Song, SH, Lee, HS, Park, JH, Kim, KH. Validity
and Reliability of the Korean Version of the
1. Korean national police agency. 2015 Police
Posttraumatic Growth Inventory. Korean Journal
Statistical Yearbook. [cited 2016 November 23].
of health psychology, 2009;14(1):193‑214.
Available from http://www.police.go.kr/portal/
main/2015. 13. Han, SW, Choi, ES. The Effects of Self‑esteem
and Problem Focused Coping on Post‑traumatic
2. American Psychiatric Association. 4th ed.
Growth among Police Officers. Korean Journal of
Diagnostic and statistical manual of mental
Occupational Health Nursing, 2016;25(3):141‑147.
disorders. Washington, DC: Author; 1994.
14. Han, SW, Kim, HS. Factors Influencing
3. Calhoun, LG, Tedeschi, RG. The post‑traumatic
Post‑Traumatic Growth with police officer. Crisis
growth inventory: Measuring the positive
and Emergency Management. Theory and Praxis,
legacy of trauma. Journal of Traumatic Stress.
2015;11(3):189‑205.
1996;9(3):455‑471.
15. Jeon, YJ, Bae, JK. The effects of self‑disclosure,
4. Choi SM. Exploration of posttraumatic growth
social support and intentional rumination
variables [Doctoral dissertation]. Korea University;
on posttraumatic growth. Journal of Human
2008.
Understanding and Counseling. 2013;34(2):215‑28.
5. Calhoun, LG, Tedeschi, RG. Posttraumatic growth:
16. Jung, YK. A Study on the Structural Relationship
Future directions. In Posttraumatic growth: Positive
of Influential Factors for Post‑traumatic Growth of
changes in the aftermath of crisis 1998:215‑238.
Police Officers [Doctoral thesis]. Seoul: Dongguk
Mahwah, NJ: Lawerence Erlbaum Associates
University; 2015.
Publishhers.
17. Jung, YK, Choi, ER. A study on influential factors
6. Maercker, A, Zoellner, T. The janus face of
of post traumatic growth in Korea Police Officers:
self‑perceived growth: Toward two‑component
Focus on police officers in the metropolitan
model of post‑traumatic growth. Psychological
cities. Korean Police Studies Association,
Inquiry.2004;15:41‑48.
2014;48(0):243‑76.
7. Calhoun, LG, Tedeschi RG. The foundation of
18. Chopko, BA., Palmieri, PA., Adams, RE.
posttraumatic growth: An expanded framework. In:
Associations between police stress and alcohol
Calhoun LG & Tedeschi RG, editors. Handbook
use: Implications for practice. Journal of Loss and
of posttraumatic growth: Research and practice.
Trauma, 2013;18(5):482‑497.http://dx.doi.org/10.1
Mahwah, NY: Lawrence Erlbaum Association;
080/15325024.2012.719340.
2006;1‑23.
19. Chopko, BA, Palmieri, PA, Adams, RE.
8. Jeon, YJ, Bae, JK. The Effects of Self‑Disclosure,
Relationships among traumatic experiences, PTSD,
Social Support and Intentional Rumination
and posttraumatic growth for police officers: A path
on Posttraumatic Growth. Journal of Human
analysis. Psychological Trauma: Theory, Research,
Understanding and Counseling . 2013; 34(2):
Practice, and Policy, 2017;10(2):183‑189. http://
215‑228.
dx.doi.org/10.1037/tra0000261
9. Calhoun, LG, Tedeschi, RG.The Foundations
20. McCanlies, EC, Mnatsakanova, A, Andrew, ME,
of Post‑traumatic Growth; New Considerations.
Burchfiel, CM, Violanti, JM. Positive psychological
Psychological injury, 2004;15(1):93‑102.
factors are associated with lower PTSD symptoms
10. Wong, CA, Cummings, GG. The relationship among police officers: post Hurricane Katrina.
between nursing leadership and patient outcomes: Stress and Health, 2014;30(5):405‑415. http://
A systematic review. Journal of Nursing dx.doi.org/10.1002/smi.2615.
Management, 2007;15:508‑521. http://dx.doi.
21. Carver, Charles S, Scheier, Michael F, Weintraub,
org/10.1111/j.1365‑2834.2007.00723.x.
Jagdish K., et al. Assessing coping strategies: A
11. Norlander, T, Schedvin, HV, Archer, T. Thriving theoretically based approach. Journal of Personality
as a function of affective personality: relation to and Social Psychology,1989;56(2):267‑283.
personality factors, coping strategies and stress.
22. Smyth, JM., Hockemeyer, JR., Tulloch, H.
Anxiety, Stress & Coping, 2005;18(2):105‑116.
Expressive writing and post‑traumaic stress
622 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01
disorder: Effects on trauma symptoms mood states, positive psychology: The broaden and build theory
and cortisol reactivity. British Journal of Health of positive emotions. American Psychologist,
Psychology, 2008;13: 85‑93. 2001;56: 218‑226.
23. Yu HJ. A study of the structural relationship 25. Kim, E, Kim, JK..The Effect of Grateful Disposition
between variables that influence posttraumatic on The Posttraumatic Growth ‑ The Mediating
growth [Doctoral dissertation]. Pusan National Effect of Social Support and Ego resilience .The
University;2012. Korean Psychological Association, 2015;8:
24. Fredrickson, BL. The role of positive emotions in 261‑261.
 Indian Journal of Public Health Research & Development, January 2020, Vol. 11, No. 01 623

HIV Stigma among Clinical Medical Students in

East Java, Indonesia

Firas Farisi Alkaff1, Adila Taufik Syamlan2, Presstisa Gifta Axelia2, Jovian Phillip Swatan2, Sulistiawati3
1Departmentof Pharmacology, Faculty of Medicine Universitas Airlangga, 2Faculty of Medicine Universitas
Airlangga, 3Department
of Public Health, Faculty of Medicine Universitas Airlangga, Surabaya, Indonesia

Abstract
Background: HIV‑related stigma is considered as major barrier for controlling the spread of HIV/AIDS.
People living with HIV/AIDS (PLWHA) that experienced stigma were less likely to disclose their HIV
status to their sexual partners and health care professionals. Medical students as the future physicians are
expected to be at the forefront to prevent and treat HIV/AIDS. This study aim