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Volume 8 Number 4 October-December 2017
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Indian Journal of Public Health Research and Development
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Indian Journal of Public Health Research &

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Contents
Volume 89,Number
Number4 7 July 2018
October-December 2017
1. Obesity as an Actual Problem: Spatial Research in Kazakhstan (2011-2016) .............................................. 1

FursovNepotism
1. Detention, Roman Аlexandrovich
and Truancy as(Fursov RА),
Predictors Ospanov Oral
of Workplace Bazarbaevich
Deviance (Ospanov OB),
in.....................................................................01
Fursov Alexandr Borisovich (Fursov AB)
Service Organizations: India's Experience
Sainath Malisetty, K
2. Medication Vasanthi
Errors Kumari Care Units in a Tertiary Hospital ................................................................... 8
in Critical
Anil Pandit, Jyoti Joshi, Megha Koul
2. A Comparative Study of Satisfaction of Midwives and Mothers of Adherence to Patient Rights..................................07
3. Knowledge,
Maryam Perception
Soheily, Akram Peyman,and Psychosocial
Beheshteh Tabarsy Preparedness for Menarche among Adolescent Girls of
Udupi District, Karnataka ............................................................................................................................ 13
Charmaine
3. Indian Crystal
Diabetes Risk Salins,
Score Anjalin of
for Screening D’Souza,
UndiagnosedMalathi G Nayak
Diabetes...................................................................................13
Individuals of Eluru City, Andhra Pradesh, India
4. Measles Rubella Immunization Campaign: Challenges Faced in an Urban Area of Chennai .................... 18
Chandrasekhar Vallepalli, K Chandra Sekhar, U Vijaya Kumar, P G Deotale
Barathalakshmi J, Rashmi Gour Patel, Kanimozhi S, Sudha V
4. Awareness
5. Factorsand Predictorsthe
Influencing of PCOD among Undergraduate
Sleep Quality Students ..............................................................................18
among the Undergraduate Nursing Students of Udupi District ...... 24
CAnn Mary
Sally Nelson,
Jane Lekha
J. K., Viswanath,
Binu Margaret,Anju Philip T Chandy
Priyanka
5. 6. Identification
The Effectiveness ofofMindfulness
Positive Deviant
on the Behaviours
Reduction ofRegarding Infant and Young Child Feeding (Iycf)
Anxiety...........................................................................................23
among Rural
and Depression Mothers Women
of Divorced for Improving Child Health and Nutrition-A Cross Sectional Study ........................ 30
Chitrarpita
Yasamin Hojatifar,Saha, Vanisha
Mina Hosein S Nambiar
Zadeh, Fariborz Dortaj
7. The Compliance to Occupational Radiation Safety to the Baggage Fluoroscopy System in

6. A Study on Clinical Profile and Trend in Suicide Attempters in Psychiatry Consultation...............................................28
International Airport .................................................................................................................................... 34
D Naveen Kumar
Siti Daryati, M. Irwan Katili, Jeffri Ardiyanto, Rini Indrati, Gatot MW, Ismi Rajiani
7. A8.
Study
The of Organo-phosphorous
Nutrition Care Process Compound Poisoning
(NCP) Impact with Reference
to the Dietary to....................................................................33
Behavior of Diabetes Mellitus Patients ............ 38
Blood Sugar
Setyo and Pseudocholinesterase
Prihatin, Sri Noormintarsih,Levels
Ana Yuliana Rahmawati, J. Supadi, Asep Tata Gunawan, Ismi Rajiani
Nithinkumar S Kadakol, Sunilkumar S Biradar, Smitha M, Mallikarjun KBiradar
9. Association between Maternal Folate Intake and Polymorphism MTHFR A1298C as
Risk Factor
8. Prevalence of Non-Syndromic
of Intestinal CleftinLips
Parasitic Infections ..................................................................................................
School 43
Going Children in...........................................................................37
Yayun
Rural AreasSiti Rochmah,
of Hapur Stefani
District, UP, Harumsari,
India Agung Sosiawan, Ismi Rajiani
KamyaVerma, Krati R Varshney, Sanjeev Dimri, S P Garg
10. Prevalence of Postural Problems among the Nurses in Chennai ................................................................. 48
Jinu Merlin Koshy, Amit Biswas, Sreelekshmi, W M S Johnson, Archana R, Bini Markose
9. Study of Osteoporosis in Women of Malwa Region of Punjab............................................................................................41
11. Applications
Veerendra of Internet of things in Non-Communicable Disease Prevention and Management:
Choudhary
A Review ..................................................................................................................................................... 55
10. The Legia
Effectiveness
Emanthaof Mindfulness-Based
Shabong Lyngdoh Group Therapy on Reducing Internet...............................................................44
Addiction and Increasing the General Health of Adolescent Girls
12. Mandibular Canine Index(Mci) Not an Accurate Tool for Gender Identification:
Nasrin Rahimi Shadbad
Results from a Systematic Review and Meta-Analysis ............................................................................... 61
11. RoleElizabeth Dony, Mamatha
of Social Support G Styles
and Coping S Reddy, Pradnya
in Mental Kakodkar
Health of Women Who Apply for Divorce..................................49
Farhad Asghari, Hajar Ramazannia
II
13. Histopathological Evaluation of White Lesions–An Institutional Observational Study ............................. 70

Roopa Madalli, Mamatha GS Reddy, Neeta Bagul, Supriya Kheur
14. A Study on Factors Influencing Competency of Pharmacists in a Tertiary Care Hospital .......................... 75
Marsha Augustin, Samuel N J David, Aileen J, G Devakumar
15. Demographic Profile of Blood Donors: A Study of a Tertiary Care Medical College Hospital
Ambala Facility Based Study ...................................................................................................................... 80
Nazuk Razdan, Randhir Kumar, Anu Bhardwaj
16. Analysis of Factors Affecting Stunting Events in Underwrapped in Cempaka Velocity Mining Area
Kota Banjarbaru in Year 2017 ..................................................................................................................... 85
Husaini, Lenie Marlinae, Ratna Setyaningrum, Dian Rosadi, Anggun Wulandari, Nida Ulfah, Hastaniah
17. Analysis of Impact of Use of Incident Thickness in Pregnant Woman in Area of Malaria
(Gunung Raja Mentawe Village Districts of Tanah Bumbu South Borneo) ............................................... 90
Lenie Marlinae, Syamsul Arifin, Nida Ulfah, Sudayat Sudarmawan, Siti Aina Putri Warsono
18. Organ Failure and Quality of Life: A Study among Patients Undergoing Maintenance Hemodialysis ...... 94
Nishtha Mishra
19. Legal Challenges in Blood Transfusion Process in India .......................................................................... 100

Rubi Talukdar, Prabir Kumar Pattnaik
20. Substance Use among Students in a Private Medical College, Southern India-A Cross Sectional Study 105
S. Rajini, C. Kameshvell, Kannan, Alli2, V. Tamilselvi
21. Nutritional Status of Children Residing at an Orphanage in Puducherry ................................................. 109

K. Kannan, S. Rajini, Kameshvell C, G. Jayalakshmi, Jenith, Karthikeya
22. Study on Prevalence of Whatsapp Addiction among Medical Students in

a Private Medical College, Pondicherry ................................................................................................... 113
S. Rajini, K. Kannan, P. Alli, V. Tamilsevi
23. Prevalence of Stress in Young Urban Population in a City of Northern India .......................................... 117
Samir Chattopadhyay, Sushil Kumar Singh, Arvind K. Shukla
24. Effects of Socio-Demographic Factors on Prelacteal Feeding Practices among

the Lactating Mothers in Meerut City ....................................................................................................... 122
Pawan Parashar, Kiran Garg, Sameer Chattopadhyay, Arvind K. Shukla, Sartaj Ahmad
25. A Cross Sectional Study to Estimate Prevalence and Maternal Risk Factors with
Term Low Birth Weight Babies ................................................................................................................. 128
Sridhar. D, A. Sai Ram, P. Narasimha Reddy
26. Role of Videofluroscopy in Rehabilitation of Dysphagia−A Case Study .................................................. 135

Kevin Gautham M, Vijay Kuamr K V, Shankar V
27. System Modeling for Forecasting of Diabetes Prevalence ....................................................................... 139

Vinaytosh Mishra, Cherian Samuel, SK Sharm
28. Knowledge, Arv Access and Compliance of Plhiv before and after Providing Health Education
Based on Community Arv and Adherence Support Group (Caasg) in Bulukumba Regency ................. 145
Andi Suswani, AA Arsunan, Ridwan Amiruddin, Andi Zulkifli, S. Ariyanti
III
29. Obesity and Pulmonary Functions in Young Non Smoker Male of Shah Alam, Malaysia ....................... 151
Aniruddha Bhattacharjee, Ariitharan A/L Thygoo, S. Rammohon
30. Prevalence of Self Medication with Antibiotics among Medical Students of Barabanki ......................... 157
Ankur Shrivastava, Nidhi Shrivastava, Sandhya Mishra, Pankaj Mishra, Vijay Kumar Singh
31. Utility of Dundee Ready Educational Environment Measure for Evaluation of

Nursing Educational Environment in Iraq ................................................................................................. 162
Mohammed Jabarah AL-ZOBAIDY
32. Drivers’ Perception Towards Road Safety in Al Hilla City ....................................................................... 168
Amean Ajeel Yasir
33. MF-GF” Horizontal Distance as a Predictor of Sagittal Jaw Dysplasia

(A Cephalometric Cross Sectional Study) ................................................................................................. 172
Kasem Ahmed Abeas, Issam Merza Abdullah, Lamees Khudir Mohamed, Arkan Muslim Abd Al-kareem
34, The Anti- Fertility and Cytotoxicity Effects of Cyproterone Acetate and Phenolic Extract of
Hibiscusrosa Sinensis Linn Flowers in Male Albino Rats ........................................................................ 177
Al-Saily H. M., Al-Hady F. N. Al-Halbosiy, M. M.
35. Self-concept in Relation to Inheritance Blood Diseases among Adolescents in

Babylon Governorate–Iraq ........................................................................................................................ 182
Sahar Hasan Issa, Saja Hashim Mohammed, Abdulmadhdi A. Hasan
36. Cytotoxic and Apoptotic Effects of Phenolic Extract of Hibiscus Rosa Sinensis Linn
Flowers Against Cancer Cells And Normal Cells ..................................................................................... 188
Al-Saily H. M., Al-Hady F. N., Al-Halbosiy, M. M.
37. Prevalence, Control and Associated Factors of Hypertension in Rural Middle Aged Women of Kerala . 193
Sandhya GI, Anitha Abraham, Ramla Beegam
38. A Survey to Assess the Facility Access of People with Mobility Disabilities in King Abdulaziz Medical
City, Riyadh, Saudi Arabia ........................................................................................................................ 198
Fayz Al shahry, Jobby George, Winnie Philip, Amirah Ageil Al Shammari, Hend Faisal Al Qudaimi,
Sarah Saad Ghemlas
39. Evaluation of Prevalence of Exercise Induce Ecg Changes in 200 Patient with Diabetes Mellitus ....... 203
Arul Murugan S, Aravind C, Vishnupriya. G, E. Prabhakar Reddy
40. Parasitic Tea Scurrula atropurpurea (Blume) Danser Active Compound Potencies Towards
Inhibition of DNA Methylation in Cancer: An In Silico Study ................................................................. 206
Ni Luh Putu Eka Sudiwati , Tatit Nurseta, Mulyohadi Ali, Aulani’am Aulani’am,
Heru Santoso Wahito Nugroho
41. Revitalization of Posyandu as an Effort to Improve the Function and Performance of Posyandu ........... 210
Antarini, Heru Santoso Wahito Nugroho
42. Global Comparison of Ambulance Services in selected Countries and Feasibility to Have
Standardized Ambulance Services for India ............................................................................................. 216
Parag Rishipathak, Rajiv Yeravdekar, Prasad Rajhans
43. A Low Cost Wireless Patient-health Tracking System .............................................................................. 221

Mandeep Singh , Deepak Jain
IV
44. The Association of Risk Factors with Dental Caries in Primary School Children in Banjar Disrtict ....... 226
Rasuna Ulfah, Erida Wydiamala, Lenie Marlinae
45. Indonesian Rural Medical Internship: The Impact on Health Service and the Future Workforce ............ 231
Hardisman Dasman, Lillian Mwanri, Angelita Martini
46. Effectiveness of an Educational Program Concerning Nurse- Midwives Knowledge Concerning

SBAR (Situation, Background, Assessment, Recommendation) Tool Communication on
Maternal Health Documentation ............................................................................................................... 237
Sunduss B Dawod, Rabea M Ali, Ezedeen F Bahaaldeen
47. Assessment of Nutritional Status of Alcoholic Liver Disease (ALD) Patients ......................................... 243
Tripti, Neeru, Karuna Singh
48. Identification and Characterization of Non-Tuberculous Mycobacteria Isolated from

Extrapulmonary Tuberculosis Suspects by Heat Shock Protein 65 by PCR–RFLP ................................. 249
V Praveen Kumar, V Sreenivasulu Reddy, P Suresh, P Vamsi Muni Krishna
49. The Influence of Health Education to Change Domain Competencies Interprofessional Collaboration
on Handling of Malnutrition Case ............................................................................................................ 254
Risnah, Veni Hadju, Ridwan Amiruddin, Sukri Palluturi, Citrakesumasari, Untung Sujianto
50. Molecular Identification of Rapidly Growing Mycobacteria Isolated from Pulmonary Specimens
at a Tertiary Care Hospital in Pondicherry ................................................................................................ 260
V Praveen Kumar, V Sreenivasulu Reddy, P Vamsi Muni Krishna, P Suresh
51. Potential of Lactobacillus Strains with Antimicrobial Activity against Acinetobacter Baummanii ......... 265
Suresh P, V Sreenivasulu Reddy, V Praveen kumar, P Vamsimuni krishna
52. Dole-Dole Tradition in Health Seeking Behavior of Buton Society, Southeast Sulawesi ........................ 270
Andi Asrina, Sukri Palutturi, Andi Tenri
53. Salivary Diagnostics in Cardiovascular Disease–A Review ..................................................................... 275

Sunil M Eraly, Mithra N Hegde, Raksha Bhat, Preethesh Shetty, Aditya Shetty
54. Antibacterial Activity of Lactobacillus (LB) Strains Isolated from Goat Milk against ESBL Producing
E. coli Causing Wound Infections ............................................................................................................. 281
Suresh P., V. Sreenivasulu Reddy, V. Praveen kumar, P. Vamsimunikrishna
55. Analysis of Nuptiality Data through Life Table Approach ....................................................................... 286
Chitra Rani Chauhan, A. K. Maini, Ajay Bhagoliwal, Anju Gahlot
56. Prevalence of Group a Streptococcal Infection among Healthy School Children in Chennai .................. 291
B. Krishna Prasanth, S. Kalpana, N. Aravindha babu, K. M. K. Masthan, S. Bhuminathan
57. A Retrospective Study of Clinical and Ultrasound Correlation in the Diagnosis of Acute Appendicitis 294
N. Parthiban, N Sundharrajan, B. Krishna Prasanth, N Pavan Kumar, Thota Siddhartha
58. Association of HbA1c Levels with Body Mass Index in a Patient Diagnosed with
Polycystic Ovary Syndrome ...................................................................................................................... 298
Zeina F. Fuad, Enas Jaleel Alobaidy
59. Appraisal of Nurses’ Knowledge and Attitude Regarding Infection Control Measures ........................... 304
Dergham Majeed Hameed, Ali Hussein Ali Aldakheel, Sameer Razzaq Oleiwi
DOI Number: 10.5958/0976-5506.2018.00603.4
Obesity as an Actual Problem: Spatial Research in Kazakhstan

(2011-2016)
Fursov Roman Аlexandrovich (Fursov RА)1,2,3, Ospanov Oral Bazarbaevich (Ospanov OB)1,2,3,
Fursov Alexandr Borisovich (Fursov AB)1,3,4
Department of Endosurgery, Medical University of Astana, Astana, Kazakhstan, 2Society of Bariatric and
1
Metabolic Surgeons of Kazakhstan, 3Kazakhstan Association of Endoscopic Surgeons, 4Russian Academy

of Natural History
Abstract
Background: Obesity is a growing problem. The dynamics of this disease spreading is changing in different
regions, it is poorly investigated and, therefore, contradictory.
Objective: To scrutinize the spatial rates of obesity in various regions of Kazakhstan.
Methodology: The operation of preventive medicine clinics, family health centers on the study of obesity
rates was investigated. Furthermore, the relationship between the growth of diabetes and obesity with
population growth rates, demographic indicators in cities and rural areas was considered.
Results: Investigations demonstrated an epidemiological picture of obesity, diabetes and other pathologies
related to nutrition. The activities of 4 050 medical organizations has been studied since 2011.
Conclusions: The investigation revealed a stable growth in obesity, diabetes, metabolic and nutritional
disorders. The rates of diabetes and obesity according to the data of preventive medical observations in the
city are higher than in rural areas. The annual increase in obesity rates during the study period amounted to
3.9%. South-Kazakhstan, Astana and Almaty were identified as the regions with the highest obesity rates.
Keywords: Spatial research, Obesity, Diabetes, Demography, Family Health Centre
Introduction interconnection with endocrinological diseases, nutrition

deficiencies in respect of demographic and geographical
To decrease the morbidity in the Republic of features of the country, has not been investigated yet.
Kazakhstan (RK), the state has strengthened financial
support for preventive treatment medical organizations
Objectives of the research
for the last 5 years.1 The main function is to coordinate
medical specialists of Kazakhstan in the field of To scrutinize the spatial rates of obesity in various
diagnostics and prevention of various diseases.2,3 regions of Kazakhstan. To study the dynamics of these
indicators’ growth for the last 5 years, in comparison
Introduction/general information: Our observations
with diabetes mellitus.
on the development of the healthcare system in
Kazakhstan indicate that the coordination of efforts has
not yet reached the required level. Method of the research
Investigations are epidemiological,
The results of national statistics are significantly continuous (covering the entire territory of the
variable including international data. For example, the
state). They are carried out by means of mass
findings of the 5th national research in Kazakhstan
indicate that 31.2% of adults suffer from obesity4 whereas medical examination. In addition, the studies
the statistics of international observers indicate: “Obesity are descriptive (descriptive-evaluative) and
Adult incidence rate - 23.5%”.5 However, obesity rate in analytical.
2 Indian Journal of Public Health Research & Development,July 2018, Vol.9, No. 7
The body of data included the total number of the country promoting sanitary knowledge. The above
population living in the country in respect of the mentioned principles were pursued in our investigation
demographic growth. Cases of morbidity on the studied very consistently and precisely.
nosology and in the regions of Kazakhstan came to be in
the test group. The morbidity was investigated by means Results
of retrospective and prospective method. The analysis of
the dynamics of the epidemiological process was carried According to the research, in respect of the state
out selectively with respect to obesity and diseases statistics in 2016, 4 050 medical organizations were
related to malnutrition, diabetes. registered in Kazakhstan including outpatient –
polyclinics – 3 149 and hospitals - 901.
The objectives of the analysis: Statistic data has been
selected in accordance with the following criteria: the Based on the results of the first year of Program
diagnosed cases of obesity, diabetes, morbidity related realization, we have selectively conducted an experienced
to malnutrition in accordance with the International pilot analysis of medical staff activity in medical
Classification of Diseases (ICD-10); The demographic organizations in Astana and the surrounding suburbs. By
survey in the country during the last 5 years; the means of questioning, the opinion of 1 000 patients and
morbidity rate per 100 000 population. 125 doctors was inquired in the HFC. The research group
was interested in a mutual opinion (patients and doctors)
Statistical analysis: The processing of information was on the motivating aspects of their intercommunion, on
carried out with the help of “Medstat” and “Statistica the principles of medical staff activities and prospects of
10” software. The information was taken into account its realization. It was clarified that the medical staff of
from the statistic registers of all governmental and non- HFC preventive branches defined the main challenges of
governmental medical outpatient hospitals and clinics, their initial stage activities. They pursue the following
hospitals. During the statistic processing of information, principles: determiners of diseases related to the lifestyle
quantitative and qualitative statistical features were depend on the social environment. However, mostly
identified. they depend on the behavior of a person and, hence, can
be changed and the risk of morbidity development will
Continuous variables are expressed as the mean ± be significantly reduced.
standard deviation. The chi-square test was used to test
differences in categorical variables between the cases Based on the questionnaire results, the majority of
and controls, and analysis of variance (ANOVA) or the patients (85%) turned out to have common interests
Student’s t-test was used for comparisons of continuous with doctors’ principles. Besides this, in 77.2% of cases
variables. Spearman’s rank correlation and univariate they supported participate in preventive activities,
regression analysis were used to determine the strength and even involve other interested patients. The rest
of the relationship between obesity and diabetes. A of patients were skeptical in success of medical staff
significance level of P<0.001 was used in this test. intercommunion with patients in the framework of the
prevention program.
Methodological approaches to achieve the aim: For
the implementation of the State Healthcare Development 93.1% of medical staff is sure in close intercommunion
Program (SHDP) in the primary division of Healthcare and only 6.9% doubted in its effectiveness, particularly,
(namely, outpatient and polyclinic organizations), in patients’ discipline, for instance, refusal to harmful
Family Health Centres (FHC) were established.2,6,7,8 habits, behavior changing, etc. However, the main result
Their basic mission is to improve the coordinated efforts of the pilot analysis reported the support and successful
of the medical community in identifying and preventing realization principles of HFC preventive measures.7
risk factors of diseases. Three basic methods were used to investigate the
In section №3 of the SHDP, it was deduced that general morbidity:
the man’s health 50% depends on his or her lifestyle. zz Data on patient treatment (actual morbidity or
This provision is recommended to be taken into account primary morbidity, spread of diseases, sickness or
by medical staff while dealing with the population of general morbidity);
Indian Journal of Public Health Research & Development, July 2018, Vol.9, No. 7 3
zz Data on medical examinations (pathologic lesion); rural (45.9%).10,11,12 In addition, the population increase
over 5 years of the research turned out to be over 1.2
zz Data on causes of death.
million people or 7.47%. The annual growth rate, on
In some cases, the fourth additional method average, amounted to 1.5%.
(survey of population, questioning) was used. The
primary treatment of the patient in a medical institution The total morbidity (in absolute numbers) for all
and a morbidity identified by home sick call was classes of diseases listed in “ICD-10” over the five-year
considered as the observation element in measuring period increased only by 1%. However, a morbidity
the total morbidity in each year. To calculate the total related to endocrinological disorders, malnutrition and
incidence rate (TM), the following formula was used: metabolic disorders (E00-E89) increased significantly
TM=the total number of registered diseases in the by 19.7%. If this rate is compared with the population
reporting year×100 000/average annual population. growth, it turns out that it exceeds it by almost 2.6 times
(7.47% to 19.7%). Moreover, with further analysis of the
During the investigation, the demographic survey
statistical results (in terms of 100 000 people), it turned
(total population) of the country was analyzed. Besides
out that the endocrine morbidity with malnutrition and
this, the dynamics of demographic growth in Kazakhstan
and its relationship with the population health rates metabolic disorders increased by 13% namely from 3
was determined. It was revealed that the number of 745.1 to 4 232.7.
population by January 1, 2011 amounted to 16 442 000
The data analysis received from various regions of
whereas this rate increased to 16 675 400 by January 1,
Kazakhstan illustrated that the morbidity of diabetes
2012.9
(the number of diseases registered for the first time, per
However, at the end of 2016, the population reached 100 000 people) is gradually increasing. In addition, the
over 17 754.1. Urban population (54.1%) prevails over same is noted with obesity. (Table 1.)
It was revealed that the number of patients with Moreover, the investigation demonstrated the similar
diabetes mellitus, registered five years after the start growth with obesity. In addition, the dynamics of obesity
of the investigation, significantly and authentically growth in cities was significantly higher than in rural
increased: in rural areas by 19.2%, in cities by 2.7%. areas. Conversely, the specific gravity of diabetes and
obesity in relation to the total morbidity (in percentage) These incidence rates of diabetes and obesity in the
among urban population turned out to be lower than that regions of Kazakhstan were calculated and presented
of rural areas. by the regional boards. According to the results of our
additional analysis in relation of 2016, the incidence
According to the official data (published in the rates turned out to be somewhat higher. For instance, the
statistical volume on health in 2015), the average incidence rate of diabetes in early 2016 was 180.7 (per
morbidity of diabetes in Kazakhstan was 168.6 (per 100 000 people). But the morbidity of obesity, without
100 000 people). However, the morbidity of obesity in consideration of overweight patients, rose to the level of
relation of overweight people was 171.7 (per 100 000). 91.2 (per 100 000 people). (Table 2.)
The results are indicated for comparison at the The results of the analysis are visually represented
beginning and at the end of the investigation. Besides this, in color mapping (Fig. 1, Fig. 2).
the rate increase of morbidity in percentage in each region
during the observation period was determined (R., %).
Fig. 1: Morbidity of obesity in different regions of the Kazakhstan (2011-2016)
Fig. 2: Regions with a high incidence of obesity (2016 year)
Discussion can be estimated as somewhat paradoxical. However, to

explain it, it is necessary to take into consideration the
The results of a five-year investigation, such as the following peculiarities of state’s development.
incidence rate distinction in rural and urban areas, uneven
correlation of diabetes rate with the obesity growth, the Firstly, the specific gravity of identified patients in
different rates of obesity growth in Kazakhstani regions rural areas is increasing as a result of the extensive and
intensive activities of HFC medical staff. Moreover, it is co-authors from the Republican Center for Development
because of the active identification of overweight people of Healthcare, rates are noticeably different.16 Should
and their inclusion in statistical reports (where many Almaty, Pavlodar and Astana are referred to cities with
patients were not registered). a high extensive rate of obesity - 13.7%, the lowest
extensive obesity rates, according to the data of the
Secondly, this process occurs because of intensive authors, are registered in Atyrau (2,2%). Moreover,
migration of the population from rural areas to large cities researchers note that the main part of examinees are not
and it increases the total number of people (including aware of their exact weight and level of fatness. In their
healthy and sick people) in absolute numbers.13,14 conclusions, the authors of the report urge the medical
organizations of Kazakhstan: to strengthen preventive
Furthermore, the treatment rate of patients to medical
measures among the population; to organize activities
organizations in the cities is traditionally higher, which
explaining the harm of this disease for health; to instruct
also affects the statistical data. Population involvement
with regular nutrition and form a healthy lifestyle.
in preventive activities, prevention of morbidity
development, the enhancement of healthy lifestyle
increased the treatment of obesity patients to doctors Conclusions
in regions and changed our analyzed medical reports.
The rates of diabetes and obesity according to the
The results of studying correlation Pearson depicted
data of preventive medical observations in the city
that obesity rates are closely related to diabetes mellitus.
are higher than in rural areas. It can be accounted for
The highest correlation (r) was in 2011 (0.97). In 2016,
intensive internal migration of the population from rural
it decreased slightly (0.96). Moreover, comparing the
areas to large cities. The annual increase in obesity rates
level of obesity correlation in regions and observation
during the study period amounted to 3.9%. The highest
years, the rate (r) turned out to be 0.83. Calculation and
correlation (Pearson) of obesity value and diabetes is
comparison of the obesity rate (r) showed an unexpected
(r, 0.96). However, the correlation with the growth of
result with the growth of diabetes as for the years from
diabetes from 2011 to 2016, as well as in respect to
2011 to 2016 and regions. This correlation was less
specific regions was not expressed (in some cases,
expected at the level of (0.58).
it decreased to 0.58). South-Kazakhstan, Astana and
The regions with the highest incidence of obesity by Almaty were identified as the regions with the highest
the end of 2016 were South-Kazakhstan (146.2), Astana obesity rates. The reasons for such obesity rating in
(144.0) and Almaty (123.8). Kostanay and Atyrau Kazakhstan should be clarified.
regions were registered in average (82-83.0). At the
Disclaimer: The content is solely the responsibility
lowest levels were Almaty (54.3), Zhambyl (57.1) and
of the authors and does not necessarily represent the
Karaganda (64.2). official views. This research received no specific grant
Comparing the results obtained in a similar from any funding agency in the public, commercial or
investigation, it can be noted that the situation of some not-for-profit sectors.
regions at that time were somewhat different on the Author contributions: FRA and FAB conceived and
territory of Kazakhstan (from 2004 to 2008). 15 designed the study, OOB and FRA carried out studies of
Regions with high rates in 2008 (from 94.9 and patients with visits to cities and regions. FAB and MA
higher) - Almaty (118.5), Astana (135.5), Mangystau prepared the project. All authors collected and processed
(139.7) and Pavlodar (143.0). With average rate (from statistical information. All authors made significant
57.9 to 94.9) - Kyzylorda (59.0), Karaganda (60.6), intellectual contributions in finalising the manuscript,
Kostanai (67.4), Aktobe (69.3) East Kazakhstan (74.0) and read and approved the final version for submission.
and North-Kazakhstan (80.6). Regions with low rate (up Ethical considerations: The proceeding paper for
to 57.9) are Zhambyl (28.4), West Kazakhstan (41.2), investigation related to obesity problems was approved
Almaty (45.8), Atyrau (50.6), Akmola (52.0) And South by the Ethics Research Committee of the Medical
Kazakhstan (56.9). University (№1, Jan. 25, 2014 and №3, Dec. 24, 2015).
Alongside, other statistical results should be The permission for receiving statistical information
indicated. According to the research of G.A. Musina and from the regional Health Departments of the Republic
of Kazakhstan was not required. The reason is that data online.zakon.kz/document/?doc_id=31144104

on demographic changes in the country, the population Accessed December 21, 2016.
treatment to medical institutions, morbidity classification
8. Ukaz Prezidenta Respubliki Kazahstan ot
are published in free access. This data does not point
2 iyulya 2014 goda № 851 «O vnesenii
out patient’s personal information in accordance with
izmenenij i dopolnenij» http://online.zakon.
inviolability of private life (Article 142 of the Criminal
Code of the Republic of Kazakhstan, dated 9.11.2011, kz/Document/?doc_id=31574933 Accessed
No. 490-IV). December 11, 2016.
9. Zdorov’e naseleniya Respubliki Kazahstan i
Conflict of Interest: No
deyatel’nost’ organizacij zdravoohraneniya v 2011
godu. Statisticheskij sbornik. Astana: 2012: 320.
References
10. Komitet po statistike Ministerstva nacional’noj
1. Postanovlenie Pravitel’stva Respubliki Kazahstan ehkonomiki Respubliki Kazahstan: oficial’naya
ot 21 dekabrya 2007 goda № 1260 /Ob statisticheskaya informaciya. Sborniki, kvartal’nye
utverzhdenii programmy «Zdorovyj obraz zhizni» izdaniya, ehlektronnye tablicy, analitika.
na 2008 - 2016 gody. Astana: 2007. http://online. Zdravoohranenie, arhiv; 2012. http://www.stat.
zakon.kz/m/Document/?doc_id=30151178#sub_
gov.kz/ faces/wcnav_externalId/home Numbers
id=100 Accessed May 01, 2010.
HealthCare Accessed November 27, 2016).
2. Kodeks Respubliki Kazahstan (№ 193-IV ot
18 sentyabrya 2009 goda «O zdorov’e naroda i
ehkonomiki Respubliki Kazahstan: oficial’naya
sisteme zdravoohraneniya». Astana: 2009. http://
statisticheskaya informaciya. Sborniki, kvartal’nye
www.mz.gov.kz/ru/node/322556 Accessed April
izdaniya, ehlektronnye tablicy, analitika.
23, 2017.
Zdravoohranenie, arhiv; 2015. http://www.stat.
3. Zdorov’e naseleniya Respubliki Kazahstan i gov.kz/ faces/wcnav_externalId/home Numbers
deyatel’nost’ organizacij zdravoohraneniya v 2015 HealthCare Accessed December 01, 2016).
godu. Statisticheskij sbornik. Astana: 2016: 358.
4. Gosudarstvennaya programma razvitiya ehkonomiki Respubliki Kazahstan: oficial’naya
zdravoohraneniya Respubliki Kazahstan statisticheskaya informaciya. Sborniki, kvartal’nye
«Densaulyқ» na 2016-2019 gody. Astana: 2016: izdaniya, ehlektronnye tablicy, analitika.
4. http://www.enbek.gov.kz/ ru/node/332663 Zdravoohranenie, arhiv; 2016. http://www.stat.
Accessed January 01, 2017.
gov.kz/ faces/wcnav_externalId/home Numbers
5. «CIA World Factbook» https://www.cia.gov/ HealthCare Accessed December 23, 2016).
library/PUBLICATIONS/the-world-factbook/
13. Demograficheskij ezhegodnik Kazahstana.
geos/kz.html Accessed April 23, 2017.
Statisticheskij sbornik. Astana: 2011: 592.
6. Gosudarstvennaya programma razvitiya
14. Arhiv novostej: 31.10. 2016. Nacional’nyj centr
zdravoohraneniya Respubliki Kazahstan
problem formirovaniya zdorovogo obraza zhizni
«Salamatty Қazaқstan» na 2011-2015 gody
Ministerstva zdravoohraneniya i social’nogo
(utverzhdena Ukazom Prezidenta Respubliki
Kazahstan ot 29 noyabrya 2010 goda № 1113) razvitiya Respubliki Kazahstan www.hls.kz/
http://adilet.zan.kz/rus/docs/U1000001113 news_1_322 Accessed December 15, 2016).
Accessed April 23, 2017. 15. Igisinov N. S., Baltakaeva A. M. Prostranstvennaya
7. O sovershenstvovanii profilakticheskih ocenka zabolevaemosti ozhireniem v Kazahstane.
uslug v organizaciyah zdravoohraneniya, Molodoj uchyonyj 2011; 2; 2: 153-156.
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sanitarnuyu pomoshch’ Prikaz i.o. Ministra Mergentaj A. Mediko-social’nye aspekty problem
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fevralya 2012 goda № 89. IS Paragraf- http:// 105-108.
DOI Number: 10.5958/0976-5506.2018.00604.6
Medication Errors in Critical Care Units in a Tertiary Hospital
Anil Pandit1, Jyoti Joshi2, Megha Koul3

1
Professor, Symbiosis Institute of Health Sciences, S B Road, PUNE, 2Gynaecologist, Private Practitioner,
Nagar Road, PUNE, 3Student, MBA (HHM), Symbiosis Institute of Health Sciences, S B Road, PUNE
Abstract
Medication errors in critical care are frequent, serious, and predictable. Critically ill patients are prescribed,
twice as many medications, as patients outside of the intensive care unit (ICU) and nearly all of them suffer,
a potentially life-threatening error at some point during their hospitalization.
Today, in the health care profession, all types of medication errors including missed dose, wrong dosage
forms, wrong time interval, wrong route, etc., are a big deal, for quality patient care. Problems related
to medications, are common in the healthcare profession, and are responsible for significant morbidity,
mortality, and cost. Several recent studies have demonstrated that patients frequently have difficulty in
reading and understanding medication labels. According to the Institute of Medicine report, “Preventing
Medication Errors”, cited poor labeling as a top most cause of medication errors in the USA. Evidence
suggests that specific content and format of prescription drug labels, facilitate a better communication to
minimize apprehension by patients regarding medication errors.
Although majority of these errors are without any serious adverse outcome but some of them are associated
with increased morbidity and mortality leading to prolonged hospital stay, high cost of treatment and
potential for litigation.
The aim of this study was undertaken to know the basic points of medication errors in the ICU set up, to identify
risk factors for medication errors, and suggest strategies to prevent errors and manage their consequences.
Keywords: Medication errors; prescription audit; prescription errors; patient medication safety
Introduction
Health care delivery is not infallible. Errors are little evidence that patient safety has improved 3. In
common in most health care systems and are reported the Intensive Care Unit (ICU), on average, patients
to be the seventh most common cause of overall death1. experience 1.7 errors per day4 and nearly all suffer a
The 1999 Institute of Medicine (IOM) report, “To Err potentially life-threatening error at some point during
is Human. Building a Safer Health System”, drew their stay. Medication errors account for 78% of serious
public attention to the importance of patient safety .The medical errors in the ICU5
Institute of Medicine (IOM) report highlights that 44000
A hospitalized patient with a single dose of a single
- 98000 patients die each year as a result of medical
medication requires many right steps 6. This hospital
errors, a large portion of these being medication related.2
medication use process can be categorized into five
This was followed with considerable interest by broad stages: prescription, transcription, preparation,
the medical community .However, to date, there is dispensation, and administration.7An error can occur at
any point in this process. A medication error is any error
Corresponding Author: in the medication process, whether there are adverse
Dr (Brig) Anil Pandit. MD (HA) DNB (H &HA) consequences or not.8
Professor, Symbiosis Institute of Health Sciences,
Aim
S B Road, PUNE-411004
Mobile: 9423212709 To study the medication errors in critical care in a
E-mail: [email protected] tertiary care hospital and determining the areas where
errors occur in order to take measures to prevent 75 percent of the prescriptions contained Fixed Dose
recurrence of errors. Combinations (FDCs) .An analysis of prescriptions for
diarrhea also revealed that about 60 percent contained
Objectives FDCs. Another study of 292 prescriptions for diarrhea
reported use of 63 different drugs.
zz To rectify the medication errors occurring in the
ICU and other critical care units in hospitals. Medication errors, defined as any error in the
medication process regardless of whether a patient
zz To prepare guidelines for correct method of giving
experiences an adverse consequence, can occur at any
medication and patient medication safety.
step. It is important to have an understanding of the risk
Limitations of this study: Those patients who were factors for medication errors and the evidence base for
discharged from hospital against medical advice before preventing medication errors and disclosure norm must
the study could be completed and those who were be there, should an error occur.
transferred to another healthcare facility for treatment
Although the medication process is similar for all
were excluded from the study.
patients in hospital, we have restricted our study to focus
on critically ill adult patients because the environment,
Review of Literature patient characteristics, and because of types of
Medication error is a major cause of morbidity and medications used in the ICU, are substantially different
mortality in medical profession, and critical care areas from those in other hospital units. The ICU brings
are no exception. Man, medicine, machine and modus together high-risk patients who require urgent, complex
operandi are the main contributory factors.9 interventions from multiple health care professionals in
a complex environment where patients are exposed to
In India, a proper reporting of medication errors in twice as many medications as those in general wards. In
the hospital is not available. Drugs worth crores of rupee addition, critically ill patients differ from most other
are consumed every year but a substantial part of these hospital patients because they have limited ability to
drugs are irrationally prescribed10 In order to promote participate in their medical care and lack the physiologic
rational drug usage, standard policies on use of drugs reserve to tolerate additional injury.
must be set, and this can be done only after the current
prescription practices have been audited.11 Critically ill patients admitted to an ICU experience,
on average, 1.7 medical errors each day and many
The main purpose of conducting a prescription patients suffer a potentially life-threatening error during
audit is to enhance the quality of care in the hospitals. their stay. Medication errors are the most common
Improvement in the prescribing practices of doctors type of error and account for 78% of serious medical
working in hospitals is one of the initiatives taken up, to errors in the ICU. Providing a critically ill patient with
improve the quality of care.12 a single dose of a single medication requires correctly
executing many steps. The medication process involves
A prescription audit is considered appropriate to
5 broad stages: prescription, transcription, preparation,
improve the usage of drugs by the doctors.13
dispensation and administration.
The World Health Organization (WHO) proposed
The earlier in the medication process an error occurs,
core-prescribing indicators 14 for prescription audit and
the more likely it is to be intercepted. Administration
drug utilization studies. The focus of Indian studies has
appears to be particularly vulnerable to error because
mainly been on the WHO core-prescribing indicators
of a paucity of system checks, as most medications are
such as the range and number of drugs per prescription.
administered by a single nurse. Nurses and pharmacists
Another study reported that half of the patients received
cause up to 70% of prescription errors Preparation
more than one antibiotic. 15
errors occur when there is a difference between the
Chemist- and hospital pharmacy–based studies ordered amount or concentration of a medication
reported that, poly-pharmacy was the norm and about and what is actually prepared and administered. The
industry standard for pharmaceutical preparations is
a concentration difference of less than 10%.However, zz Deteriorated drug error: Administration of a drug
approximately two thirds of infusions prepared by nurses that has expired or for which the physical or chemical
are outside industry-accepted standards and 6% contain dosage-form integrity has been compromised.
a greater than two-fold concentration error. Transcription zz Monitoring error: Failure to review a prescribed
errors are usually attributed to handwriting, abbreviation regimen for appropriateness and detection of
use, unit misinterpretation (‘mg’ for ‘mcg’), and problems, or failure to use appropriate clinical or
mistakes in reading. James Reason developed a well- laboratory data for adequate assessment of patient
recognized system for human error classification based response to prescribed therapy.
on observations from industries that have become highly zz Compliance error: Inappropriate patient behavior
reliable such as aviation and nuclear power. He states regarding adherence to a prescribed medication
that errors arise for two reasons:1) active failures and 2) regimen.
latent conditions.
zz Other medication error: Any medication error
Types of Medication Errors: that does not fall into one of above predefined
categories.
zz Prescribing error : Incorrect drug selection (based
on indications, contraindications, known allergies,
existing drug therapy, and other factors), dose, Methodology
dosage form, quantity, route, concentration, rate
The cross sectional study was carried out at a tertiary
of administration, or instructions for use of a drug
product ordered or authorized by physician(or other care hospital in the critical care Departments like ICU
legitimate prescriber) and High dependency units and in the neurosurgery
wards. The patient records were checked with due
zz Illegible prescriptions or medication orders that permission from the hospital authorities.
lead to errors that reach the patient
zz Omission error: The failure to administer an Both prospective study as well as retrospective
ordered dose to a patient before the next scheduled studies was carried out.
dose, if any.
Prospective studies were done by checking the
zz Wrong time error: Administration of medication patients’ medication charts and retrospective studies
outside a predefined time interval from its scheduled were carried out by checking medical files in the medical
administration time (this interval should be records department.
established by each individual health care facility).
Place and Duration of the study: The study was carried
zz Unauthorized drug error: Administration to the
out for duration of 3 months in a tertiary care hospital in
patient of medication not authorized by a legitimate
prescriber for the patient. Pune in the critical care departments.
zz Improper dose error: Administration to the patient Study Sample: The convenient sample of 294 patients
of a dose that is greater than or less than the amount in critical care units as well as OPD patients in the
ordered by the prescriber or administration of hospital receiving follow up were selected.
duplicate doses to the patient, i.e., one or more
dosage units in addition to those that were ordered. Observation and discussion: 294 prescriptions were
analyzed, in which, prescriptions were 1058. Therefore
zz Wrong dosage-form error: Administration to the
average number of drugs/prescription is 4.22. Of 294
patient of a drug product in a different dosage form
patients 65.3%were males and 34.7% were females. A
than ordered by the prescribers.
total of 72 medication errors were identified from 44 cases,
zz Wrong drug-preparation error: Drug product 32(73%) were males and 12(27%) were females. Our
incorrectly formulated or manipulated before study showed a high incidence of medication errors in
administration. males (16.6%) over females (11.7%). It showed (41%)
zz Wrong administration-technique error: of medication errors in patients between 20-40 years
Inappropriate procedure or improper technique in of age. Drugs were prescribed by generic names in 3.79%
the administration of a drug. of cases, drugs from EDL were; 53.25% and fixed dose
combinations are 26.87% of total drugs. Dosage forms The higher prevalence of these errors in the
used were mostly oral -93.51%. Injectable were only prescribing process indicated a need for improvement
6.19% and topical forms were least 0.299%. Doctors in ordering stage of the medication use process. None
profile indicates that maximum number i.e. 93.67% were of the errors identified were fatal, but approximately
general practitioners. Basic information of patient was one-third was assessed as being potentially significant
written in 72.57% prescriptions. or serious.
Out of 294 patients, 44 (15%) patients showed

Recommendations
72 medication errors. The omission error was the
most frequently (40.3%) occurring error, followed zz This study has proven that there is an urgent need of
by prescribing (19.4%) and wrong time error (18 clinical pharmacist in specialized units like MICU,
%).Majority of errors were due to nurses 78% followed where poly-pharmacy is practiced.
by physicians 22%. Errors that did not reach patient
zz The results of our study are important not only for
were 19.6% which comes under sub-category A and B,
safety of patients and the economics of health care
and errors that reach patient but cause no harm adds to
system, but future role of pharmacy personnel in ICU.
80.4% which comes under subcategory C.
zz The present results point to the establishment of a
Complete diagnoses were written in 70.04% medication error reporting system at each hospital
prescriptions. Only 88.61% prescriptions were legible
and to share data with other healthcare settings to
and only 76.79% prescriptions were complete in
prevent further occurrence of same.
terms of dose, route, strength, frequency and dosage
forms. Disease pattern seen was variable. Diseases of zz And the clinical pharmacist, initially, could only
respiratory system were maximum 44.72 % followed by confine to identification of the errors before the
infectious and parasitic diseases. 16.03 % and diseases medication is administered to the patient by
of digestive system - 13.92 %. The most common drug checking over all the charts in
groups prescribed were NSAIDs± serrati peptidases, zz each critical care unit.
antibiotics, antihistaminic, multivitamins, minerals,
enzymes and expectorants & bronchodilators. The zz Improved medication safety can be accomplished
incidence of poly-pharmacy was also common with by optimizing the safety of the medication process,
maximum number of drugs which were prescribed per eliminating situational risk factors, and providing
prescription were four in 39.24% of prescriptions. The strategies to both intercept errors and mitigate their
prescriptions also had other minor anomalies. consequences.
This study showed that there is scope for zz Several interventions have been shown to decrease
improvement in prescribing patterns in areas of writing medical error in the ICU.
generic names of drugs, essential drugs, writing legible zz Establishment and implementation of appropriate
and complete prescriptions. clinical guidelines, use of essential medicines
list, public education about medicines and regular
Overall, it is clear that prescribing errors are a
update to the clinicians will help in implementing
common occurrence, affecting 2% of patient days and
the principles of rational use of drugs.
50% of hospital admissions. However, the reported
rates of prescribing errors varied greatly and this could
be partly explained by variations in the definition of a Conclusion
prescribing error, and the methods used to collect error
Medication errors occur frequently in ICUs of
data. Furthermore, a lack of standardization between
tertiary care hospitals. Therefore it is essential to establish
severity scales prevented any comparison of error
medication error reporting system at each hospital.
severity across studies.
It was found that there was marked prevalence
In recent years, the extent and impact of adverse
of medication errors related to antibiotics in ICUs.
events in healthcare settings has made patient safety, a
Omission errors were most frequent one.
key aspect of healthcare policy.
Most of errors in MICU were not measurable and 5. Rishi RK, Sangeeta S, Surendra K, Tailang
result in harmful consequences for the patients. M. Prescription audit: experience in Garhwal
(Uttaranchal), India. Trop Doct 2013;33:76-9
This study had presented a pattern of types of
medication errors related to antibiotics in ICUs in 6. Maini R, Verma KK, Biswas NR, Agrawal SS.
tertiary care hospital and suggested areas for quality Drug utilization study in dermatology in a tertiary
improvement. This study has proven that there is an hospital in Delhi. Indian J Physiol Pharmacol
2012;46:107-10.
urgent need of clinical pharmacist in specialized units
like ICUs, where poly-pharmacy is practiced. 7. Rehan HS, Lal P. Drug prescribing pattern of
interns at a government healthcare centre in
There is an urgent need for establishing of a northern India. Trop Doct 2012;32:4-7.
medication error reporting system at each hospital and
to share data with other healthcare settings to prevent 8. Hazra A, Tripathi SK, Alam MS. Prescribing and
further occurrence of the same. dispensing activities at the health facilities of a
non-governmental organization. 2013;18:35-50
Conflicts of Interest: There is no conflict of interest.
9. WHO,Geneva: World Health Organization; 2013.
Financial support and Sponsorship: Study is not How to investigate drug use in health facilities,
funded by any agencies. selected drug use indicators, WHO/DAP/93.1; p. 10.
10. Biswas NR, Jindal S, Siddiquei MM, Maini
Ethical Approval: The study was under taken as a part
R. Patterns of prescription and drug use in
of summer internship of management studies. There was
ophthalmology in a tertiary hospital in Delhi. Br
no direct/indirect intervention on medication study of J Clin Pharmacol. 2014;51:267–272
any human beings or animals and hence there was no
ethical issues involved. 11. WHO, Geneva: World Health Organization; 1993.
How to investigate drug use in health facilities,
selected drug use indicators, WHO/DAP/93.1; p. 10.
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DOI Number: 10.5958/0976-5506.2018.00605.8
Knowledge, Perception and Psychosocial Preparedness for

Menarche among Adolescent Girls of Udupi District, Karnataka
Charmaine Crystal Salins1, Anjalin D’Souza2, Malathi G Nayak3

1
MSc Nursing in Child Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher
Education; 2Assistant Professor, Department of Child Health Nursing, 3Assistant Professor, Department
of Community Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher
Education, Manipal
ABSTRACT
Background: Adolescence is a crucial phase of growth extending from puberty to adulthood spanning much
of the second decade. It is the critical period of biological and psychosocial changes. They lack adequate
knowledge about the physical changes during the pubertal period and which in turn leads to undue anxiety.
Objectives: The objectives of the study were to assess the knowledge, perception, psycho social preparedness
for menarche and the problems experienced by the adolescent girls.
Methods: A descriptive survey study was conducted among 200 adolescents aged 11-13 years from 10 higher
primary schools of Udupi district. Adolescents who met the sampling criteria were selected by purposive
sampling. Structured questionnaire was used to assess the knowledge on menarche. A rating scale was used
to assess the perception, psychosocial preparedness towards menarche and predesigned questionnaire was
used to assess the problems experienced at the time of menstruation. Descriptive and inferential statistics
were used for data analysis.
Results: Results shows that, out of 200 adolescents, 88% of the adolescents had average knowledge, 95.5%
had negative perception, most of them 52.5% were well prepared for menarche. The most common problems
experienced by the adolescents were abdominal pain (75%), heavy bleeding (73.5%) and white discharge
few days before menstruation.
Conclusion: Social prohibitions and restrictions from attaining religious rituals have created a negative
impact on adolescents and have blocked the access to the right kind of information. Therefore much more
efforts are needed to curb the misbeliefs and taboos among the adolescent school girls.
Keywords: Menarche, knowledge, perception, psychosocial preparedness.
INTRODUCTION India has the largest population of adolescents in the

world which comprises about 243 million aged 10 -19 years
Menarche is a normal physiological process in the of age. Adolescence is regarded as unique phase of human
reproductive phase of woman’s life that occurs at regular development 2. Adolescence is a period where vital physical
monthly intervals. Menarche typically occurs around the and psycho- sexual changes take place. In this regard, the
age of 12 years. Menarche marks the onset of physical and older child that is the pre adolescents between the age of
sexual maturation in adolescent girls known as puberty1. 10 and 12 years should also receive adequate attention as a
preparation for pubertal changes and menarche3.
Corresponding Author: The gap between problems during menstruation

Anjalin Dsouza, among adolescents is due to lack of knowledge and proper
Asst.professor, Manipl College of NursingManipal, guidance4. Young adolescents experience significant
Manipal Academy of Higher Education, Karnataka, India physical and emotional difficulties during menstruation
[email protected] which stem from poor information and the reactions of
their peer group to menstrual activity. Role of school focused on common problems faced by adolescent girls.
nurses in imparting education on pubertal changes The tools were validated, translated into Kannada and
is significant and schools should explore the manner pretested. The reliability of knowledge questionnaire
in which nurses can contribute to this area of health was computed by split half method and the value was
education 5. Hence the present study focuses on assessing 0.81.The tool on perception towards menarche and
the knowledge, perception, psychosocial preparedness for psychosocial preparedness towards menarche was
menarche and the problems experienced by the adolescent computed using Cronbach’s formula and the reliability
girls in selected schools of Udupi district. scores were 0.88 and 0.89 respectively. The test re
test reliability coefficient was 0.96 for the tool on
MATERIALS AND METHOD health problem experienced by the adolescents during
menstruation. The statistical software SPSS 16.0 version
A descriptive survey was conducted among 200 was used for data analysis.
adolescent girls in the age group of 11-13 years from
selected schools of Udupi district, Karnataka. Udupi The main study was conducted among 200
district is located in the coastal region of Western adolescents after obtaining the ethical approval from
Ghats about 60 kms from Mangalore and has many Institutional Ethical Committee, Kasturba Hospital,
prominent educational centers. All adolescent girls who Manipal (IEC794/2016) and permission from the
were studying in VI and VII standard, who had attained selected schools of Udupi District, Karnataka. The
menarche one year prior to the data collection and purpose of the study was explained to the adolescents
willing to participate were included in the study. and informed consent from the parents and informed
assent from adolescents was taken. Anonymity and
Sample size was calculated based on pilot study confidentiality were ensured throughout the study.
results. Psychosocial preparedness towards menarche
(one of the objectives of the main study) was 66.7%. This RESULTS
proportion was considered as the key variable in sample
size determination. Out of 226 higher primary schools Description of sample characteristics: It was found that,
of Udupi district, ten schools were selected randomly out of 200 adolescents, 45% belonged to the age group of
to get the required number of adolescents. From these 12 years. Concerning mother’s educational status nearly,
schools the adolescents who met the inclusion criteria 38.5% of mothers had secondary education and 66% of
were selected by purposive sampling. adolescents’ mothers were house wives. Majority of the
adolescents 73.5% belonged to nuclear family. The major
Four tools were used to collect data from the source of information were mothers. (Table 1)
participants. Demographic proforma was used for
the purpose of collecting background information of
the adolescents. Structured knowledge questionnaire Table 1: Frequency and percentage distribution of
on menarche was used to assess the knowledge of sample characteristics related to adolescents N = 200
adolescents. Knowledge scores were classified as Sample characteristics Frequency Percentage
poor knowledge (0-15), average knowledge (16-21) Age in years
and good knowledge (22-30). A five point rating scale
11 50 25
was used to assess the perception of adolescent girls
12 90 45
towards menarche. Inferences were drawn according to
the scores obtained: Positive perception score towards 12 60 30
menarche was (31-50), and negative perception towards Mother’s educational status
menarche was (10-30). To find out the psychosocial No formal education 13 6.5
preparedness for menarche a five point scale was Primary (I-VII standard) 19 9.5
prepared by the researcher. Inferences were drawn Secondary VIII- X standard) 39 19.5
according to the scores obtained: well prepared (37-60) Higher secondary 37 18.5
and poorly prepared (12- 36).To identify the problems Diploma 15 7.5
experienced by the adolescent girls at the time of
Degree 77 38.5
menstruation, a questionnaire was used, which mainly
Contd…
Mother’s occupation
House wife 132 66
Skilled 60 30
Semi-skilled 8 4
Type of family
Extended 2 1
Joint 51 25.5 Figure 1: Bar diagram showing frequency and
Nuclear 147 73.5 percentage distribution of perception towards
Mother’s explanation about menarche menarche.
Yes 179 89.5
No 21 10.5
Source of information
Mother 170 85
Sibling 6 3
Friends 15 7.5
Teacher 6 3
No information 3 1.5
Figure 2: Pie diagram showing percentage
Description of knowledge, perception and distribution of psychosocial preparedness for
menarche among adolescents.
psychosocial preparedness for menarche among
adolescents Description of health problems experienced by the
adolescents during menstruation: The description of
Majority of the adolescents 176 (88%) had average health problems experienced by the adolescents during
knowledge, whereas, 21 (10.5%) had good knowledge menstruation is depicted in table 3.
and only 3 (1.5%) had poor knowledge on menarche
(Table 2). Table 3: Frequency and percentage distribution of
health problems N = 200
Majority of the adolescents 191 (95.5%) had
negative perception towards menarche whereas, only Health problems Frequency Percentage
9 (4.5%) of the adolescents had positive perception Regularity of menstruation (n = 200)
towards menarche. (Figure 1) No 78 39
Yes 122 61
The study findings on psychosocial preparedness
Abdominal pain/cramping (n = 200)
for menarche among adolescents shows that majority
No 50 25
of the adolescents 105 (52.5%) were well prepared for
Yes 150 75
menarche, whereas 95 (47.5%) of the adolescents were
Backache (n = 200)
poorly prepared for menarche. (Figure 2)
No 111 55.5
Yes 88 44.5
Table 2: Frequency and percentage distribution of Often feeling tired (n = 200)
knowledge on menarche N = 200
No 80 40
Knowledge score Frequency Percentage Yes 120 60
Good (22-30) 21 10.5 Bleeding more than seven days (n = 200)
Average (16-21) 176 88 No 161 80.5
Poor (0-15) 3 1.5 Yes 39 19.5
Contd… 15% of the adolescents had to change the sanitary pads

every 2 hourly. As per the data, 18% of the adolescents
Heavy bleeding (n = 200)
had breast tenderness, nearly 8% of the adolescents
No 53 26.5 experienced nausea/vomiting, 10% had diarrhoea and
Yes 147 73.5 44% had experienced headache during menstruation.
If yes, changing of sanitary pads (n = 147)
Hourly 6 3 DISCUSSION
Every 2 hourly 30 15
Every 3 hourly 38 19 There is a substantial lacuna in the knowledge
Every 4 hourly 73 36.5 about menstruation among adolescent girls. The present
study revealed that majority of adolescents 62% had
Missing school due to heavy menstruation (n = 200)
average knowledge on menstruation. Whereas, 33%
No 155 77.5
had poor knowledge and only 5% had good knowledge
Yes 45 22.5 on menstruation which is in consistent with findings
Itching over genital region few days before of the study conducted by Thakre, Reddy in 2011,
menstruation (n = 200) disclosed that 36.95% of the girls had good knowledge
No 108 54 on menstruation, whereas, 63.05% had poor knowledge
Yes 92 46 on menstruation 6. Mothers were the major source of
White discharge (n = 200) information regarding menstruation/pubertal changes
No 68 34.5 for majority of the adolescents7.
Yes 131 65.5
Social prohibitions and restrictions from attaining
Breast tenderness (n = 200) religious rituals have created a negative impact on
No 164 82 adolescents and have blocked the access to the right kind
Yes 36 18 of information. Present study revealed that majority of
Nausea/vomiting (n = 200) the adolescents 95.5% had negative perception towards
No 184 92 menarche and only 4.5% had positive perception
Yes 16 8 towards menarche. The findings of the present study
Diarrhoea (n = 200) are in harmony with the results of the study conducted
by Sowmya & Sequeira in 2016.It was found that 82%
No 180 90
of adolescents were not offering pooja, 66% were
Yes 20 10
taking special food items during menstruation, 83%
Headache (n = 200) were restricted from visiting religious places, 41%
No 112 56 were sleeping in a separate room during menstruation
Yes 88 44 and 64% of the adolescents reported that menstruation
is unclean and they followed different practices 8. The
The study findings on health problems experienced
findings of cross sectional study disclosed that 84.9% of
by the adolescents during menstruation shows that, most
adolescents thought that swimming and running during
of the adolescents (61%) had irregular menstruation.
menstruation is dangerous, 53% had false belief that
Majority of the adolescents (75%) had experienced
girls get cranky during menstruation, 66% believed that
abdominal pain during menstruation, out of which
blood loss during menstruation makes them weak9.
10.5% had severe abdominal pain. Forty four percent
of the adolescents experienced back pain during Lack of preparedness for menarche will lead to
menstruation. Most of the adolescents (60%) felt tired undue anxiety in adolescents. Present study showed
during menstruation. Bleeding for more than seven that majority of adolescents (52.5%) were well prepared
days accounted for 19.5% where, 73.5% had heavy for menarche and (47.5%) were poorly prepared for
bleeding during menstruation and the data showed menarche. The findings are in agreement with the
22.5% of the adolescents missed their school due to cross sectional study which showed that 25.5% of the
heavy menstruation. About 3% of the adolescents had adolescents expressed anxiety when they had their first
to change their pads hourly due to heavy bleeding, menstruation, 18.78% expressed fear, 10.3% experienced
ashamed and embarrassment feelings, 14.24% had REFERENCES

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DOI Number: 10.5958/0976-5506.2018.00606.X
Measles Rubella Immunization Campaign: Challenges Faced

in an Urban Area of Chennai
Barathalakshmi J1, Rashmi Gour Patel2, Kanimozhi S3, Sudha V4

1
Associate Professor, Department of Community Medicine, Sri Lakshmi Narayana Institute of Medical
Science, Puducherry, 2Associate Professor, Sree Balaji Medical College Hospital & Research Institute,
Chennai, 3,4Assistant Professor, Department of Community Medicine, Sri Lakshmi Narayana Institute of
Medical Science, Puducherry,
ABSTRACT
Background: Like other countries in Asia, measles-rubella (MR) vaccine coverage in India is suboptimal
whereas 90–95 % coverage is needed for elimination of these diseases. The Ministry of Health and Family
Welfare (MOHFW) of the Government of Tamilnadu implemented MR campaign in February 2017 to
increase MR vaccination coverage. Strategically, the MOHFW used both routine immunization centres and
educational institutions for providing vaccine to the children aged 9 months to <15 years. This evaluation
was carried out to assess the MR vaccination coverage.
Objectives: To assess the MR vaccination coverage and barriers of vaccine coverage in the community
Methods: A community based cross-sectional study was carried out in March and April 2017. Household
visits were made to collect the data from 330 children using a pre-structured questionnaire. The data was
analyzed by SPSS 20 using Proportions and Chi square tests.
Results: Of the total 330 children surveyed, MR immunization coverage was 77.2% (255). Among the
255 vaccinated children 6.3% of them had mild fever after vaccination. 74.5% and 25.5% of them got the
vaccination in their schools and government health centres respectively. Among the 75 non-immunized
children, 62.8% and 29.4% were denied vaccination due to inflated information about the adverse events
following immunization shared in television and social media respectively
Conclusion: The results of our evaluation indicated that the campaign was suboptimal in terms of Measles
Rubella immunization coverage. Achieving measles and rubella elimination worldwide will be an important
milestone in public health, and every effort toward elimination, including vaccination campaigns should be
of high quality and ensure adequate information regarding immunization and its effects to the community.
Keywords: Campaign, Coverage, Measles, Rubella, Barriers
INTRODUCTION childhood morbidity and mortality, caused by vaccine

preventable diseases worldwide. However, outbreaks
Measles is one of the most infectious human diseases of vaccine preventable diseases continue to occur in
and can cause serious illness, long term complications developing countries2,3. Good routine immunization
and death. Prior to the availability of measles vaccine, levels and campaigns to vaccinate children are thought
the virus infected over 90% of children before they to be behind the figures. The WHO says measles is still a
reached 15 years of age1. Immunization is one of the global threat and some populations remain unprotected.
most effective public health tools reducing the infant and We need to move beyond 84% global routine
immunization coverage. It’s also vital that parents are
Coresponding Author:
fully aware of the benefits of immunization and the risks
Barathalakshmi J,
associated with not vaccinating children4.
Associate Professor, Department of Community Medicine,
Sri Lakshmi Narayana Institute of Medical Science, The World Health Organization estimated that
Puducherry global deaths from measles dropped 78% between 2000
and 2015. New figures from the WHO suggest that Maintaining high levels of routine immunization
around 13.8 million deaths were prevented during this coverage each year reduces the accumulation of
time and reported cases declined by 77%.The Measles susceptible populations, thereby lengthening the
and Rubella Initiative wants to reduce measles deaths by interval needed between Supplementary Immunization
95% by 2015 and get rid of measles and rubella in at least Activity and conceivably eliminating the need for them
five regions of the world by 20205.The GAVI Alliance is altogether if validated routine coverage with two doses
investing more than US$ 600 million in the fight against of measles vaccine were to exceed 90–95% for at least
measles and rubella through large-scale campaigns. The three consecutive years15
Alliance targets over 700 million children in 49 countries
A higher level of education and increased parental
aged 9 months to 14 years to immunize against measles
awareness would facilitate increased vaccination
and rubella.
coverage because they ensure increased awareness of
High level of herd immunity is required for the health issues and provide individuals with increased
elimination of measles. Studies on sero prevalence of access to services, information, and the skills to interact
measles suggest that vaccine coverage in the range of with professionals and health care services16, 17, 19
90–95 % is needed. Early vaccination is also suboptimal,
because children who receive the measles vaccination METHODOLOGY
too early are at increased risk for vaccine failure. Low
measles vaccination coverage in a community can also A community based cross-sectional study was
have a deleterious effect on children who have been carried out in Anakaputhur, urban field practice area
adequately vaccinated, putting them at elevated risk for of Sree Balaji Medical College Hospital & Research
contracting measles6.Measles and rubella are vaccine- Centre, Chennai. The required sample size of 236
preventable diseases with similar symptoms and are children was obtained from the global coverage of 82%
frequently confused with each other. Both viruses cause for MR vaccine. A total of 218 households with 330
children were included in the survey.
rash and fever. Measles can be deadly for children with
poor nutrition and weakened immune systems7, 8. A house to house survey was done immediately after
the MR vaccination campaign which was conducted all
Rubella is also very contagious but causes relatively
over Tamilnadu in the month of February 2017 in order
mild disease in children; in pregnant women, rubella can
to reduce the recall bias. Data was collected in the month
lead to miscarriage or severe birth defects congenital
of March and April.The mothers were interviewed
rubella syndrome (CRS), including blindness, deafness,
individually to collect the data regarding the details of
and heart problems9, 10. Rubella can become a major
their children’s MR vaccination status, demographic
public health issue when infection occurs during first information like birth order, parent’s education, their
trimester of pregnancy. Most anomalies occur if rubella attitude, occupation, place of vaccination, source of
infection occur before 11 weeks of pregnancy; however information about vaccination and the reasons for not
studies show that up to 25% of congenital cataract vaccinating their children.
follows rubella infection in pregnancy11, 12.
Research tool used was a pretested and semi
Rubella and measles are a public health problem structured questionnaire. The data was collected and
in poor countries in Africa and Asia, where uptake then analyzed using SPSS 20 version. The results were
of the measles and rubella vaccine is relatively low expressed in proportion and association by applying Chi
and increasing access to immunization through large square test.
scale vaccination campaigns can significantly reduce
deaths and illnesses13.In India, places like Delhi, Goa, RESULTS
Puducherry and Sikkim have higher vaccine coverage
since they have taken the initiative and lead to the two A total of 330 children was included in the study,
dose schedule of measles mumps and rubella (MMR) of whom171 (51.8%) were males and 159 (48.2 %)
at 9 months and at 15 months respectively. Now a days females.50% of children were aged between 9 months
there is a distinct change in the measles and mumps and 6 years.237 (71.8 %) of mothers had attained only
disease pattern due to measles and MMR vaccination14. secondary level of education.
Table 1: Demographic characteristics of the participants n = 330
Age in years No Percent % MR coverage (%) Chi square ‘p’value

<3 82 24.8 58(22.7)
3-6 81 24.5 66(25.9)
6-9 79 23.9 64(25.1)
0.46
9-12 60 18.1 45(17.6)
>12 28 8.4 22(8.6)
Total 330 100
Sex
Male 171 51.8 135(52.9)
0.45
Female 159 48.2 120(47.1)
Total 330 100
Mother educational status
< Secondary level (10thstd) 237 71.8 183(71.8)
0.97
> Secondary level 93 28.2 72(28.2)
Mother occupation status
Employed 219 66.4 180(70.6)
0.003
Unemployed 111 33.6 75(29.4)
Father educational status
< Secondary level (10thstd) 253 76.7 195(76.5)
0.87
> Secondary level 77 23.3 60(23.5)
The MR vaccine coverage rate in the present study Table 2: Source and Barriers (reasons) of Non
was 77.2% (255). Among the vaccinated children, 190 Immunization according to respondents
(74.5%) and 65 (25.5%) received their vaccination in
Sources n = 75 Percent %
educational institutions and government health centres
respectively. Television 47 62.8
Social media 22 29.4
Neighbours 2 2.6
Friends 2 2.6
Healthcare professionals 2 2.6
Reasons for not vaccinating
Fear of side effects 43 57.4
Child was sick 17 22.6
Child refused 5 6.7
Absent on vaccination day 4 5.3
Fig. 1 Child is young to receive 3 4
Mother had no time 3 4
Among the 255 vaccinated children 6.3% had mild
Mother is not aware of the 2 2.6
fever following immunization. Among the 22.8% of place of vaccination
non-immunized children, 57.4 % were not immunized
because of the fear of side effects and major source of Only 18.4% of the mothers had known that rubella
information was through television (62.8%). About vaccine is available already as optional vaccine. Only
77.5% of the mothers had taken special advice before few mothers (9.1%) of the were aware of the Congenital
getting their children vaccinated. Rubella Syndrome.
Table 3: Attitude and Knowledge of mothers on Though the attitude of the mothers were found to
MR immunization be positive, two hundred and ninety five (90.9%)of the
mothers were not aware of the benefits like prevention
Awareness n = 330 Percent %
of Congenital Rubella Syndrome. Hence elaborate
Already available vaccine as 61 18.4
information about the eligible age of recipients, place of
optional one
vaccination, mass immunization duration and alternate
Newly introduced vaccine 269 81.5
places from where they can get vaccinated if they miss
Congenital Rubella Syndrome in their schools has to clearly reach the community
Aware 30 9.1
Not aware 300 90.9 Majority (81.5%) of the participants were not
Attitude aware that measles and rubella vaccines are already in
the immunization schedule of some states like Delhi,
Vaccine will benefit my 239 72.4
child Puducherry, Sikkim and Goa. For the rest of the states
the same measles and rubella vaccines are available as
Will be of no benefit 91 27.6
optional vaccines8. The participants are still in belief that
MR vaccine is a new vaccine which is tried on people
DISCUSSION for the first time. Correct and detailed information about
The study found that the MR immunization coverage the vaccine has to be provided to the public which will
rate was 77.2%which is lower than the WHO target really make a difference in their attitude and practice.
coverage of 90-95% for elimination of Measles. The
About 77.5% of the mothers had sought second
strategy of inclusion of educational institutes as campaign
opinion from health care professionals after witnessing
centre for giving vaccine to the school children showed
vomiting and faint attacks which were shared in
significant positive impact on MR vaccine coverage.
television and social media. This reflects the amount
However the estimate is less but still it is comparable
anxiety and negative impact created by the media. The
with the rates in Delhi17. This sub optimal coverage of
media can be used effectively to spread the correct facts
77.2% might lead to an epidemic in future. Rubella occurs
about the immunization campaign. The responses to the
as epidemics every 5 to 9 years. The WHO estimates
frequently asked questions by the community covering
incidence of CRS between 0.5–2.2/1000 live births during
the particular mass campaign clearing all possible doubts
epidemics in developing countries
about the concerned vaccination should actually reach
In the present study, the various reasons for non- the community before the campaign.
immunization were evaluated. The most common reason
for non-immunization was the fear of side effects (57.4%) Government has to be prepared with adequate
following immunization which is similar to a study in ground work anticipating wrong propagandas through
Bangaladesh18. The other reasons for not immunizing television and social media which could virally spread to
were child refusal, mothers thought that the measles thousands of people within a fraction of time ultimately
vaccination is done already, their child is too young to affecting the success of the mass campaign.
receive it and even few mothers stated that their child was
Earlier the mother’s literacy level and the media
sick (22.6%) were absent on the day of vaccination in
communication was not as good as now and those were
spite of adequate announcement regarding the availability
main reasons for immunization coverage19.But now both
of vaccine in the nearby government health centres for the
literacy level and media communication have improved
entire month of February. In the present study, mother’s
and if the media is used appropriately, the vaccine
occupation was one of the factors significantly associated
coverage rate can even surpass the WHO target of 95%
with the immunization coverage.
coverage which is mandatory for elimination of measles
The exaggerated information about the adverse and rubella.
events that occurred in few children and in few places
were shared in television and social media extensively CONCLUSION
which had significant negative impact about the
immunization campaign and the vaccine coverage. The results of our evaluation indicated that the
campaign was suboptimal in terms of Measles Rubella 5. World Health Organization. Immunization, Vaccines
immunization coverage. This is the first mass campaign and Biological: Over 700 million children in 49
of a rubella containing vaccine and was only recently countries to be protected against measles and
introduced into the routine EPI system. Enhancing rubella. 2013. Available from: http://www.who.
population awareness about rubella disease and int/immunization/newsroom/press/700_million_
prevention of congenital rubella syndrome is an important children_49_countries_protected_measles_rubella/
mechanism for increasing understanding of the rationale en/. Accessed 14 July 2013.
of the MR vaccine over traditional measles vaccine. The 6. Koehlmoos TP, et al. Impact of measles eradication
possibility and the nature of adverse events should also activities on routine immunization services
be explained to the community during the pre-campaign and health systems in Bangladesh. J Infect Dis.
activities to avoid such suboptimal coverage. 2011;204:S90–7.
7. Maina LC, Karanja S, Kombich J. Immunization
STUDY LIMITATIONS AND STRENGTHS coverage and its determinants among children aged
The present study had few limitations. It was 12-23 months in a peri-urban area of Kenya. Pan
conducted locally, among families of low and middle Afr Med J. 2013;14:3. [PMC free article] [PubMed]
income and is, therefore, not representative of the whole World Health Organization. EPI Fact Sheet:
city. The coverage was estimated based the mother Bangladesh 2011. 2012.Google Scholar
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However the reach of the media is so viral and uniform Surveillance Bulletin. 2013. Available from: http://
throughout the state, the reasons for non-immunization www.dghs.gov.bd/images/docs/EPI/Bulletin%20
can be generalized. Therefore it could be used as a model f o r % 2 0 E P I % 2 0 We b % 2 0 S i t e / 2 0 1 3 / E P I % 2 0
for designing strategies in order to improve the content Surveillance%20Bulletin-Issue%2001-2013.pdf.
and quality of pre vaccination campaign. Accessed 17 Jan 2015.
Conflict of Interest: Nil 9. GAVI Alliance. Over 700 million children in 49

countries to be protected against measles and rubella.
Source of Funding: Self 2013. Available from: http://www.gavialliance.org/
library/news/press-releases/2013/over-700-million-
Ethical Clearance: Obtained from the ethical committee
children-in-49-countries-to-be-protected-against-
measles-and-rubella/. Accessed 14 July 2013
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DOI Number: 10.5958/0976-5506.2018.00607.1
Factors Influencing the Sleep Quality among the

Undergraduate Nursing Students of Udupi District
Sally Jane J. K.1, Binu Margaret2, Priyanka Chandy3

1
MSc, Nursing in Child Health Nursing, 2Assistant Professor, Department of Child Health Nursing,
3
Lecturer, Department of Mental Health Nursing, Manipal College of Nursing Manipal,
Manipal Academy of Higher Education, Manipal
ABSTRACT
Background: Sleep is a physiological phenomenon and is very essential for the healthy functioning of
the individual. Many factors like study habits, personal factors, life style, mass media, usage of electronic
media, academic schedules can influence the quality of sleep.
Objective: To find association between sleep quality and factors influencing sleep quality.
Material and Methods: The study was done among undergraduate nursing students who were in the age
of 19 to 24 years from Udupi District, Karnataka. The study used a cross sectional design. Pittsburg Sleep
Quality Index and a semi-structured questionnaire was used to obtain the data.
Result: There was an association between sleep quality and selected factors like duration of sleep at night,
did not often wake up at night, no difficulty in falling asleep, good environment, studying till late at night
after 11 pm, writing assignments late at nights, did not work continuously the whole night, get enough
sleep before examination, performance in the current year II Sessional examination, not engaging in social
activities late at nights (p<0.05).
Conclusion: Sleep quality was dependent on selected factors influencing sleep quality. Interventions
promoting heath awareness for the undergraduate students to adopt good study habits and to manage the
time effectively is utmost recommended for developing good sleep habits.
Keywords: Factors influencing sleep quality, undergraduate nursing students, sleep quality, Udupi
INTRODUCTION Increasing sleep problems in adolescents are an

obstacle in the learning process of an individual, which in
Sleep is a function of physical and mental restoration turn negatively affects their behavior, accomplishment of
and is a physiological phenomenon. Sleep, which societal capability and excellence of life.2 Many factors
is inadequate, causes emotional instability, daytime affect the quality of sleep in the individual. A descriptive
sleepiness and decreased concentration leading to memory survey done among 400 undergraduate students of Hong
loss. Mood dysregulation, increased dissatisfaction in Kong showed that 57.5% had poor quality of sleep, and
daytime functioning, decrease in cognitive functions and had an association with the factors such as sex, class of
obesity are caused by sleep deprivation, which in turn study, and sufficient sleep in the former month.3 Students
affects the academic performance.1 had slept 7.95±1.34 hours at night, and (12.3%) students
had sleep less than 6.5 hours and a majority were poor
Corresponding Author: sleepers. Poor sleep quality among 540 undergraduates
Binu Margaret had an association with inadequate sleep which was
Assistant Professor, Department of Child Health Nursing, prevalent among the undergraduates in Lebanon.4
Manipal College of Nursing, Manipal,
Manipal Academy of Higher Education, Manipal, The incidence of poor sleep quality among 2854
Udupi District, Karnataka, India. Pin: 576104 undergraduates of Thailand was 48.1%. Poor sleep quality
Email: [email protected] had a significant association with a maximum (58.0%)
of students who took beverages.5 Also, a cross sectional influencing sleep quality (r=0.75) was used to assess the
study done in Peru among 418 undergraduates showed a factors. The tool assessed the various factors such as,
significant association with dependence of Facebook and personal factors, familial factors, environmental factors,
poor quality of sleep by dysfunction at daytime.6 academic schedules and study habits, performance
in the examination, usage of electronic media, and
Students of a medical college (19.17%) had poor peer influence. The questionnaires were given to the
quality of sleep. There was no difference in the sleep participants and were asked to fill all the items.
quality among the genders (p>0.05) but a difference was
found among the year of study. Anxiety and depression The data were categorized and analyzed using SPSS
among the students also had a significant correlation. version 23.0. Descriptive statistics was used for sample
Many factors like stress, health condition, relationship characteristics and the inferential statistics to find the
with classmates, irregular work/rest, late to bed, association.
environment of the place of stay, worry of examination
and sleep had a significant association with sleep quality.7
RESULTS
Irregular bedtimes, average sleep in day and inadequate
sleep resulted in poor sleep quality.8 Out of 224 undergraduate students, majority 206
Inadequate sleep indeed does, however, disturb (92.0%) were females and 175 (78.1%) of the students
the roles of the central nervous system. Persistent were hostelites. Eighty two (36.6%) students from fourth
sleeplessness is frequently related with progressive year and 71 (31.7%) students each from second and
failure of the thought processes and occasionally even third year respectively. Majority 144 (64.3%) students
leading to unusual behavioral activities. Increased followed Christianity, 14 (18.3%) were Hindus and 1
sluggishness of thought occur heading the end of a (0.4%) was Muslim. Maximum 80 (35.7%) students
lengthy sleepless period, but in adding, an individual can were in the age group of 21 years. Maximum 80 (35.7%)
become short tempered or even psychotic after enforced and 70 (31.3%) of students had their mother’s and
sleeplessness.1
father’s education as higher secondary.
Literature review showed different results between
Majority 123 (54.9%) of the students had poor sleep
the sleep quality and its selected factors influencing
quality and 101 (45.1%) had good quality of sleep. The
sleep quality, and hence an attempt was made to assess
an association. mean sleep quality was 4.98 ± 2.705. Majority of students
130 (58%) can get to sleep within 30 minutes in the last
month, 50 (22.3%) did not get sleep less than once a
METHOD
week, 29 (12.9%) once or twice a week and 15 (6.7%)
Two hundred twenty four undergraduate nursing three or more times a week. Maximum of students 108
students were surveyed using a semi-structured (48.2%) did not wake up in the middle of night in the
questionnaire on factors influencing sleep quality and last month, 42 (18.8%) woke up less than once a week,
Pittsburg Sleep Quality Index (PSQI). All the students of 53 (23.7%) once or twice a week and 21 (9.4%) three or
second, third and fourth year from a selected college of
more times a week.
nursing from Udupi district, Karnataka state, who have
given the informed consent and willing to participate in The sleep quality is influenced by various factors.
the study were included. The study used a cross-sectional The factors influencing sleep quality that are included
design. The students were in the age group of 19 to 24 in the study are the demographic factors, environmental
years. Ethical clearance was taken from the Institutional
factors, personal factors, familial factors, academic
Ethical Committee. Formal administrative permission
schedules and habits, performance in previous
was taken from the concerned authorities.
examination, usage of electronic media and peer
The data were collected by using valid, pretested influence. The association of these factors with the sleep
and reliable questionnaires. The sleep quality was quality was computed by chisquare test and is given in
assessed using PSQI (r=0.70) and a tool on factors table 1, 2,3 and 4.
Table 1: Association between sleep quality and the demographic factors using Chi square test
Demographic factors Good sleep quality Poor sleep quality χ2 df p value
Age in years
19 23 15
20 29 45
5.644 3 0.227
21 36 44
>=22 13 19
Gender
Male 4 14
4.134 1 0.042*
Female 97 109
Class of study
II Year BSc Nursing 33 38
III Year BSc Nursing 31 40 0.114 2 0.945
IV Year BSc Nursing 37 45
Current place of stay
Home 25 24
0.891 1 0.345
Hostel 76 99
* - Significant; (p<0.05)
Table 2: Association of sleep quality with the personal factors and familial factors using Chi square test
Personal Factors Good sleep Quality Poor sleep Quality χ2 df p value

Sleep peacefully at night
No 2 18
10.921 1 0.001*
Yes 99 105
Get enough sleep at night
No 2 26
18.611 1 0.001*
Yes 99 97
Duration of sleep at night
>7 hours 55 11
6-7 hours 42 60
72.301 3 0.001*
5-6 hours 4 47
< 5 hours 0 5
Often wake up at night
No 92 90
11.688 1 0.001*
Yes 9 33
Difficulty in falling asleep
No 96 103
7.155 1 0.007*
Yes 5 20
Drinking beverages at night
No 91 111 0.001 1 0.971
Yes 10 12
Contd…
Late evening physical activity

No 95 106
3.738 1 0.053
Yes 6 17
Familial Factors Good sleep quality Poor sleep quality χ2 df p value
Family problems
No 98 117
0.523 1 0.469
Yes 3 6
Financial concerns
No 96 115
0.245 1 0.621
Yes 5 8
Table 3: Association between sleep quality and the academic schedules, study habits and performance in
previous examination computed using Chi square test
Academic schedules and study habits Good sleep quality Poor sleep quality χ2 df p value
Studying late night after 11 pm
No 39 29
5.931 1 0.015*
Yes 62 94
Writing assignments at late nights
No 48 37
7.166 1 0.007*
Yes 53 86
Work continuously the whole night
No 88 88
8.000 1 0.005*
Yes 13 35
Get enough sleep before examination
No 22 59
16.473 1 0.001*
Yes 79 64
Lack of confidence during examination
No 73 73
4.084 1 0.043*
Yes 28 50
Performance in the previous university
Not satisfactory performance 33 48
0.969 1 0.325
Satisfactory performance 68 75
Performance in the current I sessional
1.241 1 0.265
Performance in the current II sessional
7.674 1 0.006*
Table 4: Association between sleep quality and usage of electronic media, peer influence and environmental
factors using Chi square test
Usage of electronic media Good sleep quality Poor sleep quality χ2 df p value
Listen to music till late at night
No 49 69
1.279 1 0.258
Yes 52 54
Chat with friends till late night
No 60 66
0.744 1 0.388
Yes 41 57
Peer Influence Good sleep quality Poor sleep quality χ2 df p value
Engage in social activities at late nights
No 92 100
4.339 1 0.037*
Yes 9 23
Extracurricular activities late at nights
No 84 94
1.546 1 0.214
Yes 17 29
Environmental Factors Good sleep quality Poor sleep quality χ2 df p value
Good environment for sleep
No 2 19
11.839 1 0.001*
Yes 99 104
Put on lights when going to bed
No 80 103
0.762 1 0.383
Yes 21 20
Noise disturbance at night
No 71 79
0.924 1 0.337
Yes 30 44
Snoring of roommate at night
No 96 116
0.060 1 0.807
Yes 5 7
(p<0.05); * - Significant
The data presented in table 1 and 2 showed a due to their academic schedules, poor management
significant association of sleep quality with the selected of time, study habits and other environmental factors,
factors like, gender (p=0.042), sleep peacefully at night which could influence them. The present study revealed
(p<0.001), get enough sleep at night (p<0.001), duration that sleep quality was dependent on certain academic,
of sleep at night (p<0.001) and did not often wake up personal and environmental factors and was found
at night (p<0.001). Studying late night after 11pm to have a statistical significant association with these
(p=0.015), writing assignments late at nights (p=0.001), selected factors. It could be due to that, most of the
get enough sleep before examination (p<0.001), lack students, inspite of having a good environment of living
confidence during examination (p=0.043), performance and sleep, they are continuously exposed to a rigid
in the current year II Sessional examination (p=0.006) curriculum pattern whereby, the students start adapting
were the academic factors which were dependent themselves slowly according to their schedules in order
on sleep quality (Table 3). The table 4 shows that
to excel themselves.
sleep quality had a significant association with good
environment for sleep and engaging in social activities The findings of this study are supported by few studies.
late night (p<0.05). In the present study, gender had an association with sleep
quality. A cross-sectional survey conducted among 2,551
DISCUSSION University students in which, the female students of
second and third year had poor sleep quality. The students
Sleep is a very essential physiological process in had apparent anxiety level which had a strong association
the human being. Many factors could distort this sleep with sleep quality.9 Another study was conducted in
process which inturn can affect the health and wellbeing examining the risk factors associated with poor sleep
of the individual. Undergraduate students in the nursing quality among 4318 students in Taiwan which showed
profession also could face the problems related to sleep that, poor sleep quality had a significant association with
the undergraduates, among the females, who had skipped Factors among University Students in Hong
breakfast and had the habit of drinking tea, frequent users Kong. Chronobiology international. 2008 Jan
of internet and those who had a poor social support.10 1;25(5):760-75.
In a study done by Shelly D H and Ronald D C 4. Kabrita CS, Hajjar-Muça TA, Duffy JF. Predictors
revealed that, most college students (70.6%) were of poor sleep quality among Lebanese university
deprived of sleep, of having less than eight hours of students: association between evening typology,
sleep, which led to the negative impact in their academic lifestyle behaviors, and sleep habits. Nature and
performance.11 Another cross-sectional study conducted science of sleep. 2014;6:11.
among 1,444 students in China also revealed that, more 5. Lohsoonthorn V, Khidir H, Casillas G, Lertmaharit
than half of the students who used social media exhibited S, Tadesse MG, Pensuksan WC, Rattananupong
poor sleep quality. These studies contradict the findings T, Gelaye B, Williams MA. Sleep quality and
of the present study, which showed that quality of sleep sleep patterns in relation to consumption of
was independent of usage of social media.12 energy drinks, caffeinated beverages, and other
stimulants among Thai college students. Sleep
The results of this study, enables us to identify and and Breathing. 2013 Sep 1;17(3):1017-28.
explore the factors which influences the sleep quality
6. Wolniczak I, Caceres-DelAguila JA, Palma-
among the undergraduates, by which we could prevent
Ardiles G, Arroyo KJ, Solís-Visscher R, Paredes-
the risk factors or the areas where a student feels
Yauri S, Mego-Aquije K, Bernabe-Ortiz A.
uncomfortable or hazardous in their perspectives of
Association between Facebook dependence
health and education in their everyday lives.
and poor sleep quality: a study in a sample of
undergraduate students in Peru. PloS one. 2013
CONCLUSION Mar 12;8(3):e59087.
Sleep quality was dependent on the selected factors 7. Feng GS, Chen JW, Yang XZ. Study on the status
like gender, academic schedules, study habits, sleep and quality of sleep-related influencing factors
habits of the undergraduate students. Nursing students in medical college students. Zhonghua Liu Xing
should manage their time effectively and adopt good Bing Xue Za Zhi. 2005 May;26(5):328-31.
study habits to improve the sleep quality. Health care 8. Kang JH, Chen SC. Effects of an irregular bedtime
professionals should focus their intervention to empower schedule on sleep quality, daytime sleepiness,
and motivate the undergraduate nursing students to and fatigue among university students in Taiwan.
manage their time effectively and balance between the BMC Public Health. 2009 Jul 19;9(1):248.
academic schedules, clinical schedules and study habits,
9. Lemma S, Gelaye B, Berhane Y, Worku A,
thereby adopting healthy sleep habits to improve the
Williams MA. Sleep quality and its psychological
quality of sleep.
correlates among university students in Ethiopia:
Conflict of Interest: Nil a cross-sectional study. BMC psychiatry. 2012
Dec 28;12(1):237.
Source of Funding: Nil
10. Cheng SH, Shih CC, Lee IH, Hou YW, Chen
KC, Chen KT, Yang YK, Yang YC. A study on
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DOI Number: 10.5958/0976-5506.2018.00608.3
Identification of Positive Deviant Behaviours Regarding Infant

and Young Child Feeding (Iycf) among Rural Mothers for
Improving Child Health and Nutrition-A Cross Sectional Study
Chitrarpita Saha1, Vanisha S Nambiar2

Research Scholar, 2Professor, Department of Foods and Nutrition, Faculty of Family and Community
1
Sciences, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India
ABSTRACT
Aims: The present study aimed to identify positive deviant behaviour (PDB) regarding IYCF practices
among mothers and correlate with the nutritional status of children (<5y).
Methods: Cross sectional study conducted in 2 rural clusters of Vadodara district, Western India, covering
all mothers with children (<5y), enrolled in the ongoing ICDS program. Data regarding IYCF practices
based on UNICEF guidelines, were elicited by interviewing mothers using semi structured questionnaires,
scored using a10-point scale, categorized as Positively Deviant (PD) (scored ≥6) and Negatively Deviant
(ND) (scored<6) and correlated with the current nutritional status of children determined by anthropometric
assessment.
Results: Overall poor IYCF practices were observed in the study area as incidence of timely initiation of
breastfeeding was 48%, colostrum feeding 72%, exclusive breastfeeding (EBF) 32%, pre-lacteal, water and
top milk feeding for 1st 6m 50%, 61% and 20% respectively, timely initiation of complementary feeding
64%, continued breast feeding upto 2 years 36%, breastfeeding during illness 88% and active feeding 37%
only. Among 96 mothers, 47 (48.9%) were identified as positively deviant (PD) who practiced ≥6 PDBs.
Incidence of child undernutrition was significantly (p<0.05) higher among ND mothers (44% wasted, 61%
stunted, 61% underweight) as compared to PD mothers (40% wasted, 53% stunted 61% underweight). EBF
had the highest impact on PD score according to OR value at 95% CI.
Conclusion: Improving child nutrition using Positive deviance approach by mobilizing community mothers
can be an effective, replicable and sustainable strategy if properly planned and implicated.
Keywords: IYCF practices, Positive Deviant Behaviours, stunting, wasting
BACKGROUND regions rural people in all over the world are much more
affected by malnutrition than urban people.
Globally approximately 162 million children under
the age of 5 years are affected by stunting and 52 million Nearly half of the stunted children live in south
children are severely wasted (WHO, 2012). UNICEF Asia (WHO, 2012) and though India has made progress
20131 report made it very clear that irrespective of the towards the international hunger targets, its progress in
improving nutrition is unacceptably slow and it still has
Corresponding Author: the second-highest estimated number (194.6millions) of
Prof. Vanisha S Nambiar undernourished people in the world (FAO 2015).
Department of Foods and Nutrition,
Many programs do not give sufficient attention to
Faculty of Family and Community Sciences,
the constraints that can prevent caregivers from feeding
The Maharaja Sayajirao University of Baroda,
their children properly, like beliefs that colostrum is
Vadodara-390002, Gujarat, India
bad for a new born baby, family pressures to feed water
Email: [email protected],
instead of exclusive breastfeeding, or a heavy workload
[email protected]
that gives mothers little time to prepare appropriate and children who were less than 5 years old along with
nutritious complementary foods (USAID). In India about their mothers were selected (N=96) as target group and
44.2% 0-23months children were breastfed within 1hr enrolled in the study after giving consent.
of birth, 65.1% 0-5months were exclusively breastfed,
47.1% 6-8months were fed complementary food. Experimental procedure: Data collection occurred
in the year 2015 from July to December (6months
It is often seen that in communities there are a few duration). Mothers were interviewed personally using a
‘deviant’ individuals whose uncommon behaviors or pre-tested semi structured questionnaire to elicit data on
practices enable them to outperform their neighbors with IYCF practices. Details of IYCF practices were noted
whom they share the same resources. Identification of these down as they align with current, age-specific feeding
“positive deviants” can be crucial to bring sustainable recommendations for young children (World Health
change as their behaviors are likely to be affordable Organization 2010).
and acceptable by the wider community. Identification
of positive deviant behaviour helps to understand the Anthropometric measurement (Height and weight)
psychosocial environment that effects behaviour change of children was taken and z-scores were calculated for
and the valuable role of self-efficacious Positive deviant weight/age (Underweight), height/age (Stunting) and
mothers/family members as counselors2. weight/height (Wasting) using WHO Anthro software
(WHO, 2006).
Therefore, the present study aimed to identify
positive deviant behaviours (PDB) regarding Infant and Using the UNICEF guidelines for IYCF, the
Young Child Feeding (IYCF) among rural mothers for identification of the positive deviant behaviours was
improving child health and nutrition. done. The mothers were scored using a 10 point scale,
categorized as PD (≥6) and ND (<6) and correlated with
nutritional status of their children
MATERIALS AND METHOD
Statistical analysis: Collected and calculated data was
Ethical clearance: Ethical approval was obtained
entered in excel 2010 datasheet and SPSS23 datasheet
from the ethical committee of the Food and Nutrition
and analysed to determine the survey results as per the
Department of the university (Approval No:
objectives. Graphs and tables were made to show the
IECHR/2015/16). Local community leaders were
results clearly for better understanding.
informed about the aim and procedures of the study. All
study participants gave their verbal consent to participate
after the study objectives were explained to them. RESULTS
Study design: It was a cross sectional study conducted The study showed that the IYCF practices in the
for 6months at Ekalbara village of Padra taluka, rural area were very poor and 48% positive deviant mothers
Vadodara, western India. Two clusters of Ekalbara were identified who practiced 6 or more than 6 positive
village were selected for the study location. All the IYCF practices.
Table 1: 10 ideal IYCF practices in the study area and their impact on overall IYCF score of PD and ND
PD (≥6) = 47 OR value at
Code No. Criteria N = 96 N value %
ND (<6) = 49 95% CI
PD 32 68
PDB1 Timely initiation of breastfeeding 46 (48%) 5.33
ND 29 29
PD 41 87
PDB2 Colostrum Feeding 69 (72%) 5.12
ND 28 57
No Pre-lacteal feeding of honey PD 39 83
PDB3 498 (50%) 21.67
or patasa water ND 9 18
No Practice of providing water at PD 35 74
PDB4 37 (38.5%) 68.54
1st 6 months ND 2 4
Contd…
No Practice of providing top milk PD 45 96

PDB5 76 (79%) 13.06
at 1st 6 months ND 31 63
PD 31 66
PDB6 Exclusive breastfeeding practice 31 (32%) 100
ND 0 0
Continued breastfeeding upto 2 PD 23 49
PDB7 35 (36.5%) 2.95
years ND 12 24
PD 45 96
PDB8 Breastfeeding during illness 85 (88.5%) 5.06
ND 40 82
Timely initiation of PD 39 83
PDB9 62 (64.5%) 5.51
complementary feeding ND 23 47
PD 26 55
PDB10 Active feeding 36 (37.5%) 4.83
ND 10 20
Table 1 shows only 48% mothers initiated stunted, 61% underweight) as compared to PD mothers
breastfeeding within 1 hour after birth. Colostrum feeding (40% wasted, 53% stunted 61% underweight). Statistical
rate in the area was comparatively better as 71% mothers analysis in SPSS23 software showed significant
fed colostrum to their children after birth. Pre-lacteal correlation between PD score and weight for age
feeding was carried out in case of 50% children; water (Underweight status) of the children.
and top milk were provided to 61% and 20% children
respectively within 1st 6 months after birth. As a result DISCUSSION
only 32% children were exclusively breastfed which
was not at all satisfactory. Only 36% mothers continued Previous studies in rural India, In villages of UP2,
breastfeeding upto 2years and 64% mothers initiated West Bengal3 , and Tamil Nadu4, positive deviance
complementary feeding after 6 months. Only 37% mothers and normal growth of children was enhanced under
practiced active feeding but the rate of breastfeeding conditions of small family size (<5), parity below 3,
during illness was quite high (88%). Table 1 also shows family support to mother, timely initiation of breast
exclusive breastfeeding; practice of pre-lacteals and water feeding, higher frequency of breastfeeding.
feeding were main PDBs identified among PD mothers
Desirable IYCF practices such as frequent breast
which had higher impact on the PD score according to
feeding, timely initiation of Complementary Food (CF),
their respective OR value at 95% confidence interval active feeding, giving foods of thicker consistency etc5
(CI). Therefore, these practices can be easily promoted are some major factors contributing better nutritional
through PD approach as they are the major PD behaviours status.
present among the study population.
Viewed collectively, available evidence shows
that whether rural or urban, key child feeding and
hygiene healthcare practices contributing to normal
child growth are similar in most regions. Following the
recommendations is not only important for child growth
and development, but evidence from observational
studies suggests that sub-optimal infant and young
children feeding practices can increase the risk of
morbidity and mortality in young children6.
Figure 1: Incidence of child undernutrition among
PD and ND groups Another study done in Indonesia stated that PDA
could be a community based solution to improve child’s
Figure 1 shows incidence of child undernutrition nutritional status. Nutritional surveys are needed to
was higher among ND mothers (44% wasted, 61% identify most significant malnutrition determinants to
see adoption of new behaviours and sustainability of REFERENCES

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Promotion of PDBs can be crucial to bring
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sustainable change as these behaviours are likely to
6. Black RE, Allen LH, Bhutta ZA, Caulfield
be affordable and acceptable by the wider community.
LE, deOnis M, Ezzati M. Maternal and child
Interaction of similar cohorts is important for promotion
undernutrition: global and regional exposures and
of PDBs. Positive deviance behaviours regarding quality
health consequences. Lancet 2008; 371: 243–260.
and quantity of complementary foods, dietary diversity,
sanitation and hygiene, quality of care, health care access 7. Hidayat, S. The influence of positive deviance
and stimulations for various domains of development are approach on nutrition (POS GIZI) outcomes in
also need to be identified and promoted. Service, delivery children under 5 years (CU-5) in Aceh Besar
and utilization of the existing government programme district 2009.
need to be studied and empowerment of community 8. Sethi V, Kashyap S, Agarwal S, Pandey RM,
workers has to be initiated to bring a sustainable change Kondal D. Positive deviance determinants in
in the situation young infants in rural Uttar Pradesh. Indian J
Pediatr 2007; 74: 78–9.
Source of Funding: The study was supported by
9. Saha C, Chowdhury AR, Nambiar VS. Effect of
University Grant Commission (Junior research fellowship
personalized counseling as a tool for behaviour
provided by UGC) and CSR cell of Transpek Silox
change communication for improving the
Industries Private Limited, Vadodara, Gujarat, India
nutritional status and IYCF practices of children(0-
Conflicts of Interest: The authors declare that they have 5years) in under 5 clinic and day care centre, south
no conflicts of interest. 24 Parganas, West Bengal. International journal of
food and nutritional sciences 2015; 4(3): 86-96.
DOI Number: 10.5958/0976-5506.2018.00609.5
The Compliance to Occupational Radiation Safety to the

Baggage Fluoroscopy System in International Airport
Siti Daryati1, M. Irwan Katili2, Jeffri Ardiyanto2, Rini Indrati2, Gatot MW2, Ismi Rajiani3
1
Assistant Professor, 2Associate Professor, Politeknik Kesehata Kementrian Kesehatan, Semarang, Indonesia;
3
Deputy to Chairman, STIAMAK Barunawati, Surabaya, Indonesia
ABSTRACT
Background: Radiation safety program applied on the X-ray fluoroscopic screening baggage unit at Airport
is important to detect and identify any of the prohibited goods or things that thread the aviation’s world. This
study aims to evaluate on site dose rates and occupational dose when the fluoroscopic screening baggage is
on duty.
Method: A total 25 sample of dose measurements obtained from the population by purposive random
sampling. The radiation dose rates and occupational doses selectively monitored with the TLD incorporated
with Survey meter. Descriptive statistics and interactive models were blended in analyzing the acquired data.
Results: The X-ray baggage unit at gate-1 contributes the minimum dose rates at 0.00017 mSv/h. The gate-
5 shows the highest maximum value at 0.00133 mSv/h. Occupational doses (operator and metal detector
personnel) were within the safe limit at 0.00001 mSv. The estimated occupational dose received by each
worker/year was made up of 0.95 mSv.
Conclusion: Most employees who work in the X-ray baggage section had lack understanding about
radiation safety and its biological effect on human cells. Possible biological effects could be reduced
amongst responsible personnel in duty if they create the safety radiation program based on this study
recommendations
Keywords: Radiation safety program, dose rate, occupational dose, X-ray fluoroscopic baggage
INTRODUCTION High doses of ionizing radiation apparently produce

deleterious consequences in humans, including cancer
The application of X-ray in radiography industry induction(2). Similarities in cellular effects lead to the
is closely similar to that of the medical field. One of assumption of a common mechanism and the DNA
the requests of industrial radiographic technic is the double strand break is identified as the severe radiation-
utilization of baggage fluoroscopy as X-ray device for induced lesion. A cancer model extends the cellular
passengers and crews’ luggage safety at the airport. The consequences of the main radiation risk confirming the
implementation of X-ray used to baggage fluoroscopy is dose effect for cancer at low doses(3).
intended to detect passengers’ baggage before entering
the airport. Nevertheless, caution should be exercised Ahmad Yani International Airport of Semarang has
when using baggage fluoroscopy due to its utilization of six baggage X-ray devices, 2 for baggage and 4 for cabin
relatively high electromagnetic radiation (140 – 180 kV) materials wherein they are operated to monitor incoming
which can cause biological effect toward the people things to the aircraft. These devices are operational from
surrounding the device(1) 06:00 AM WIB to 21:00 WIB, causing a big amount
of radiation but the monitoring of the measurement of
exposure and dosage rates is not yet to be optimized.
Corresponding Author:
Therefore this research is highlighting the compliance to
Siti Daryati,
the safety as regulated.
Politeknik Kesehatan Kementrian Kesehatan Semarang,
Indonesia
METHODOLOGY In Gate 2, lowest exposure rate happened to E

(scanner operators of outgoing goods) which amounts
This study was performed in quantitative and
to 0.00013 mSv/h, and the highest exposure rate
qualitative ways. The quantitative approach is used to
happened to B (scanner operators of incoming goods)
measure the exposure rates on baggage cabin fluoroscopy
which amounts to 0.0008 mSv/h. The average of the five
and operators’ occupational radiation doses. Radiation
exposure rates of the five units of baggage fluoroscopy measurement points is 0.00041 mSv/h with a standard
(two baggage X-ray, two domestic Cabin X-ray, and one deviation of 0.00027 mSv/h resulting in the lowest
international Cabin X-ray) were measured by survey average rate of 0.0004 mSv/h and highest average rate
meter (Babyland, USA) and occupational doses of 25 of 0.00107 mSv/h.
operators on duty were measured by personal dosimeter
In Gate 3, the lowest exposure rate happened to C
of Thermo Luminescence Dosimetry (TLD) Chip. The
(scanner operators of outgoing goods) which amounts to
qualitative method was performed by conducting a
deep interview to assess workers’ knowledge about 0.00010 mSv/h, and the highest exposure rate happened
X-ray utilization. Five respondents were involved in to D (scanner operators of incoming goods) which
giving information concerning operators’ knowledge amounts to 0.00077 mSv/h. The average of the five
about X-ray use. The analysis outcome of exposure measurement points is 0.00039 mSv/h with a standard
and dose rates of radiation workers was compared to an deviation of 0.00026 mSv/h resulting in the lowest
international publication(4) and national value of Dose average rate of 0.00036 mSv/h and highest average rate
Reference Limit (DRL) standard(5). of 0.00103 mSv/h.
Gate 4 is used for scanning hand-carries such as

RESULTS
handbags, souvenirs, and hand-carried items.
Dosage Exposure Rate: The measurement of radiation
The lowest exposure rate happened to A (baggage
exposure was done on 5 scanner fluoroscopy devices
with the following detail: 2 Baggage X-ray, 2 domestic X-ray operator) which amounts to 0.00013 mSv/h,
Cabin X-ray, and 1 international Cabin X-ray. In Gate and the highest exposure rate happened to D (scanner
1, the lowest exposure rate happened to F (passengers) operators of incoming goods) which amounts to 0.00093
which amounts to 0.00017 mSv/h and the highest mSv/h. The average of the five measurement points is
exposure rate happened to E (scanner operators of 0.00036 mSv/h with a standard deviation of 0.00031
outgoing goods) which amounts to 0.00067 mSv/h. The mSv/h resulting in the lowest average rate of 0.00044
average of the five measurement points is 0.00047 mSv/h mSv/h and highest average rate of 0.00124 mSv/h.
with a standard deviation of 0.00021 mSv/h resulting in
the lowest average rate of 0.00038 mSv/h and highest Gate 5 is the international flight scanner. To sum up,
average rate of 0.00088 mSv/h. the summary of all measurement is shown in Table 1.
Table 1: Summary of the lowest and the highest exposure rates
Measurement Lowest Rate Highest Rate

No. Remark
Location (mSv/h) (m Sv/h)
1. Gate 1 0.00017 0.00067 Baggage X-ray, 1-meter distance from X-ray source
2. Gate 2 0.00013 0.00080 Baggage X-ray, 1-meter distance from X-ray source
Domestic cabin X-ray 1-meter distance from X-ray
3. Gate 3 0.00010 0.00077
source
Domestic cabin X-ray 1-meter distance from X-ray
4. Gate 4 0.00013 0.00093
source
International cabin X-ray 1-meter distance from
5. Gate 5 0.00010 0.00133
X-ray source
The average exposure rates at seven measurements for Dosage Limit (DL) of 20 mSv/year (6) is still within
are shown in Table 2. a safe boundary.
Personnel Dosage: Personnel Dosage is measured using

Table 2: Exposure rate average Thermo Luminescence Dosimetry (TLD) for 1 month
toward 12 staffs of licensed operators and 13 outsourced
Location
(supporting) metal detector personnel, altogether 25
Gate 1 0.00047 ± 0.00021 personnel. Based on the TLD reading of the airport 1274
Gate 2 0.00041 ± 0.00027 001 T up to 1274 025 T series on staff using TLD on
Gate 3 0.00039 ± 0.00026 their waists.
Gate 4 0.00036 ± 0.00031
The above result is collected by Safety Guide Test
Gate 5 0.00039 ± 0.00053
Method(6), and the element was read by TLD reader
The mean and standard deviation values resulting BARC type TL 1010. The reading was converted into
from the highest exposure rate measurement at Gate the radiation dose based on appropriate calibration
1 (Astrophysics Baggage X-ray) show the value of curve/factors.
(0.00047 ± 0.000212) mSv/h. The mean and standard
Airport operators work daily for 8.5 hours for the
deviation values resulting from the lowest exposure
morning shift and 7.5 hours for the afternoon shift, and
rate measurements at Gate 4 (Fiscan Domestic Cabin
the radiation collected is accumulative. Within 168.5
X-ray) show the value of (0,00036 ± 0,00031) mSv/h.
hours a month and 2022 hours a year under the mean
Deviation value resulting from the measurement is quite
score of 0.00047 mSv/h, the accumulated annual dosage
low between (0,00021 ± 0,00053) mSv/h.
is 0.95 mSv/year, and it is still below the safe boundary.
Table 1 shows that the Astrophysics Baggage X-ray
Operators Knowledge in X-ray Utilization: The
(Gate 1) gets the highest minimum score of 0.00017mSv/h
operators’ opinion during their work with X-ray so far are
as compared to other gates (0.00010 – 0.00013 mSv/h).
they work according to schedule, but they are not aware
Gate 5 obtains the highest maximum score of 0.00133
of the impact of the danger of X-ray to health. According
mSv/h as compared to other gates (0.00067 - 0,00093
to respondent, operator for X-ray monitor must have a
mSv/h). The highest mean and standard deviation of the
license of Junior Av Sec while metal detector operator
exposure rate measurement at Gate 1 shows the value
must have Basic Av Sec. Medical check-up for baggage
of 0,00047 ± 0,00021 mSv/h. The effective dosage
and cabin X-ray operators is given once a year for each
outcome of the monitor and the metal detector operators
employee, consisting of blood and urine test, yet there is
using TLD dosimeter is 0,00001 mSv.
no first check-up for X-ray operators. Formerly radiation
The minimum exposure rate of Gate 1 gets a high dosage Monitor was given to operators in the form of a
score because it has a device with voltage specification of filmed badge to be put on their trousers, but it has been
165-180 kV. Gate 1 scanner is utilized to check materials 5 years they don’t use it anymore because the company
that are inside numerous items of baggage. Therefore does not provide it anymore.
a higher X-ray energy is required to penetrate them.
From the interview result it was found that operators’
Higher voltage produces potentially higher penetrating
knowledge about radiation is still lacking, yet from the
power so that the shield of the device is not sufficiently
measurement outcome of the exposure rate and personal
effective to protect the radiation scatters.
effective dosage, their dose levels are still within the safe
The measurement of exposure rate conducted at the boundary.
area of 1-meter distance from the radiation source shows
By the regulation (6) if a radiation operator receives
a leak of the X-ray around at a distance. Therefore, the
excessive dosage, he/she should be given a break or
operators should not stand too close to the scanner device.
transferred to radiation-free section. One of the efforts
The mean of exposure rate as compared to the standard
is by scheduling the work shift for each operator
is 1 mGy/h which is still within the safe boundary. The
beginning with morning shift, afternoon shift and then
effective radiation doses of the monitor and the metal
taking an off day, in the attempt to minimize radiation
detector operators worked for 1 month shows a much too
dose received by the operator. Despite the existence of
small a value where the result of the effective dose score
shield protection within the fluoroscopy device, new
Pb protection curtain should be provided for X-ray Ethical Clearance: The research received permission
operators. Besides, at present situation operators are not of ethical approval from the Health Research Ethics
using a radiation monitoring tool. This practice is against Committee of Poltekkes Kemenkes Semarang,
the regulation(6) that every radiation worker must use Indonesia.
radiation monitoring tool and be periodically monitored.
References
CONCLUSION
1. Heye S, Maleux G, Oyen RH, Claes K, Kuypers
The baggage X-ray at gate 1 (domestic passengers) DR.J (2012) Occupational Dose: Percutaneous
of Ahmad Yani Airport, Semarang, Indonesia shows the Interventional Procedure on Hemodialysis
highest level of average dose rates per hour (0.00047 ± Arteriovenous Fistulas and Grafts.radiology
0.00021) compared to that of the rest baggage X-rays RSNA .org. Radiology:Vol 264, 1-2
at gate 2-5. For all baggage X-rays, however, their
2. Brenner DJ, Doll R, Goodhead DJ, Hall EJ,
average dose rates per hour are declared still within the
safe boundary. Similarly, the effective personal dose Land CE, Little JB, et al. (2003).Cancer risks
of monitor and metal detector operators using TLD attributable to low doses of ionizing radiation:
dosimeter device is 0.00001 mSv, which is also still Assessing what we really know. Proc Natl Acad
within a safe edge. Sci USA 100:13761–6.
Shortly, although all domestic and international 3. Chadwick, KH, and Leenhouts, (2005). Radiation
baggage X-rays are run within recommended radiation risk is linear with dose at low doses. The British
dose limit, a relatively small radiation dose received by Journal of Radiology, 78 (2005), 8–10.
the operators would still have a potential danger to the 4. U.S. National Academy of Sciences, National
human cells as it accumulates, absorbs and is deposited Research Council, Committee to Assess Health
in the human tissues in the long term. Additional Risks from Exposure to Low Levels of Ionizing
protective barriers should be placed appropriately around
Radiation. BEIR VII Phase 2, Washington, DC:
the baggage X-rays so that the low energy radiation
National Academic Press, 2006.
levels would be absorbed by the barrier and protect the
operators from stochastic biological effects. 5. BAPETEN, (2009), Peraturan Kepala BAPETEN
No. 7 Tahun 2009, tentang Keselamatan Radiasi
Conflict of Interests: The authors have no conflict of dalam Penggunaan Peralatan Radiografi Industri,
interests related to the conduct and reporting of this
Jakarta.
research.
6. BAPETEN, (2011), Peraturan Kepala BAPETEN
Source of Fundings: The authors would like to thank No. 8 tahun 2011, tentang Keselamatan Radiasi
Polytechnic of Health Ministry of Health located in dalam Penggunaan Pesawat Sinar-X Radiologi
Semarang, Central Java, Indonesia for funding.
Diagnostik dan Intervensional.
DOI Number: 10.5958/0976-5506.2018.00610.1
The Nutrition Care Process (NCP) Impact to the Dietary

Behavior of Diabetes Mellitus Patients
Setyo Prihatin1, Sri Noormintarsih1, Ana Yuliana Rahmawati1, J. Supadi1, Asep Tata Gunawan2, Ismi Rajiani3
1
Assistant Professor, 2Associate Professor, Politeknik Kesehatan Kementrian Kesehatan Semarang,
Indonesia; 3Deputy to Chairman, STIAMAK Barunawati, Surabaya, Indonesia
ABSTRACT
Background: The regulation number 24 in 2015 obliging the Community Health Center or Pusat Kesehatan
Masyarakat in Indonesia to handle Diabetic patients affects the changing in nutritional care system including
the Diabetes Mellitus management.
Objective: The purpose of the study is to know the effect of the Nutrition Care Process (NPC) on knowledge,
attitude, behavior and blood glucose of patients with DM.
Method: This experimental study used the Pre and Post Test Control Groups Randomized Design to 44
diabetic patients of treatment and control groups. The treatment group was given the NCP and the data of
knowledge, altitude, and behavior and blood glucose were measured twice. The independent T-Test was
applied to analyze the effect of NCP.
Result: The study found that no differences between control and treatment group at the beginning of the
survey. The independent T-Test showed that the NCP affect attitude and behavior of Diabetic patients
significantly, but the knowledge did not produce any different result between control and treatment group.
Fasting blood glucose level was significantly different while the 2-hour postprandial blood glucose level
shows no difference.
Conclusion: It is concluded that NCP should be applied in the Community Health Center as one of
procedures to provide the high-quality nutritional care.
Keywords: NCP, Behavior, Diabetes Mellitus
INTRODUCTION in the implementation of DM diet achieving 91.4%

(4)
. Another study conducted on 100 Indonesian DM
Diabetes Mellitus (DM) is a chronic disease that patients visiting the Diabetes Polyclinic, who adhered to
cannot be cured, but blood sugar levels can be stabilized the implementation of diabetes mellitus diet only 37% of
to normal. Maintaining blood sugar levels require patients and non-adherent to the implementation of DM
medication adherence and diet as a self-management diet as much as 63%(5).
process (1). Useful independent DM management is
possible if individuals have the knowledge, skills to The Nutrition Care Process (NCP) is a comprehensive
perform DM control behaviors independently (2), (3). and individualist approach to increased awareness and
Compliance of DM patient diet in many studies conducted behavioral change. The role of nutritionists is crucial
was still small, for example, the research carried out in in helping the process of healing the patient through
Banyumanik Sub-district of Semarang showed the high nutritional services. Effective, efficient, and integrated
percentage of respondents who did not become obedient nutrition services through Nutrition Care Process (NCP)
are proven to reduce disease complications (6). The
Corresponding Author: application of NCP has so far had a positive impact on
Setyo Prihatin, the patient’s nutrition service system at the Hospital.
Politeknik Kesehatan Kementrian Kesehatan Research at Sultan Agung Semarang Islamic Hospital
Semarang, Indonesia showed that there was an increase of energy and protein
intake of chronic renal failure patients after nutritional RESULTS

intervention following NCP procedures at 12% average.
Nutrition service standards at Community Health
Increased intake of nutrients will positively affect
Centers, especially in patients of chronic disease service
improving the nutrition of patients so that it may help
program of Diabetes Mellitus patient at Bangetayu and
speed up the healing process of patients (7).
Genuk Health Center, include assessment of patient’s
This study is to determine the effect of food treatment nutritional status, investigation (blood pressure and
through NCP on changes in attitude knowledge, diet blood glucose level) and nutritional counseling. Thus,
the nutritional services undertaken have not been based
compliance and blood sugar levels in patients with
on the nutritional problems experienced by patients
Diabetes Mellitus in Community Health Centers.
but based on medical therapy. The nutrition services
using Nutrition Care Process model (NCP) given to the
METHODOLOGY treatment group in this study are:
This experimental study used pre and post 1. Assessment: i.e., identification of nutritional
randomized controlled randomized design. The study problems related to nutrient intake and bioactive
was conducted at two health community centers in Genuk substance, clinical aspects (observing the results
of nutritional status measurement, laboratory
sub-district, Semarang city. The test was performed on
examination, and support), behavioral and
forty four participants under chronic disease service
environmental issues and causes.
program who have met the inclusion criteria of Diabetes
Mellitus. The selected samples were then randomly 2. Diagnosis of nutrition: determining the nutritional
assigned to the control and treatment groups. The data problems based on assessment results.
collected include identity data, knowledge, attitude, diet 3. Interventions: given nutritional counseling
behavior and blood sugar level of patients taken before according to the patient’s nutritional diagnosis
and after treatment by interview method. In the treatment and nutrition education about DM diet.
group after the data were taken at the next stage 1, 4. Monitoring and evaluation: results of the
Nutrition Care Process (NCP) was given a treatment interventions provided are monitored and
of nutritional care service. NCPs included nutrition evaluated through diet after the intervention,
assessment, diagnosis of food, dietary interventions laboratory outcomes and changes in knowledge,
based on the diagnosis of nutrition and evaluation attitudes, and behavior.
monitoring. Nutrition intervention includes nutrition
The treatment group of women mostly equal to
education, nutrition counseling. In the other hand, the 36,4% and in control group mostly women as big as
control group only gets the standard service of chronic 34,1% Scores of nutritional knowledge, attitudes and
disease service program. Hypothesis test employed the dietary compliance of study subjects before treatment
independent t-test analysis with 0.05 confidence level. presented in Table 1.
Table 1: Knowledge, attitudes, and adherence to treatment
Treatment (n = 22) Control (n = 22)

Variables p
Mean SD Mean SD
Knowledge 8 3.8 10.6 6.0 0.095
Attitude 26.5 2.8 27.3 4.3 0.481
Dietary compliance 26.9 3.9 27.1 4.3 0.885
The mean score of knowledge before treatment in with the mean of 27.3 + 4.3 and 27.1 + 4.3 respectively.
control group was higher than treatment group that was These results show the sample at the beginning of the
10.6 + 6.0, but statistically there was no difference (p study was not different between control and treatment
= 0.095). Similarly, the mean scores of attitudinal and groups (homogeneous). Blood sugar levels of the subjects
obedience scores were also greater in the control group of the study before treatment were presented in Table 2.
Table 2: Fasting blood sugar and blood sugar Levels before treatment

Variables P
Mean SD Mean SD
Fasting blood sugar 186.8 62.3 150 59.9 0.060
Blood sugar 2 hours postprandial 186.5 66.7 158.4 58.8 0.145
Table 2 shows the mean fasting blood glucose level in the treatment group was higher than the control group
that was 186.8 g / dl + 62.3. Similarly, the average blood glucose level of 2 hours postprandial was also greater in
the treatment group with the mean of 186,5 + 66,7. However, statistically there was no difference (p = 0.060 and p
= 0.145). Research subjects both in the treatment and control group were re-measured for nutritional knowledge,
attitude, and diet compliance after being treated where the results were presented in Table 3.
Table 3: Knowledge, attitudes and diet compliance of study subjects after treatment

Variables P
Mean SD Mean SD
Knowledge 10.36 3.7 10.36 5.6 1
Attitude 30.86 2.4 26.86 3.7 0.040
Dietary compliance 31.22 2.97 28.18 4.69 0.014
Table 3 shows that the mean score of knowledge was contradict previous studies that found a significant
almost the same score of 10.36 + 3.7 and in the treatment relationship between counseling and knowledge (3).
group and 10.36 + 5.6 in the control group. Statistical The influence of nutrition service model NCP on
analysis showed no difference in both groups (p = 1). the attitude of treatment group increased more than
The average score of attitudes and diet compliance was with control group. There is an increase in the normal
higher than the control group that was 30.86 + 2.4, and view stance in case and control groups after receiving
31.22 + 2.97 Statistical analysis showed that there was NCP nutritional services. The result of hypothesis test
a difference in both groups after treatment (p = 0.04 and shows that there is a significant influence of attitude on
p = 0.014). control group and treatment after receiving Nutritional
Care with NCP model (P Value = 0.04) Hypothesis test
The influence of nutrition service model NCP on demonstrated a major impact of the provision of NCP
group treatment knowledge increased compared to with dietary compliance of DM patients in the Health
control group that decreased. There was an increase Community Center with P value = 0.014. Table 4 shows
in the mean of knowledge scores in both control the mean fasting blood glucose level and 2 hours post
and treatment groups after receiving treatment of prandial blood glucose concentrations in the lower
nutritional services with NCP. The result of the treatment group after being given NCP model nutrition
statistical test showed inconsistent results where the services compared to controls that received the standard
result is not significant at P-value = 1.00. These results nutritional services of the Health Community Center.
Table 4: Fasting blood sugar and 2 hours postprandial blood sugar

Variables P
Mean SD Mean SD
Fasting blood glucose 126.09 32.7 175.63 66.07 0.04
Blood glucose 2 hours postprandial 180.82 76.89 198.64 76.09 0.44
The mean fasting blood glucose level of the treatment group was 126.09 g / dl + 32.7 lower than the control group,
and there was statistically different in both groups. The mean blood glucose level of 2 hours postprandial treatment
group was 180,82gr/dl + 76,89 lower than the control group, and statistically, there was no difference in both groups.
The results of statistical tests showed a significant cognitive responses such as nutrition education will
effect of NCP nutrition service on fasting blood glucose produce behavioral changes. Inadequacy with previous
level (P Value = 0.04) while at 2-hour polyurethane studies is possible because the interventions given in NCPs
postprandial level although there was a decrease in depend on approaches and objectives where the emphasis
gum sugar statistically did not show a significant effect is focused on behavior change rather than on knowledge
(p-value = 0.44). change. This occurrence is in line with a finding (8) that
with the NCP service can improve changes in drug-taking
DISCUSSIONS behavior in Diabetes Mellitus patients.
The results of the study found that chronic disease According to Theory of Reasoned Action (TRA),
service system performed in the two Health Community individual attitudes and norms towards a disease affect
Centers is a medical service in the form of drug services dietary adherence. Decision theory also mentions the
and medical examination. Nutrition services that run in patients themselves make decisions about what to do
the kind of group services are counseling. Food services in the treatment business. This notion is related to the
in the form of NCP should be applied to patients with communication that exists between the patient and the
chronic diseases that are more individual. This personal health professional. If patients are well informed about
service will give positive results both on knowledge, procedures, risks, and effectiveness of the engagement
attitude, and behavior. There is one fundamental as done in the NCP intervention, then they will make the
difference between the standard of the nutritional service right decision. In the NCP nutrition assessment carried
of the Health Community Centers and the NCP. The out not only leads to the proper enforcement but also in
level of nutrition services in Health Community Centers nutritional diagnoses.
is located on “what should be done” and is a component
of care in certain diseases. Nutrition Care Process (NCP)
CONCLUSIONS
is a standardized process, further demonstrating “how
nutritional care is done.” In essence, the NCP accurately 1. There is an increase in attitude score, knowledge,
displays the nutritional care spectrum that emphasizes the dietary behavior after being given a nutritional
consistent and accurate steps of dietitians when delivering service model NCP. Also, there is an improved
nutritional care, as well as guidelines in nutrition education dietary adherence after being given a nutritional
and other preventive nutrition care venues. service of NCP model.
Although the results of the study were statistically no 2. There is a decrease in fasting blood glucose levels
difference between the control group and the treatment after being given a dietary service model NCP, and
of knowledge, there was an increase in the mean of also there is a reduction in fasting blood glucose
knowledge scores between the baseline data and the levels after being given a nutritional service of
final data. Experience as an individual’s cognitive part NCP model.
is influenced by adequate information from anyone. An
3. There is an influence between the application of
increase in the knowledge scores provides evidence of
NCP in chronic Diabetes Mellitus patients with
the development of disease-related information obtained
knowledge, attitude and dietary behavior as well
by the sample.
as increased blood sugar after being given NPC
The NCP which is a standardized nutrition service model of nutrition service.
begins with a nutritional assessment to find nutritional
problems in samples that are technically made in a Nutrition officers of Community Health Centers
nutritional diagnosis. The Nutrition intervention given is are recommended to provide food services as echoed
based on the etiology present in the nutritional diagnosis, by NCP model, especially in patients of chronic disease
so the approach is so specific and individual that it service program because it proved to increase knowledge,
will encourage a change of attitude. According to the attitudes and dietary compliance of Diabetes Mellitus
theoretical model of persuasion communication with the patients. Given these changes will have an impact on the
cognitive theoretical approach, that stimulus that produces achievement of healthy blood sugar levels.
Conflict of Interest: The author has no conflict of 4. Ernaini (2005) Hubungan Kepatuhan Diit Dengan
interests related to the conduct and reporting of this Pengendaliaan Kadar Gula Darah. (Studi Pada
research. Penderita Diabetes Melitus Usia Lanjut Di
Puskesmas Padangsari Banyumanik Kecamatan
Source of Funding: Source of the fund for this project Banyumanik Semarang. Prodi S1 Gizi. Semarang,
was by Politeknik Kesehatan Kementrian Kesehatan Universitas Diponegoro.
Semarang.
5. Witasari, U. (2009) Hubungan Tingkat
Ethical Clearance: Before conduct of the study written Pengetahuan, Asupan Karbohidrat dan Serat
permission was obtained from Politeknik Kesehatan Dengan Pengendalian Kadar Glukosa Darah Pada
Kementrian Kesehatan Semarang, Indonesia. Consent Penderita Diabetes Melitus Tipe 2 Rawat Jalan di
and willingness were established from all the subjects RSUD Dr. Moewardi Surakarta. Jurnal Penelitian
who meet inclusion criteria of this study. Sains & Teknologi, Vol. 10, No. 2.
6. Asdi, P. (2005) Proses Asuhan Gizi Terstandar
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Penderita Diabetes Mellitus Tipe 2 Pada Pasien 7. TRI, N. (2011) Perbadaan Intervensi Gizi
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DOI Number: 10.5958/0976-5506.2018.00611.3
Association between Maternal Folate Intake and

Polymorphism MTHFR A1298C as Risk Factor of
Non-Syndromic Cleft Lips
Yayun Siti Rochmah1, Stefani Harumsari2, Agung Sosiawan3, Ismi Rajiani4

1
Departement of Oral and Maxillofacial Surgery Faculty of Dentistry, 2Departement of Biology Faculty of
Medicine, Sultan Agung Islamic University, Semarang, Indonesia; 3Department of Dental Public Health,
Faculty of Dental Medicine, Universitas Airlangga, Surabaya Indonesia; 4Deputy to Chairman, STIAMAK
Barunawati, Surabaya, Indonesia
ABSTRACT
Background: Methylenetetrahydrofolate reductase (MTHFR) is often associated with the incidence of
orofacial clefts. Folic acid deficiency has gained considerable attention because of its promising role in
modulating diverse clinical condition such as cleft. The objective of the study is to describe the association
of MTHFR A1298C polymorphism and maternal folate intake with an orofacial cleft in Sasak Population.
Method: This study used control case design, the number of the subjects were 148 who were divided into
case groups and their mother (70 issues) and control groups and their mother (78 items). The detection of
Polymorphism MTHFR A1298C used PCR-RFLP and sequencing for confirmation. The information on the
dietary pattern and folic acid intake used FFQ (Food Frequency Questionnaire).
Results: MTHFR A1298C polymorphism was associated with maternal folic acid intake in Sasak (p =
0,001), OR = 14,7 CI 95% (2,49-85,53) for cases and (p= 0,041), OR = 4,4 CI 95%(0,9-19,16) for control
group. Maternal folic acid intake was associated with cleft (p=0,037) OR= 2,7 CI 95% (1,06-6,94) in Sasak
Population.
Conclusion: Maternal folic acid was as the risk factor cleft lip/palate in Sasak population and association
with MTHFR A1298C Polymorphism.
Keywords: Polymorphism MTHFR A1298C, folic acid, orofacial clefts
INTRODUCTION A1298C is MTHFR genotype variants that are thought to

contribute to cleft lip, or palate (5). MTHFR is an enzyme
The incidence of nonsyndromic cleft lip with or that converts 5, 10-methylenetetrahydrofolate from folic
without cleft palate (NS CL/P) remains high in all over the acid into 5-methyltetrahydrofolate in folate cycle, The
world. In Indonesia, there will be 3000 to 6000 new cases endogenous folate cycle is a predominant methyl donor
of cleft lip annually accounting for 2.4% or 1.7 per 1,000 to remethylate homocysteine (Hcy) into methionine (6).
live births (1). In Asian countries such as India, the incidence Pregnant women with MTHFR polymorphism have a
of cleft lip is high in which 35. 000 babies were born with higher risk to get folate deficiency (7). The food sources
the cleft (2). In Africa, the number of people with cleft lip that rich in folate are liver, fish, and meat, mushroom,
tends to be less ( 1: 2,500 births) (3). Multifactorial factors green leafy vegetables such as spinach, bean leaves, nuts,
including genetic and environmental are contributing in and yeast. Food processing can destroy 50-90% of folate
cleft lips (4). Methyltetrahydrofolate Reductase (MTHFR) content by heating, oxidation, and exposure to ultraviolet
light (8). Dietary folates are conjugated by Gamma-
glutamyl hydrolase/folate into monoglutamate assisted
Yayun Siti Rochmah,
by Zink (9). Folate deficiency and abnormal metabolism of
Jl Raya Kaligawe Km.4,
folic acid and Hcy play a significant role in the incidence
PO BOX 1054, Semarang Central Java of Indonesia.
of neural tube defect (NTB), facial cleft, congenital heart Genotyping: The MTHFR were amplified with three-
disease, pregnancy complications, and other congenital step Polymerize Chain Reaction (PCR) followed by
abnormalities (10). Because of foods high in folic acid are Restriction Lenght Fragment Polymorphism (RFLP).
found from an animal source that is quite expensive for The PCR RFLP was done at Cebior Laboratory Faculty of
most Indonesian including Sasak population. Medicine Diponegoro University, Semarang Indonesia.
MTHFR A1298C forward primer 5’-CAA GGA GCG
To ensure that pregnant women folic acid intake GCT GAG GAA GA-3 ‘and reverse primer 5’-CCA
is sufficient a folic acid supplementation program CTC CAG CAT CAC TCA CT-3 ‘. MboII, restriction
began after 2002. The supplementation programme has enzymes were used in the identification of MTHFR
just been set by the government in 2014 but still lack genotype. The enzyme will digest the PCR product of
of monitoring report. Hence, this study assessed the 128 bp into two fragments measuring 100 bp and 50 bp.
relationship between maternal genetic background and
folate status with or without supplementation. Folate status: data were obtained with the administration
of Frequency Questionnaire (FFQ) 10 and analyzed by
Nutrisoft 10.1 software.
Statistical analysis: The relationship between MTHFR
Study design: The study design was a case control.
gene and cleft lip were analyzed by using a Chi-Square
Subjects were 70 children and their mother from Sasak
test and the Odd Ratio (OR), Confidence Intervals 95%.
Tribe population with a non-syndromic cleft lip with or
If the relationship between folate status and cleft lip
without cleft palate. The control population was enrolled
had normally been distributed, data were analyzed by
from 78 healthy normal children and their mother. The
T-independent Test. Otherwise, Mann Withney analysis
clinical examination of the subjects was done by Lips
was performed.
- Alveolar - Hard palate - Soft palate - Alveolar – Lips
(LAHSAL). Inclusion criteria that obtain in this study RESULTS
were the mother and her child less than five years old,
average weight and body length at birth, without other The distribution of variant cleft for case subjects was
congenital abnormalities associated with cleft lip/ unilateral cleft lips (31.4%), bilateral cleft lips (21,5%),
palate syndrome. The exclusion criteria were orphaned cleft palates (28.5%) and cleft lips with palates (18,6%).
children, and the mother had undergone chemotherapy The FFQ data analysis with Nutrisoft Software was used
or radiotherapy. to determine the Odd Ratios (OR) of folic acid in 2.7
(95% CI: 1, 1-6,9). Mann Whitney test was applied to
Blood Sampling: Blood Ethylenediaminetetraacetic determine the difference between the subjects with the
Acid (EDTA) samples were withdrawn for 5 ml cleft lip the control resulting in p = 0.037 which (<0.05)
from all of the study subjects for salting out DNA meaning that there was a significant difference in folic
(Deoxyribonucleic Acid). Extraction. acid between the case and oversight group.
Table 1: Genotype distribution of MTHFR A1298C gene
Genotype case (n = 70) N (%) control (n = 78) N (%) P value OR (CI 95%)
A1298C/AA 30(42.9%) 27 (34.6%) -- --
A1298C/AC 31 (44.3%) 41(52.6%) 0.036 2.7(1.1-7.0)
A1298C/CC 9 (12.9%) 10 (14.3%) 0.041 2.7(1.0-7.0)
CI: Confidence Interval, N: Number, OR: Odd Ratio
Table 1 showed the distribution of MTHFR A1298C mutant heterozygotes, and mutant homozygotes and
genes. In the MTHFR A1298C gene showed a uniform there was a significant difference between cases and
distribution of genotype between the common allele, controls.
Table 2: The relationship between maternal folate status during pregnancy and polymorphism MTHFR A1298C
MaternalFolate MTHFR A1298C gene

P Value OR (CI:95%)
Status Polymorphism Normal Allele
Case
Poor 16 (88.9%) 6 (35.3%)
0.001 14.7 (2.49-85,53)
Good 2 (11.1%) 11 (64.7%)
Control
Poor 7 (63.6%) 8 (28.6%)
0.046 4.4 (0.9-19.16)
Good 4 (36.4%) 20 (71.4%)
CI: Confidence Interval, OR: Odd Ratio
Table 2 shows that in the protective case group (mothers of children with cleft lip), folate status (both poor and
good), there was a significant relationship between the maternal folate status and the occurrence of polymorphism
MTHFR A1298C in both case and control group.
Table 3: Relationship between maternal folate status during pregnancy and cleft lip
Cleft lip/palate
Maternal folate status P Value OR (CI: 95%)
case(celah) control (normal)
Poor 22(62.9%) 15(38.5%)
0.037 2.7 (1.06-6.94)
Good 13(37.1%) 24(61.5%)
CI: Confidence Interval, OR: Odd Ratio
Table 3 showed that the number of women with poor and good folate status 22 subjects (62.9%) and 13 subjects
(37.1%) respectively, in cases compared to 15 subjects (38.5%) and 24 subjects (61.5%), respectively among the
control group.
DISCUSSION biological organs besides socioeconomic factors and the

lack of responsibility leading to the development of fetal
Non-syndromic cleft lip with or without palate disorders (17). Low educational and economic level of the
is caused by multifactional factors both intrinsic and elderly on the Sasak population can be risk factors for
extrinsic. Intrinsic factor includes genes and heredity, cleft lip. The low level of education may lead to poor
external factors include nutrition during pregnancy, parental knowledge on the importance of maternal and
smoking and drinking alcohol in the mother during fetal health, and low socioeconomic factors may lead to
pregnancy, drinking herbal medicine during pregnancy, the inability to provide proper nutrition to the fetus(18).
environmental pollution(11). The results of the study
showed that the most common maternal age during We found that the maternal folate status during
pregnancy was more than 35 years old, a hight age pregnancy was associated with cleft lip development.
for pregnancy, the maternal age was not a risk factor There was a significant difference between maternal
for cleft lip in Sasak population. in women aged more folate status in both cases (p = 0.001) and control
than 35 years, biological and environmental changes subjects and MTHFR A1298 gene polymorphism (p
occur(12,13). Besides the failure of vascularization of the = 0.046). Folic acid deficiency can be detected by a
uterus during pregnancy, that can affect the transfer decrease in MTHFR (methyltetrahydrofolate reductase),
of nutrients to the fetus(14,15) also, the pregnant woman causing deficient remethylation of homocysteine into
above 35 years old are at a higher risk of preeclampsia, methionine and reducing the production of SAM
chronic hypertension, placental abnormalities(16). Under (S-adenosylmethionine) (19). This results in disruption of
19 years is a high risk for pregnancy due to immature the methylation reaction leading to disturbance of that
DNA methylation. Methylation defect causes disruption Ethical Clearance: Informed consent was obtained
of the expression with the result of inhibited fetal from all of the participants. The research protocol was
development and the of some malignancies(20). approved by Medical Research Ethics Commission
Faculty of Medicine, Diponegoro University and Dr.
Table 3 shows that the maternal folate status during
Karijadi Hospital, Semarang Indonesia No. 023/EC/FK-
pregnancy affects cleft lip incidence in the Sasak
RSDK/2016.
population in Lombok (p: 0.037) in which poor maternal
folate status during pregnancy tend to have a 2.7 times
higher risk to cause cleft lip compared to that of real CONCLUSION
maternal folate status. This incidence shows that the In Sasak population living in Lombok Indonesia,
maternal diet during pregnancy affect the state and health MTHFR A1298C gene polymorphism is a risk factor for
of the fetus and can modulate their offspring through cleft lip, and maternal folic acid status during pregnancy
epigenetic mechanisms (21). Folic acid is required for the is associated with the cleft lip and polymorphism of the
metabolism of carbon playing a role in several cellular
MTHFR A1298C gene.
reactions including in the metabolism of amino acids, the
biosynthesis of purine and pyrimidine, the formation of
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DOI Number: 10.5958/0976-5506.2018.00612.5
Prevalence of Postural Problems among the Nurses in Chennai
Jinu Merlin Koshy1, Amit Biswas3, Sreelekshmi2, W M S Johnson4, Archana R5, Bini Markose6
Professor, Department of Anatomy, Sree Balaji Dental College and Hospital, BIHER, Chennai;
1
2
Professor, 3Post Doctoral Fellow, SQC & QR, ISI Institute, Chennai; 4Professor & HOD, Department
of Anatomy, 5Associate Professor, Department of Anatomy, Sree Balaji Medical College and Hospital,
BIHER, Chennai; 6Research Fellow, Department of Anatomy, BIHER, Chennai
Abstract
Aim & Objective: The aim of the present study was to evaluate the postural problems arising due to the
working posture among nurses in Chennai, with an objective to determine the prevalence of musculo skeletal
disorders.
Materials and Methods: The study was conducted on 176 nurses working in different hospitals. The
randomly selected subjects were given the Standardized Nordic Questionnaire to find out the perception of
musculoskeletal symptoms. Ergonomic assessment tools such as Rapid Upper Limb Assessment (RULA)
Rapid entire body assessment (REBA) was used to assess the type of unpredictable working postures. The
data were analyzed with Binary Logistic Regression using the Mini Tab (14) statistical software.
Results: The RULA score for most of the subjects (84%) were left, 4 & 5 and right 6 & 7. The REBA
score for 85% of the subjects were 7 and above which indicates the risk level is medium to high. There were
significant association with socio demographic variables like age, work experience, patients attended per
day, height, weight and BMI with the musculo skeletal disorders.
Conclusion: The study revealed that various socio demographic variables contributed to the musculoskeletal
symptoms experienced by the nurses.
Keywords: Musculoskeletal disorders; Standardized Nordic Questionnaire; Posture; REBA; RULA;
Introduction WRMSD3. Physical factors such as height of equipments

used in work affects the posture4. The risk of work
Musculoskeletal disorders (MSD) refer to more related upper limb disorders (WRULD) may be caused
than 200 conditions that affect the body causing ache, by the postural stress and demands of work.5
pain and functional impairment1. Since the beginning
of 18th century, it has been shown that MSDs may have Nursing profession focused on the care of
occupational causes.2 In recent years investigations of individuals, families and communities to attain optimal
workrelated musculoskeletal disorders (WRMSD) health and quality of life. Work hours in healthcare often
has attracted considerable attention because of its involve long work hours, on-call work, compulsory
importance in assessing ergonomics risk factor involved overtime and shift work to meet the patient care round the
in workplaces. Occupational risk factors such as clock6. Nursing profession is established as a physically
force, posture, movement and vibration can affect the and psychologically demanding profession with
high prevalence rate of musculoskeletal complaints7.
Corresponding Author: Working condition of the nurses differs from corner
Dr. W M S Johnson to corner around the world8. In India some healthcare
Professor & HOD, Department of Anatomy, organizations have the modern infrastructure facilities,
Sree Balaji Medical College and Hospital, most of the healthcare unit personnel have to work
BIHER, Tamil Nadu-600100 without proper infrastructure. There is always heavy
Phone: 9962055993 demand for medical services in both the government and
Email: [email protected] private hospitals9.
The present study aimed at evaluating the working The reliability of Nordic questionnaire for MSD
posture and the different ergonomical problems among measured by Cronbach’s alpha test was 89.5%.
nurses.
The collected data were thoroughly screened and
entered into MS-Excel spread sheets and statistically
Material & Method
analyzed. Descriptive statistics were reported for socio
Randomly selected 176 nurses employed in different demographic variables. The prevalence of postural
hospitals in Chennai participated in the study. The problems in the study population was computed as
study proposal was submitted to the Institutional Ethics percentages. Binary logistic regression was done as
Committee and due clearance was obtained. Persons pain in different regions as the dependent variable.
within 20-45 years with a work experience of 3-20 years The independent variables entered were age, height,
experience were included. Persons with systemic diseases weight, BMI, work experience, working hours per day
and pregnant women were excluded from this study. and number of patients attended per day. The acquired
data was statistically analyzed by using the Mini Tab
Body weight and height of the subjects were statistical software version 14. A value of P < 0.05 was
measured with the help of a properly calibrated weighing
considered as statistically significant.
scale and Freemans measuring tape. Body Mass Index
(BMI) was calculated from the stature and body weight
of the respective subjects. Results
A self-administered questionnaire was used to The study population included 176 with an average
collect data after obtaining a written consent from the age of 30 years and average work experience of 8 years
participant. The method for answering the questionnaire working in different hospitals in Chennai. The general
was explained in a general meeting of nurses before characteristics of the study population are shown in Table 1.
dissemination of the questionnaire. A pilot study was
performed among the nurses before commencing Table1: Demographic characteristics
the study. The instrument used in this study is the
Age 30 ± 3.589
Standardized Nordic Questionnaire (SNQ) ( License No.
work experience 8 ± 3.707
3316900588799). SNQ consists of structured, forced,
working hr/day 8 ± 0.237
binary or multiple choice variants. After completion
Height 158 ± 6.281
of the questionnaire, the candidates were interviewed Weight 63 ± 5.252
to clarify any confusion and to furnish any missing BMI 24.836 ± 2.18
data. We assigned ‘1’ to each positive response to each
question and a ‘0’ to each negative response. n = 176, data are mean ± Standard deviation
Rapid Entire Body Assessment {REBA}: Rapid entire Table 2 and Table 3 represent the REBA and RULA
body assessment (REBA) was developed to assess the score of the subject group respectively. The REBA score
type of unpredictable working postures found in health- for the nurses group were 6 and above. RULA score
care and other service industries. Data were collected ranges between 4 and 7.
about the body posture, forces used, type of movement
or action, repetition, and coupling. A final REBA score Table 2: Reba Score of Nurses
was generated to give an indication of the level of risk &
REBA SCORE OF NURSES N = 176
urgency with which action should be taken.
Number of Persons SCORE
Rapid Upper Limb Assessment (RULA): The RULA 2 11
ergonomic assessment tool considers biomechanical and 23 10
postural load requirements of job tasks/demands on the 54 9
neck, trunk and upper extremities. After the data for each 59 8
region were collected and scored, tables on the form are 37 7
then used to compile the risk factor variables generating 1 6
a single score that represents the level of MSD risk. n = 176
Table 3: Rula Score of Nurses The intensity of elbow pain which caused the
prevention of work was having statistically significant
RULA
association with the work experience (P =0.05) (Table
No. of Persons Left Score Right Score
4).The wrist pain which caused the prevention of work
16 3 4 and the socio demographic variables like age (P =0.01),
35 4 5 work experience (P =0.02), patients attended per day
97 4 6 (P=0.008), height (P =0.04), weight (P =0.05) and BMI
15 5 6 (P =0.03) were having significant association (Table 4).
13 5 7 It was also found that there was statistically significant
association between the upper back pain which prevented
n = 176 the nurses from work and the patients attended per day
(P =0.04) (Table 4).
The association between the frequency of pain and
discomfort in different regions of the body for the past Patients attended per day by the nurse (P =0.037)
12 months, trouble causing prevention of work and and elbow pain experienced during the past seven days
the trouble in the last seven days shows there was a were having significant association (Table 4). The
socio demographic variables like age (P =0.01) work
significant association between age (P=0.03), patients
experience (P =0.02), height (P =0.04), weight (P =0.05)
attended per day(P=0.038) and wrist pain for the past and BMI (P =0.05) were having significant association
one year data (Table 4). with the knee pain for the last seven days (Table 4).
Table 4: Association between the frequency of pain and discomfort in different regions of the body in respect
to the past 12 months, trouble causing prevention of work and the trouble in the last seven days
Variables Past 12 months

One or One or
Wrist/ Upper Low
Neck Shoulders Elbow both both Ankles
hand back back
hips knees
Age 0.168 0.4 0.13 0.03* 0.7 0.8 0.31 0.18 0.21
Gender 0.34 0.16 0.71 0.8 0.89 0.45 0.29 0.16 0.99
Work
0.19 0.34 0.12 0.06 0.62 0.97 0.41 0.17 0.19
experience
Working
0.301 0.99 0.33 0.7 0.67 0.633 0.72 0.99 0.66
hours/day
Patients/day 0.66 0.12 0.48 .038* 0.44 0.21 0.2 0.01 0.22
Height 0.17 0.09 0.9 0.071 0.5 0.26 0.18 0.44 0.3
Weight 0.18 0.11 0.8 0.075 0.5 0.25 0.21 0.47 0.34
BMI 0.19 0.11 0.94 0.066 0.49 0.245 0.18 0.46 0.34
Prevented from work
One or One or
Wrist/ Upper Low
hand back back
hips knees
Age 0.49 0.03* .03* .01* 0.5 0.45 0.65 0.68 0.9
Gender 0.28 0.33 0.14 0.6 0.28 0.66 0.11 0.21 0.9
Work
0.76 0.04 .05* 0.02* 0.75 0.42 0.47 0.55 0.99
experience
Working
0.75 0.45 0.52 0.5 0.58 0.29 0.68 0.82 1
hours/day
Contd…
Patients/day 0.49 0.72 0.81 .008* .04* 0.76 0.26 0.53 1

Height 0.952 0.29 0.16 .04* 0.69 0.7 0.44 0.21 0.99
Weight 0.9 0.26 0.14 .05* 0.72 0.87 0.42 0.21 0.99
BMI 0.98 0.3 0.17 .03* 0.61 0.77 0.49 0.31 0.99
Last 7 days
One or One or
Wrist/ Upper Low
hand back back
hips knees
Age 0.73 0.36 0.68 0.43 0.65 0.8 0.23 .002* 0.16
Gender 0.37 0.44 0.94 0.39 0.92 0.69 0.44 0.44 0.51
Work
0.82 0.25 0.91 0.41 0.89 0.88 0.3 .005* 0.34
experience
Working
0.56 0.9 0.72 0.19 0.07 0.976 0.75 0.27 0.27
hours/day
Patients/day 0.28 0.77 .037* 0.37 0.63 0.622 0.3 0.25 0.019
Height 0.7 0.44 0.4 0.75 0.31 0.3 0.88 .021* 0.23
Weight 0.69 0.39 0.39 0.7 0.32 0.33 0.9 .022* 0.238
BMI 0.63 0.38 0.49 0.68 0.36 0.34 0.95 .024* 0.196
Statistically significant p < 0.05
The percentile of subjects having the persistence of the pain for the past 12 months, persistence of pain which
prevented the subjects from work , and the persistence of pain for the past 7 days were shown in Graph1. Frequency
of pain in the neck, lower back and hip were independent of the socio demographic variables.
Graph 1: Distribution of MSDs reported in different sites during past one year, prevented from work for the
past one year and during the past one week.
Graph 2 and graph 3 depicts the percentile primary risk factors that have been associated with
distribution of REBA and RULA score respectively. WRMSD15. Ando et al reported the prevalences of low
back, shoulder,neck and arm pain among hospital nures
to be 54.7%, 42.8%, 31.3% and 18.6% respectively16.
Larese and Fiorito found that 48% of ward nurses
and 33% out patient nurses reported back pain due to
work, 29·4 and 16·1% respectively have had X-ray or
orthopaedic examinations, 19·2% and 9·1% had been
absent from work because of back pain17. In another
study among nurses in India by Goswami et al studied
the occurrence of symptoms of the neck pain, shoulder
pain, hand pain and knee pain and was reported that 73%
of nurses complained about pain after returning back
home and 21% during work 13.The results of the present
study were similar as the reported prevalence of pain
and discomfort during the last one year were found to
be high in the upper back( 80.11%),low back (78.98%)
neck (72.3%) and knee (40.25%) (Graph 1). The
Graph 2: Percentile distribution of REBA score present study also indicates the the pain was continous
as the last seven days data shows comparitively higher
prevalence in some regions like neck (60%), upper back
(65.91), low back (56.25%) and knee (41.48%). Pain in
different body parts of nurses were related to different
ergonomic risk factors at work, namely, bending and
twisting of the waist and standing for extended periods
of time. Similar observations were made by Hou JY e in
Taiwan among nurses.18
The REBA score for 85% of the subjects were 7

and above which indicates the risk level is medium to
high. The RULA score for most of the subjects (84%)
were left, 4 & 5 and right 6 & 7. This score indicates
investigation and changes were required soon in their
posture. Transferring and changing the body position
Graph 3: percentile distribution of RULA score of the patients were set up to be the most physically
challenging and postural strenuous task.
Discussion Daraiseh et al reported that MSD in various body
Nurses perform a wide range of clinical and non- regions of nurses were influenced by stressful working
clinical functions necessary to the delivery of health care conditions19. It was reported that low back pain of
and therfore musculoskeletal disorders (MSD) represent the nurses was not only associated with physical
a significant problem among nurses13. The reported factors but also with a complex interaction of working
prevalence of the present study was very high, as 80% conditions.9,13,20.
of the subjects were reported with at least one MSD in
The Pan-European research suggests that early
the last one year which is less than 90% reported by K.
detection and intervention of MSD, eventually reduces
R. Shafiezadeh14.
the burden on governments’ health and disability
Silverstein et al reported repetitious movement, budgets21. Intervention and management of work place
awkward postures and high force levels as the three and outside work place risk factors can reduce the
prevalence of MSD and their consequences. There are with an emphasis on the healthcare sector.
some evidence which indicate that some simple and Industrial Health 2008. 46: 523–534.
practical participatory action-oriented training can
7. Menzel, NN. Back pain prevalence in nursing
prevent or reduce the prevalence of MSD22 personnel:measurement issues. AAOHN Journal
2004. 52: 54–65.
Conclusion
8. Simon, M. Tackenberg, P. Nienhaus, A. Estryn-
The goal of ergonomics is to reduce work related Behar, M.Conway, PM and Hasselhorn, HM.
musculoskeletal disorders by adapting the work to fit Back or neck-painrelated disability of nursing
the person, instead of forcing the person to adapt to staff in hospitals, nursing homes and home care
the work. Design of successful work methods requires in seven countries—results from the European
the use of ergonomic principles that best match human NEXT-Study. International Journal of Nursing
capabilities with job demands. Studies 2008. 45: 24-34.
9. Sahu, S. Goswami, S. Haldar, P and Sett, M.
Conflict of interest: Nil
An ergonomic evaluation of tasks of healthcare
Source of Funding: Self unit personnel in different shifts in general
hospitals in West Bengal. International Journal of
Ethical clearance: Institutional Ethical Committee Occupational Safety and Health 2012. 2: 14-22.
10. Kuorinko et al. Standardised Nordic Questionnaires
Reference for the analysis Of musculoskeletal symptoms
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Factors, A Critical Review of Epidemiologic method for the investigation of workrelated upper
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Disorders of the Neck, Upper Extremity, and Low 1993, p. 91-99.
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uq.edu.au/public/pdf/97-141.pdf. on healthproblems and postural stress of nurses
3. Kilbom,A.E., 1994.Repetitive work of the upper working in hospitals of Burdwan district. Journal
extremity:Part ii- The sciectific basis(knowledge of Environmental Physiology, 3 (1&2), 25 -33.
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59-58. Number 3; July, 2011
4. Bergqvist, U., Wolgast, E., Nilsson, B., Voss, 15. Silverstein, BA. Fine, LJ and Armstrong, TJ.
M., 1995b. The in.uence of VDT work on Occupational factors and carpal tunnel syndrome.
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unit work and upper extremity musculoskeletal Hattori, Y. Hori, F and Takeuchi, Y. Association
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1.Arbetslivsininstitutet, Solna, Sweden. 17. Larese, F and Fiorito, A. Musculoskeletal disorders
6. Caruso, CC and Waters, TR. A review of work in hospital nurses: a comparison between two
schedule issues and musculoskeletal disorders hospitals. Ergonomics 1994. 37: 1205-1211.
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nurses.
21. McGee R, Bevan S, Quadrello T. Fit for work?
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Musculoskeletal Disorders and the Greek Labour
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DOI Number: 10.5958/0976-5506.2018.00613.7
Applications of Internet of things in Non-Communicable

Disease Prevention and Management: A Review
Legia Emantha Shabong Lyngdoh

State Programme Coordinator, National Programme for Prevention and Control of Cancer, Diabetes,
Cardiovascular diseases & Stroke, National Health Mission, Government of Meghalaya, India
Abstract
Objectives: The gravity of the burden of Non-Communicable Diseases (NCDs) has been recognised
globally. India has introduced the National Programme for Prevention and Control of Cancer, Diabetes,
Cardiovascular disease & Stroke (NPCDCS) to tackle NCDs which accounts for 60% of all deaths. However,
there are major constraints in the implementation of the programme which significantly can be overcome
by the adoption of the Internet of Things (IoT) in healthcare delivery. The paper aims to looks at IoT as a
viable option for remote health monitoring of patients with NCDs, giving room to more effective and timely
treatment which leads to better health outcomes.
Methods: Content analysis of textual data from multiple sources such as journals, reports and electronic
source was applied in the paper.
Results: Given the nature and outcome of studies conducted, benefits of IoT in NCD management is
indicated.
Conclusions: In the context of India, the advancement of the digital technologies coupled with the growth
of the health care sector raise the scope for enhancing healthcare services, with ample opportunities for
the development of IoT for healthcare. With regards to NCDs, this would mean access to better coverage,
surveillance and monitoring, and disease prevention.
Keywords: Internet of Things, Non-Communicable Diseases, digital healthcare, India.
Introduction India, following 2011 High Level Meeting convened

by the United Nations General Assembly began to
The burden of NCDs is sweeping the entire globe, recognise NCDs as issues of development and launched
with an increasing trend in developing countries. In the National Programme for Prevention and Control of
1990, 47% of all mortality related to NCDs was in Cancer, Diabetes, Cardiovascular disease & Stroke in
developing countries1; in 2005 an estimated 35 million 2010.
deaths were caused by NCDs representing 60% of
all deaths globally, with 80% of deaths due to NCDs Despite these attempts there has been major
occurring in low- income and middle-income countries. drawbacks in terms of diseases surveillance and
management. To point out a few, firstly the public health
system faces enormous constraints in terms of financial
and human resources. Secondly, the NCD surveillance
Legia Emantha Shabong Lyngdoh
system is significantly weak, case reporting follows
State Programme Coordinator,
no protocols or guidelines which limits the effective
National Programme for Prevention and Control of Cancer,
use of data for decision making. Thirdly, coverage is a
Diabetes, Cardiovascular diseases & Stroke,
clear problem as NPCDCS emphasis on facility based
National Health Mission,
opportunistic screenings. Referrals, treatments and
Government of Meghalaya, India
follow up of patients diagnosed with NCDs is a major
Mobile: +91 9774751740
hurdle that need to be addressed.
Email: [email protected]
To counter some of these issues, the introduction and Methodology

implementation of the Internet of Things (IoT) can be a
Content analysis with conventional approach was
viable option. The IoT has potential to give rise to many
used.
medical applications, up-to-date healthcare networks
driven by wireless technologies are expected to support Data collection: the paper incorporated multiple
chronic diseases, early diagnosis, real time monitoring, sources of data such as journal articles, reports,
medical emergencies and elderly care. Gateways, conference proceeding and electronic sources.
medical servers, and health database are instrumental
Data analysis: the analytical strategy used is that of
in creating health records and delivering on-demand
Coffey & Atkinson, 1996; Miles & Huberman, 1994 and
health services to authorised stakeholders. IoT based
Sandelowski, 1995 whereby the approach is to divide the
healthcare services are expected to reduce costs, increase
content analysis into three phases: immersion, reduction
the quality of life, and enrich the user’s experience. From
and interpretation3.
the perspective of healthcare providers, the IoT has the
potential to reduce device downtime through remote Discussion
provision. Furthermore, the IoT can correctly identify
optimum times for replenishing supplies for various IoT Architecture: in remote health monitoring, most
devices for their smooth and continuous operation. IoT proposed frameworks leverage a three-tier architecture
provides for the efficient scheduling of limited resources a perception layer, gateway/network layer and service
by ensuring their best use and service of more patients2. layer.
Figure 1: IoT Architecture for remote health monitoring
To understand the architeture, here a wearable IoT layer. Here sensors form an IoT based architecture as
network is proposed. A Wireless Body Area Network each indicidual sensor’s data can be acessed through the
(WBAN) consisting of werable sensors measure internet via the concentrator4.
physiological markers such as heart rate and respiratory
rate, the data acquired is then connected the data
aggregator or concentrator usually a smartphone through
Zigbee or low power Bluetooth. The agrregated data
is then transmitted to healthcare server using internet
connectivity on the aggregator, via the smartphone WiFi
or cellular data connection. The server then turns the data
into an observation and measurement file for processing
and later stores the data in a remote server or cloud
which can be retrived by health professionals, family
members of patients who may alert emergency services
professionals should need arise forming the service Figure 2: Wearable IoT network
Islam et al. in their publication The Internet of glucose data were automatically transferred to the
Things for Health Care: A comprehensive survey give medical staff through the smartphone application
an in-depth look at the subject of IoT applications in the over the course of 12 weeks. The medical staff
health care setting. In their paper, they survey advances in analyzed the data and sent recommendations and
IoT- based health care technologies and review the state- feedback tailored to the patient an average of once
of-the-art network architectures/platforms, applications, per week.
and industrial trends in IoT-based health care solutions2.
Result: In the smartphone group, the mean HbA1c

Similarly, Gomez, Oviedob and Zhuma, 20165 and Maia
decreased after 3 months from the baseline level
et al. 20146 among other scholars have also discussed
of 7.7%±0.7% to 7.5%±0.7% (P=0.077). In the
IoT architectures and platforms. control group, there was no change from baseline
Numerous studies have explored IoT applications (7.7%±0.5% to 7.7%±0.7%) over the same period
for NCD management. The following pilot studies thus showing no intergroup difference after 3
examine the utility of IoT in NCD management: months8.
1. Smartphone Enabled Heart Monitoring 3. CHRONIOUS wearable system in patients

System: with chronic disease:
Composition: The real-time heart monitoring

Composition: The CHRONIOUS system consists

of a wearable shirt that integrates several body
system comprises of wearable device known as
sensors, external devices (weight scale, glucometer,
the Zephyr HxM-BT device (Zephyr Technology
blood pressure monitoring device, spirometer,
Corporation), a heart rate monitor and smartphone
air quality sensor), a portable smart device and a
or tablet and a web portal.
central sub-system that is responsible for the long-
Working: The data acquired by the heart rate
term storage of the collected patient’s data.
monitor is processed on a smartphone to (i)
Working: CHRONIOUS addresses a smart

provide detailed test reports about the user’s
wearable platform, based on multi-parametric
health state; (ii) store report records; (iii) generate
sensor data processing, for monitoring people
emergency calls or SMSs; and (iv) connect to a
suffering from chronic diseases in long-stay
remote telemedicine portal to relay the data to an
setting. It is constantly monitoring their activity
online database. The system uses sophisticated
using audio observation methods and activity
algorithms to detect stress states, detect and
sensors while at the same time tracking their
classify arrhythmia events, and calculate energy
medical condition via vital signs sensors. Any
consumption.
trait of abnormal health status and possible
Results: Application usability and usefulness
alerting incidents are detected by CHRONIOUS
was tested. The 10-item System Usability Scale Intelligence. The system generates alerts in case
(SUS), which is a platform-independent model of invalid medical data or if current activity and
widely used in subjective software evaluation was behaviour lay outside the well-established activity
administered to 20 participants. They scored the patterns and locomotion behaviour.
application at 75.625 percent, corresponding to a Results: The COPD (Chronic obstructive

B grade which is satisfactory7. pulmonary disease) trial involved 30 patients,
2. Smartphone enabled glucose monitoring: while the CKD (Chronic kidney disease) trial
involved 28 patients. Inference from analysis
Composition: The glucose monitoring system

suggest that a large percentage of COPD
comprises of a smartphone, CareSens-LINK blood
(Chronic obstructive pulmonary disease) and
glucose monitor (i-SENS, Wonju, Korea), and CKD (Chronic kidney disease) patients are
S(M)BPM-1 blood pressure monitor (Samsung generally satisfied or have a positive thinking of
Electronics). CHRONIOUS platform. Due to the limited time
Working: Thirty-five patients were provided with
period (only 4 months) that the system supports
a smartphone device, and self-measured blood chronic disease patients, the judgment about the
reduction of the patient’s medical visits as well logic in different application silos12.
as their health status improvements couldn’t be
zz Data volume and performance: Easy to imagine
clearly evidenced. From the clinical point of view,
the amount of data to be taken in, stored and
although some of the user’s feedbacks referred to
analysed is enormous. This will make standard
small systems contribution on clinicians every-
architecture and platforms inadequate which calls
day schedule, the consensus is that the utilization
for scaling up of applications and the backend
of the system in larger target groups will highlight
database to adapt to the complexity of operations.
systems’ clinical value9.
zz Data privacy: data securitisation is of utmost
Further, systematic review undertaken by Vegesna importance and numerous challenges arise in the IoT
et al. reported numerous positive health outcomes device design, development and scalability of security
specifically in terms of reduction in symptoms severity schemes. Islam et al. in their paper address security
and hospital visits or stay of NCD patient through remote issues analysing distinct IoT security and privacy
monitoring using digital technologies10. Similarly, features, as well as proposes an intelligent collaborative
Goldman Sachs Global Investment Research have security model to minimise security risk2.
examined pilot studies to illustrate IoT efforts that have
succeeded in engaging patients, providing key data to zz Network capacity constraints: Challenges
physicians resulting in lower rates of hospital admissions may arise in developing initiatives to sustain
and overall costs11. uninterrupted networks with capacities to cater to
heavy mobile data traffics.
The integration and management of IoT into remote
health monitoring of NCDs comes with significant Conclusion
challenges. Major challenges include:
In the context of India, factoring the Digital India
zz Managing device and their interoperability:
Programme, India’s Global Innovative Index ranking
wearable devices poses challenges to the design
and India’s growing health care sector; the deployment
of sensors. Sensor ought to be light, small,
of IoT in remote health monitoring of NCDs in India
energy efficient and cause minimum hindrance
may not be a distant dream. India is ranked 6th in income
to the patients’ movement and mobility. Further,
with 0.66 in efficiency ratio in the Global Innovation
approved standards and certifications may not be
Index 2017 ranking13. India’s healthcare sector is
followed by vendors in their products (devices)
considered as one of the fastest growing industries,
which is required in the interface between sensors,
expected to advance at a CAGR of 22.87 per cent during
the aggregated devices and the backend database.
2015–20 to reach US$ 280 billion by 2020. Further,
This results in significant interoperability issues conducive policies for encouraging FDI, tax benefits,
and increase system integration costs. favourable government policies coupled with promising
zz Data integration: to create intelligent and growth prospects have helped the industry attract private
meaningful applications there is a need to integrate equity, venture capitals and foreign players. The sector
data from multiple sources such as medical devices registered 88 funding deals amounting to US$ 397.41
that monitors blood pressure, weighing scales, million as of September 201614. In terms of internet
glucometers etc. as well as social network feeds and usage, reports from the Internet and Mobile Association
other web sources for patient – specific contextual of India (IAMAI), titled ‘Mobile Internet in India 2016’,
data. Here, the problem lies in understanding the predicted that the country was estimated to have 371
structure and syntax of data, understanding of million mobile Internet users by June 2016. While 71%
semantics will enable the creation of intelligent of this number will belong to urban areas, rural India is
application and mashups using techniques such said to hold the potential to further fuel the growth of
as correlation, complex event processing and mobile Internet in the years to come. Another notable
automated reasoning with semantics technology. fact that there has been growth driver for mobile internet:
The semantics of the data must be part of the data content in Indian languages, the number of consumers of
itself and not be locked up within the application online content in regional languages in June 2015 was
pegged at 127 million, a 47% increase from the previous Kwak. The Internet of Things for Health Care:
year15. This will enable more people to effectively and A Comprehensive Survey . IEEE 2015; 3: 658-
critically navigate devices making optimal use of the 708. http://ieeexplore.ieee.org/stamp/ stamp.jsp?
digital technology. arnumber = 7113786.
With the advancement of the digital technologies 3. Forman Jane, Laura Damschroder. Qualitative
coupled with the growth of the health care sector, Content Analysis. Liva Jacoby and Laura
the scope for enhancing healthcare services has A. Siminoff (eds) In Empirical Methods for
increase significantly with ample opportunities for Bioethics: A Primer (Advances in Bioethics,
the development of IoT for healthcare. In the context Volume 11). Emerald Group Publishing Limited,
of NCDs, this would mean access to better coverage, 2007, pp. 39-62.
surveillance and monitoring. Real time visibility of 4. Hassanalieragh, Moeen, Alex Page, Tolga Soyata,
patients’ conditions, activities, context and physiological Gaurav Sharma, Mehmet Aktas, Gonzalo Mateos,
parameters; compliance monitoring of treatment, diet Burak Kantarc, and Silvana Andreescu. 2015.
and exercise regime; real time feedback for patients, Health Monitoring and Management Using
family and health professionals to implement corrective Internet-of-Things (IoT) Sensing with Cloud-
action for better patient outcomes. based Processing: Opportunities and Challenges.
2015 IEEE International Conference on Services
In conclusion, the paradigm shift in the healthcare Computing, 2015, pp.285-292. New York: IEEE.
system from conventional healthcare (whereby patients doi: 10.1109/SCC.2015.47.
with symptoms or ailments makes appointments
with physicians and receives treatment), to that of 5. Gómez, Jorge, Byron Oviedob, and Emilio Zhuma.
digital healthcare (whereby healthcare providers take Patient Monitoring System Based on Internet
of Things. The 7th International Conference on
the initiative to alert potential patients of imminent
Ambient Systems, Networks and Technologies
health issues and provide medical interventions before
2016, pp.90-77. ELSEVIER.
disease progress) will unlock the future of development
in India. To truly leverage the potential of digital 6. Maia, Pedro, Thais Batista, Everton Cavalcante,
healthcare numerous issues such as untapped potential, Augusto Baffa, Flavia C. Delicato, Paulo F.
infrastructural constraints, government policies etc. Pires, and Albert Zomaya. A Web platform for
need to be tackled and effectively addressed. However, interconnecting body sensors and improving
considering India’s leadership and capacity for health care. Fourth International Conference on
collaborative innovation, digital healthcare may be a Selected Topics in Mobile & Wireless Networking,
reality sooner than expected. 2014, pp. 135-142. ELSEVIER.
7. Pierleoni Paola, Luca Pernini, Alberto Belli,
Competing Interest: No conflict of interest to report.
and Lorenzo Palma. An Android-Based Heart
Funding Disclosure: Funds have not been received for Monitoring System for the Elderly and for
any aspect of the submitted work. Patients with Heart Disease. International
Journal of Telemedicine and Applications 2014,
Ethical Clearance: Written permission was obtained 1-11. doi:10.1155/2014/625156.
from NASSCOM to reproduce data.
8. Kim Hun-Sung, Wona Choi, Eun Kyoung Baek,
Yun A Kim, So Jung Yang, In Young Choi, Kun-
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DOI Number: 10.5958/0976-5506.2018.00614.9
Mandibular Canine Index(Mci) Not an Accurate Tool for

Gender Identification:Results from a Systematic Review and
Meta-Analysis
Elizabeth Dony1, Mamatha G S Reddy2, Pradnya Kakodkar3

Post Graduate Student, 2Reader, 3Professor, Dr. D. Y. Patil Vidyapeeth’s, Dr. D. Y. Patil Dental College
1
and Hospital, Pimpri, Pune
Abstract
Objective: Mandibular Canine Index(MCI) is being used by many researchers for gender identification,
however the accuracy shows variations in the results. The aim of this review is to estimate the diagnostic
accuracy of MCI in gender identification.
Methods: An electronic search of literature was carried out in pubmed MEDLINE database and Google
scholar. 26 observational studies published from January 2000 to May 2016 in English were shortlisted
using PRISMA guidelines. Study characteristics were entered in excel sheet and quality assessment was
done using modified QUADAS 2. The diagnostic accuracy was assessed using sensitivity (males correctly
identified) and specificity (females correctly identified) values.
Results: 37.9% percentage of the articles followed the Rao et al. guidelines in calculating MCI and rest
modified the guidelines using mean of right and left canine width, right and left canine width separately and
only right canine width. 25% of the studies showed high risk bias in patient selection and index test domain.
In applicability, 50% of the studies showed high risk bias in patient selection domain. Overall summary
measures of sensitivity was 0.65 and specificity 0.63. On subgroup analysis, high heterogeneity (I2 >90%)
was observed.
Conclusion: Few authors have already refuted the use of MCI in gender identification. The results of the
present systematic review and meta-analysis showed lack of homogeneity in the data across the studies and
concludes that MCI is not an accurate tool in gender identification.
Keywords: MandibularCanines. Forensic Odontology. Gender Determination .Mandibular Canine Index.

Sexual Dimorphism.
Introduction technique, but is considered as a last resort due to

operational complexity and high cost 1. Anthropological
Gender identification plays a vital role in forensic measurements on the cranial and pelvic bones are helpful
medicine. There are various methods to correctly for gender estimation in forensic cases 2,3. However,
determine the sex of an individual, particularly in in massive disaster cases, the gravely damaged and
postmortem cases. Among these methods, DNA disfigured corpses may restrict measurements on the
examination is regarded as an accurate and reliable skull and pelvic bones. Under such circumstances,
odontometric analysis may be a good adjunct because
Corresponding Author: teeth and jaws are often intact when recovered 4,5. Thus,
Dr. Mamatha G S Reddy, MDS teeth have become increasingly significant for addressing
Reader, Department of Oral Pathology and Microbiology forensic concerns as they are strong anatomical structures
Dr. D. Y. Patil Vidyspeeth’s, which have the ability to endure various insults, such as
Dr. D. Y. Patil Dental College and Hospital, Pimpri, thermal, microbial degradation , air disasters, hurricanes
Pune-18 or conflagration6,7. It has been found that the mandibular
E-mail: [email protected] canines consistently exhibit greater sexual dimorphism
in mesio-distal crown width and inter-canine distance. to PUBMED, Google Scholar was also searched. We
These teeth erupt by the age of 12 years and are least also manually searched the reference lists of eligible
affected than other teeth by dental caries and periodontal studies to ensure identification of relevant published and
diseases. Also, canines are the last teeth to be extracted unpublished studies. We also contacted study authors to
with respect to age. provide full text articles, wherever necessary.
Rao et al. considered canine to be the ‘key tooth’ Inclusion and exclusion criteria: Eligible study
for the purpose of personal identification8 and explored designs included observational studies published
its application in gender identification. He introduced between 1 January 2000 and 31 May 2016 in English
the “Mandibular Canine Index” which was calculated which evaluated the diagnostic accuracy of Mandibular
by obtaining the ratio of greatest mesio-distal (MD) Canine Index. Both, in-vitro and in-vivo studies, where
dimension of the permanent mandibular canine and the percentage accuracy of gender identification was given
inter-canine arch width (measured in mm). A cut-off with respect to MCI were included. We excluded studies
value to differentiate the sexes was then calculated from which clearly did not mention the MCI value and the
the MCI, which was termed as the ‘Standard MCI’9.If accuracy of gender identification.
the MCI value was less than or equal to the standard
MCI, the individual was categorized as female and vice Assessment of relevant studies: Two reviewers (E.CD
versa as male. and M.GS) independently performed the first stage of
screening by titles of all the identified studies. Round
Rao et al., first used this MCI for gender determination 2 included screening by the abstracts. Round 3 was full
in a heterogeneous sample that originated from the text assessment.
state of Karnataka in Southern India and obtained an
accuracy of ~86% (7). Later, MCI was employed in Data extraction: A standardized, pre-piloted form
numerous studies in large populations as it was simple, was used to extract data from the included studies for
reliable, inexpensive, and easy to perform10. However, evidence synthesis and assessment of study quality.
controversies regarding this index emerged, when a few One review author (E.CD) extracted data independently
studies proved that MCI is practically unreliable and and second author (M.GS) cross checked the data.
questioned the reliability of MCI and revealed that this Discrepancy if any, was identified and resolved through
index was not sufficiently sensitive7,9. discussion with a third author (P.VK) where necessary.
Therefore, in view of this controversial background, Quality assessment: Two review authors (E.CD and
the present review was undertaken to systematically M.GS) independently assessed the quality of the included
review the published evidence and to estimate the studies, where disagreements occurred, these were either
summary measures of diagnostic accuracy of the resolved by discussion or by consulting a third review
Mandibular Canine Index (MCI) as a tool for gender author (P.VK). QUADAS-2 checklist for studies of
identification in adult humans. diagnostic accuracy was modified and used to assess risk
of study bias.Under the “Patient selection”:Was random
Materials and Method sampling method employed for patient selection?, Did
the study include a narrow age-range of patients?, Did the
Search strategy: The review protocol was registered study avoid inappropriate exclusions? In “Applicability
in PROSPERO (CRD42016046949). We conducted a concern” “Was a native sample considered?”In “Index
search for relevant studies evaluating the accuracy of Test”:Was the MCI calculated based on greatest canine
Mandibular Canine Index (MCI) for gender identification width?, “If a threshold was used, was it pre-specified?”,
in a given population. The electronic search was “Is the alignment of teeth in the study population likely
initially conducted on the MEDLINE via PUBMED to affect the Std. MCI?”, “Was digital Vernier calipers
database with the following keywords: ‘mandibular used for measuring MCI?” In“Reference standard”:
canine index’, ‘mandibular canine index AND gender “Is the reference standards likely to correctly classify
determination’, ‘canine index AND sexual dimorphism’ the target condition?, Were the reference standard results
and ‘canine index AND forensic odontology’. In addition interpreted without knowledge of the results of the index
tests? and In “Flow and timing of participants”: Did Statistical analysis

all patients receive the same reference standard?, Were
The diagnostic accuracy was determined by
all patients included in the analysis? Each question were
assessing the sensitivity and specificity values. True
assessed as ‘yes’, ‘no’, or ‘unclear’.
positive (TP) represented the number of males identified
A ‘Risk of bias’ judgement (‘high’, ‘low’ or ‘unclear’) correctly and true negative (TN) were the number
was made for each domain. If the answers to any two of females identified correctly . Using the TP and TN
signaling questions within a domain were judged as values and the total number of males and females
participating in the respective study, the values of false
‘yes’ , it indicated low risk of bias and hence the domain
positive (FP) and false negative (FN) were ascertained.
was judged as low risk of bias. If any two signaling
OpenMeta(analyst) software was used to present a
question were judged as ‘no’, it indicated a high risk of
combined forest plot. Subgroup analysis was carried
bias and hence the domain was scored as a high risk of out to investigate the differences in summary measures
bias. In case of equal distribution of ‘yes’ or ‘no’ in a across categories of covariates. Sensitivity analysis
domain, then the decision of high and low risk was taken was carried out to investigate how the risk assessment
by considering the questions, which can comparatively of studies affected the summary measures. A p value of
have more relevance with MCI calculation. <0.05 was considered to be statistically significant.
Results
Table:1 PRISMA Flow chartof search results and study selection

Records identified through Additional records identified
Identification
database searching (n = 222) through other sources (n = 8)
Records excluded after

Titles screened (n = 230)
review of titles (n = 30)
Screening
Titles screened for duplicate removal (n = 200) Excluded- duplicate (n = 30 )
Abstracts screened Records excluded after review of

(n = 170) abstracts (n = 142)
Eligibility
Studies excluded after review of

Full texts screened
full text (n = 2)Accuracy and MCI
(n = 28)
values not mentioned.
Included
Studies included in qualitative synthesis One study excluded.

(n = 26) and meta-analysis (n = 25) Accuracy % not mentioned.
Table:1 shows the PRISMA flowchart of search results and study Finally a total of 26 articles were considered
for the systematic review and 25 articles (29 estimates) for meta-analysis. Table 2, summarizes the characteristics
of the individual studies. Overall, risk of bias was high in less than 25% studies for “Patient Selection” and around
25% for “Index Test. 100% studies were assessed as low risk for both the reference standard and Flow and timing. In
applicability concerns, more than 50% studies reported high risk in the “Patient selection” domain. (Fig.1)
Table 2: Study Characteristics

Age Sample Type of Method of MCI MCI used to predict
Author name Country Population STD.MCI
group(yrs) size study calculation gender
Dental MCI of greatest
Acharya AB et al (A)8 Nepal 19-28 117 invitro Greater canine width 0.26
students canine width
General
Acharya AB et al(B)9 India 19-32 203 invitro Right canine Right MCI 0.244
population
Ahmed HMA 11 Iraq 17-23 200 invitro Greater canine width 0.26
General MCI of both right Rt and Lt MCI used 0.281(R) ;
Bakkannavar SM et al12 India 15-25 500 invivo
population and left canine seperately 0.283(L)
Medical MCI of both right Rt and Lt MCI used 0.205(R);
Chukwujekwu et al13 Nigeria 17-30 400 invivo
students and left canine seperately 0.215(L)
Engineering MCI of both right 0.270(R) ;
Dayananda et al14 India 18-22 200 invivo Unclear
students and left canine 0.276(L)
General Mean of MD of right
Edibamode EI et al15 Nigeria 18-35 184 invivo Mean MCI 0.21
population and left canine
General MCI of greatest
Hosmani JV et al16 India 15-21 100 invitro Greater canine width 0.27513
population canine width
Medical MCI of greatest
Iqbal R et al10 China 18-25 216 invitro Greater canine width 0.247
Kakkar T et al17 India 17-25 250 invitro Greater canine width 0.1921
Medical MCI of both right Rt and Lt MCI used 0.273(R) ;
Kaushal S et al18 India 17-21 60 invivo
students and left canine seperately 0.28(L)
University Mean of MD of right
Krishnan RP et al19 India 18-25 50 invitro Mean MCI 0.25
students and left canine
Latif M et al20 India 17-40 150 invitro Mean MCI 0.257
Mughal IA et al21 Pakistan 18-25 200 invivo Greater canine width 0.2504
University MCI of greatest
Muller M et al22 France 17-24 424 invitro Greater canine width 0.268
General MCI of both right
Nagalaxmi et al23 India 20-30 60 invivo Right MCI 0.245
Narang RS et al24 India 20-40 410 invitro Greater canine width 0.249
Paramkusam G et al25 India 18-25 120 invitro Mean MCI 0.26
Medical MCI of both right
Parekh D et al26 India 18-24 368 invivo Right MCI 0.205
students and left canine
General MCI of both right 0.255(R);
Rajarathnam BN et al (A)27 India 18-25 200 invitro Unclear
population and left canine 0.25(L)
Rajarathnam BN et al (B)27 India 18-25 200 invivo Unclear 0.26(R); 0.25(L)
Reddy VM et al28 India 17-25 200 invitro Greater canine width 0.256
Sassi C et al29 Brazil 21-60 112 invitro Greater canine width 0.267
General
Silva AM et al30 Portugal 16-30 120 invitro Right canine Right MCI 0.282
population
Singh SK et al31 India 20-30 100 invitro Unclear
MCI of greatest
Srivasatava PC32 India 17-21 400 students invivo Greater canine width 0.257
canine width
Yadav S et al33 India 15-21 360 invitro Greater canine width 0.298
Fig. 1: Results of QUADAS-2, Risk of bias and concerns regarding applicability

Fig. 2: Forest plot of sensitivity and specificity estimates
The forest plot is presented along with the estimates of sensitivity and specificity for each study (Fig. 2).
Sensitivity refers to the percentage of males identified correctly and specificity to the percentage of females identified
correctly. Overall, the summary measure of sensitivity was 0.65 (0.59,0.71) and specificity was 0.63 (0.56,0.69).
Table 3: Summary measures of accuracy for Mandibular Canine Index (MCI) for sex identification
[Subgroup analysis]
Summary Summary
Study Q value, Q value, Het p
accuracy: accuracy:
estimates Het p value, I2 value, I2
Sensitivity Specificity
339.092, < 0.001, 408.321, < 0.001,
All studies 29 0.65 (0.59,0.71) 0.63 (0.56,0.69)
91.74% 93.14 %
Country
165.726, < 0.001, 127.771, < 0.001,
India 20 0.67(0.61, 0.73) 0.69(0.63, 0.74)
88.54 % 85.13 %
127.066, < 0.001, 163.321, < 0.001,
Others 9 0.59(0.49, 0.71) 0.48 (0.33,0.63)
93.7% 95.1 %
Region within India
155.726, < 0.001, 125.726, < 0.001
North India 9 0.65 (0.55, .74) 0.69 (0.61,0.75)
88.39% 89.54 %
148.726, < 0.001 145.726, < 0.001,
South India 10 0.71 (0.65, .77) 0.71(0.64, 0.77)
77.08 % 88.54 %
Study Population
145.035, <0.001, 193.247, < 0.001,
College students 12 0.57(0.47, 0.67) 0.56 (0.44,0.67)
92.42% 94.31 %
General 116.525, < 0.001, 139.509, < 0.001,
17 0.69 (0.63,0.75) 0.67(0.60, 0.74)
population 86.27% 88.53 %
Conted…
Type of study
162.235, < 0.001, 145.099, < 0.001,
In vitro 16 0.67 (0.58,0.57) 0.60 (0.52,0.68)
90.75 % 89.66 %
171.012, < 0.001, 260.377, < 0.001,
In vivo 13 0.63 (0.53, .71) 0.66 (0.54,0.77)
92.98 % 95.39 %
I2 - measure for heterogeneity.
Table 4: Sensitivity analysis
No. of study estimates Summary accuracy: Summary accuracy:

Subgroup
included Sensitivity Specificity
ROB criteria 1
High risk 4 0.71 (0.59, 0.81) 0.64 (0.43, 0.80)
Low risk 25 0.64 (0.57, 0.70) 0.63 (0.55, 0.70)
ROB criteria 2
High risk 6 0.59 (0.52, 0.66) 0.66 (0.57, 0.74)
Low risk 23 0.66 (0.58, 0.73) 0.62 (0.53, 0.70)
ROB criteria 3
High risk 18 0.69 (0.61, 0.76) 0.65 (0.54, 0.74)
Low risk 11 0.59 (0.48, 0.68) 0.61(0.52, 0.68)
ROB criteria 4
High risk 19 0.68(0.61,0.74) 0.70(0.64,0.76)
Low risk 10 0.59(0.48,0.70) 0.48(0.36,0.60)
ROB criteria 5
High risk 23 0.67(0.61,0.72) 0.68(0.62,0.73)
Low risk 6 0.58(0.42,0.72) 0.42(0.27,0.58)
Note: ROB – risk of bias, criteria 1 – risk of bias in patient selection, criteria 2 – risk of bias in measurements
using the index test (MCI), criteria 3 – risk of bias in using the greatest canine width, criteria 4- risk of bias using
nativity of the population, criteria 5- Overall risk of bias
All the covariates (Table 3) investigated showed a by an expert is of the order of 98%. If only long bones,
significant heterogeneity. Sensitivity analysis is showed such as femur and humerus are present, determination
in (Table 4). Comparison of the summary measures of sex accurately by an expert is of the order of only
could not be done because of high heterogeneity present 80%. During disaster, these bones easily get fragmented,
between the two risk groups. which may be major hindrance for assessment of sex
using osteometry.
Discussion In such cases, teeth can be especially useful, since
Gender determination of damaged or mutilated they are known to resist a great variety of physical,
dead bodies or from skeletal remains constitutes a major chemical and biological insults 30.Canines are the
challenge in medico-legal examination 26.Although the ideal teeth for identification of sex, due to its sexual
use of DNA gives robust results, the fact is that biological dimorphism and durability in the oral cavity 29.
samples are not always available or suitable for DNA Hence, this review was undertaken to estimate the
fingerprinting 30. Osteometry is considered the preferred diagnostic accuracy of MCI in gender identification.
technique because it is more effective in determining Our review summarized the evidence from 26 studies
sex 34.In the case of adult, when a 90% skull and 95% where MCI was used as a tool for gender identification
pelvic bones are present, determination of sex accurately for a given population. The results of this meta-analysis
showed that MCI yielded a total sensitivity of 65% (0.59, unknown geographical location) in mass disasters.
0.71) and total specificity of 63% (0.56, 0.69).
All the 26 studies considered in the review have used
Overall, the identification accuracy varied from MCI as a tool for gender estimation in a living population
32% to 94% for the males and 24% to 87% for females with known gender. No studies could be retrieved where
indicating a wide variation.. To explain this heterogeneity/ MCI has been used for victim identification in mass
variation subgroup analysis and sensitivity analysis were disasters or in post mortem cases. The actual application
undertaken. However, both the analysis could not explain for which MCI is designed has never been tested.
the variation as the subgroups itself did not demonstrate
homogeneity. Rao et al7 proposed that MCI should be calculated in
the well aligned mandibular arch. Three studies 8,9,22 have
The varying degree of diagnostic accuracy could performed these calculations in the mal-aligned teeth.
be probably explained on the basis of lack of sexual Such malocclusion can affect the accuracy of the MCI.
dimorphism with regards the mesio-distal canine width More-so, this again limits the application of MCI in mass
and intercanine distance. This is further explained with disasters, where there is a slender chance that the victim
an example: In a study by Hosmani JV et al 16, the would have well aligned mandibular teeth available for
sensitivity reported was 0.40 (40% males identified estimation. Mandibular arch with missing teeth, rotated or
correctly) and specificity was 0.50 (50% females crowed teeth limits the application of MCI.
identified correctly). The measurement of their study
participants were: mesio-distal width of the canine The unique feature of this review is that, probably this
in males was 7.18(6.02,8.34) and in females was 6.95 is the first largest systematic review and meta-analysis
(5.37, 8.53) and the inter-canine width of males was with 26 studies. Because of lack of homogeneity in the
27.17(22.03, 32.31) and females was 26.25 (21.58 , data across the studies complex meta-analytic statistics
31.31) respectively. Observing the values closely, one could not be performed. Since only two databases were
can appreciate that there is an overlap indicating lack searched there is a possibility to miss on some more
of sexual dimorphism. All those participants falling in relevant articles.
this overlap region are misdiagnosed (False positives
=50% and False negatives=60%). From this example Conclusion
one can interpret that only 40% males have unique
The fact that several studies13,16,19,30 have already
bigger measurements and 50% females have unique
refuted the application of MCI in sex estimation and
smaller measurements and hence they have been
synergistically the results of this systematic review
identified correctly. While those in the overlap region,
and meta-analysis along with the explanation of its
the 60% males have smaller measurements and are
limitation in the above section clearly indicates that
misdiagnosed as females and 50% females have bigger
Mandibular Canine Index is not an accurate tool for
measurements of their teeth similar to males and hence
gender identification.
are misdiagnosed as males. This accomplishes that only
when there is distinct sexual dimorphism , MCI can have Acknowledgement: The authors would like to
better accuracy in gender identification 8,30,32,33. acknowledge Dr.Rizwan SA, for guidance during
systematic review.
A varying range of Std MCI (cut off point values)
from a minimum of 0.19 to a maximum of 0.3 has Ethical Clearance: Not required.
been observed across the different studies. Each study
showed its own unique Std MCI value. This variation Source of Funding: Self
in the cut off points is the result of the varying mesio- Conflict of Interest: None
distal canine width and the inter-canine distance of
the population indicating that there is no one standard
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DOI Number: 10.5958/0976-5506.2018.00615.0
Histopathological Evaluation of White Lesions–

An Institutional Observational Study
Roopa Madalli1, Mamatha GS Reddy2, Neeta Bagul3, Supriya Kheur4

Lecturer, 2Reader, 3Professor and Head, 4Professor and Head; Department of Oral Pathology and
1
Microbiology; Dr. D. Y. Patil Vidyapeeth’s, Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune-18
Abstract
The most common oral manifestation of tobacco use is in the form of white lesions.They
may reflectas benign, pre‑malignant or malignant condition. There are no clinical signs and
symptoms which canpredict whether a pre‑malignant lesion or a condition will undergo
malignant change or not.An institutional based cross‑sectional study was conducted including total of
344 casesreporting to the outpatient wing from 2004 - 2016. Demographic details of various white lesions
of oral cavity along with histopathological findings were studied. Results showed the habit of tobacco quid
placement and Gutkha chewing was followed maximum.The most common white lesion was leukoplakia
andout of 344 cases 125 (36.33%) had dysplasia. 8 (2.32%) cases in our study did not have correlation
between clinical and histopathological diagnosis. The aim of the study was to clinicopathologically correlate
the white lesions.
Keywords: Oral pre-malignant disorders, dysplasia, leukoplakia, lichen planus.
Introduction restorations are also irritants.2 White lesions in non-

habit cases such as stress also reported.White lesions
White lesion is a non-specific term used to describe in the oral cavity may be benign, pre‑malignant or
any abnormal area of oral mucosa that on clinical malignant. On the other hand, suspicious looking lesions
examination appears whiter than surrounding tissue & is can be pursued and a definitive diagnosis made through
usually slightly raised, roughened or of different texture subsequent biopsy.
from adjacent normal tissue. White lesions appear white
due to many reasons such as production of abnormal Identifying and recognizing a premalignant lesion
keratin which imbibe fluid far more readily, coagulation or a frank malignancy in the early stages will go a
of surface tissue & formation of pseudo membrane, long way in averting the development of a malignancy
traumatic, chemical, infectious or immunologic injury and will provide an excellent prognosis with minimal
and reduced vascularity of subjacent connective tissue.1 disfiguration and functional handicaps.4The purpose of
this study is to analyze the clinical and histopathological
Chronic irritation from all forms of tobacco patterns of white lesions in the oral cavity.
represents the most common cause of white mucosal
lesions. Ill-fitting dentures, rough teeth, and dental
Materials and method
An institutional based cross‑sectional study was

Corresponding Author: conducted in the Department of Oral Pathology and
Dr. Supriya Kheur, MDS, Microbiology, Dr D Y Patil Dental College, Pimpri
Professor and Head, Pune, from 2004 to 2016. All the lesions with differential
Department of Oral Pathology and Microbiology diagnosis as oral potential malignant diseases, clinically
Dr. D. Y. Patil Vidyapeeth’s, presenting as non-scrapable white lesions (leukoplakia,
Dr. D.Y.Patil Dental College and Hospital, Pimpri, lichen planus, oral submucous fibrosis) were included in
Pune-18 the study.
The total of 344 cases during the period of mucosa 60(55.5%) followed by right buccal mucosa
13yrs.were retrieved from the records. A detailed 30(27.7%) and labial vestibule 18(16.6%). There were
demographic data and clinical history recording of only 8 (2.32%) cases without habit and categorized as
age, gender, occupation, chief complaint, duration, risk non-habit related white lesions.
factors associated personal habits,location, extent, size
and type of lesions,past medical and dental history and Table 2: Clinical type of white lesions
family history were entered in Microsoft excel. The
histopathological diagnosis was then correlated with the Total no. of
Type of white lesion Percentage
clinical data and provisional diagnosis. cases N-344.
Leukoplakia 192 55.8
Results Oral Submucous
66 19.18
fibrosis
Oral Lichen Planus 80 23.25
Table 1: Distribution of cases based on habits
Frictional keratosis 06 1.74
Total no.
Type of habit of cases Percentage Table 3: Clinical presentation of the white lesions
N-344
Tobacco chewing 46 13.37 Clinical presentation Total no. of
Percentage
Tobacco quid placement 108 31.39 white lesion cases N-344
Gutkha chewing 120 34.88 Homogenous 304 88.37
Combination of smoking Non-homogenous 40 11.62
28 8.13
and nonsmoking habit
Clinically the white lesions were diagnosed as
Smoking 30 8.72
leukoplakia (55.8%), lichen planus (23.25%) and along
Stress 08 2.32 with the white lesion in the oral cavity, pain or burning
Trauma 02 0.58 sensation, difficulty in opening mouth was present in
Non habit 02 0.58 66 cases with fibrotic bands seen maximum on buccal
mucosa following retromolar area and soft palate were
Three hundred and fortyfour cases were included
diagnosed as OSMF (19.18%), and frictional keratosis
in the study. 280(81.39%) were males and 64(18.6%)
(1.74%) [Table2]. According to the appearance of the
females in the study population. On basis of personal
lesions most of the lesions were homogenous (88.37%)
habit,list of non- tobacco habits and tobacco habits are
and few non-homogenous (11.62%) [Table 3].The
summarized in table 1. Commonest found was tobacco
leukoplakic patches were homogenous in most cases
quid and Gutkha chewing. Out of 108 (31.39%) cases
(64) and erosive in 11 cases.
of tobacco quid placement, maximum was in left buccal
Table 4: Age-wise distribution of white lesions
Age Years Leukoplakia Oral Lichen Planus Oral Submucous fibrosis

M F M F M F
10-30 38 02 26 08 40 04
31-50 64 16 20 12 12 04
51 and above 68 10 10 04 02 04
Total 170 22 56 24 54 12
All male and female patients were grouped separately depending on type of white lesion i.e leukoplakia, lichen
planus & oral submucous fibrosis under different age groups. Findings stated that OSF and OLP were common in 2nd
decade and leukoplakia was mainly found in 5th decade both in males and females [Table 4].
Table 5: Prevalence of dysplasia among white lesions
Type of white lesion Mild dysplasia Moderate dysplasia Severe dysplasia

Leukoplakia 33.7% 14.6% 6.7%
Oral Lichen Planus - 4% -
Oral Submucous fibrosis - - -
Histopathological examination of these lesions was more frequently than females in our society and changing
done by two pathologists to rule out the interobserver lifestyles of the youngsters.
bias. Leukoplakia histopathologically was categorized
as hyperkeratotic complex 46(75%) and hyperkeratotic In the present study the major diagnosis of oral white
simplex 29(25%) respectively. Biopsy specimens lesions was Leukoplakia. There is male preponderance
which showed parakeratosis, elongated rete pegs, and (170:22 ). According to study by Swati Parikh et al gave
submucosal lymphocytic infiltration were diagnosed as the ratio of 2.74:1.7In the study of Nadia Zaib et al,
OLP. Out of 80(23.25%) cases with diagnosis of OLP only male to female ratio was 1.1:1.9 In our study, the peak
4 (5%) patients showed dysplasia and rest were without incidence of OSF and OLP were common in 2nd decade
dysplasia which is the consistent feature with OLP and leukoplakia was mainly found in 5th decade both in
(Table 5).The histopathologic picture of oral submucous males and females. In study by Swati Parikh et al, the
fibrosis showed atropic epithelium, flat reteridges, dense peak incidence of oral cavity lesions was between 4th
fibrous connective tissue and subepithelial hyalinization. to 6th decades while in the studies undertaken by Al-
Khateeb TH&Pudasaini S et alit was between 2nd to 4th
decades.9, 11,12
Discussion
Commonly used non‑smokeless tobacco forms were
The oral cavity is vulnerable to a limitless number
pan masala, tobacco chewing, gutka chewing, betel quid
of environmental insults because of its exposure to
placement, non-habit such as stress, trauma was found
the external stimuli and can be host to a multitude
as a significant risk factor for white lesions in the current
of pathological lesions which may be neoplastic,
study. In the present study 78% of patients had habit in
premalignant, or reactive.5 Lesions in oral cavity are
form of chewable tobacco or gutka. Only 8% had the
generally regarded as a strong indicator of general
habit of smoking. As against the study of Laronde DM
health.6Chronic irritation from all forms of smoking
et al. in which 75% of users had habit of both tobacco
represents the most common cause of white mucosal
and alcohol.13 We found chewable form of tobacco is
lesions. The direct contact of tobacco with the oral
common in our study and can be justified by the group of
mucosa is responsible. Snuff dipping is a potent irritant
lower socioeconomic people, orthodox group of society
and carcinogen. Ill-fitting dentures, rough teeth, and
so, smoking was not so common in our particular study.
dental restorations are also irritants.2Suspicious looking
lesions can be pursued and a definitive diagnosis made The most common site in the present study was
through subsequent biopsy. There are very few studies, buccal mucosa (52.9%) as, as chewable form of tobacco
especially from developing countries such as India, was common and general human tendency of placing it
which have evaluated the clinical and pathological in buccal region for a long duration. Hard palate was
diagnostic factors of white lesions in the oral cavity. found to be the least common site. Similar findings was
found in the studies by Simi SM et al ,Axell et al and
Out of 344 study population 70% (274) were males
by Silverman et al.3, 14, 15In contrast to these studies,Al-
and 30% (116) were females, with a male to female ratio
Khateeb TH and Pudasaini S et al showed palatal and lip
being 2.36:1, which was in accordance to Chaturvedi et
lesions predominance respectively.11, 12
al in India.7 We observed that half the study population
was in the age group of second decade, which was However, clinically to classify lesions as
in contrast to age group that of Ranganathan et al.8 premalignant is difficult because they vary in appearance
Male predominance in our study can be due to easy and are likely to be interpreted subjectively by the
accessibility for males to use areca nut and its products clinician. A histopathologic diagnosis is generally more
definitive of premalignant change than clinically appar References

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found. Though OLP known to undergo transformation Study from a Tertiary Care Dermatology Centre
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The white lesions affecting the oral cavity constitute 2010;14:1085‑95.
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from Institutional Subethics Committee
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DOI Number: 10.5958/0976-5506.2018.00616.2
A Study on Factors Influencing Competency of Pharmacists in

a Tertiary Care Hospital
Marsha Augustin1, Samuel N J David2, Aileen J3, G Devakumar4

1
Postgraduate Student, Department of Hospital Administration, Ramaiah University of Applied Sciences,
Bangalore, 2Senior Manager(Management Studies and H.R.) and Head of Department of Staff Training
and Development, Christian Medical College (CMC), Vellore, 3Assistant Professor, Department of
Hospital Administration, Ramaiah University of Applied Sciences, Bangalore, 4Associate Professor and
Head-Innovation & Entrepreneurship Development Research Centre, Ramaiah University of Applied
Sciences, Bangalore
ABSTRACT
Enhancing the performance standards of employees with competency assessment has become a cutting-edge
development among the industries. It is more vital for the organization to recruit the right people for the
right job so as to ensure continued stability and growth. In the recent past, health organizations have stepped
forward to map competencies for their nursing department, which is considered to be back bone of health care
organizations. Likewise, pharmacists are most often neglected in the healthcare delivery system, but are a
key component as they are the sole providers of medications for treatment. Identifying competencies among
pharmacists will help provide a better platform for them to grow in their profession with utmost diligence,
dedication and patient centered care which eventually contributes towards the organizational goals.
The main aim of this study was to identify the factors influencing competency with respect to pharmacists
in a tertiary care hospital and provide recommendations for future training needs.
The total population size of 153 Pharmacists were considered for this study. Initially, pilot study was
conducted to identify the contemporary knowledge, attitude and skills of the pharmacists. This was done
through a checklist, so as to understand their roles and responsibilities and identify major competency
factors. Based on this input, a survey questionnaire was developed to capture data for further investigation.
The analysis was carried out using SPSS tools such as: Descriptive statistics, Correlation and Two-way
Analysis of Variance (ANOVA) followed by Hypotheses testing.
The result shows that, there is scope for improvement by providing training with respect to technical
knowledge and technical skills to the pharmacists. It suggested to incorporate interpersonal relationship
training module in vernacular languages, so as to attain superior customer satisfaction.
Keywords: Competency, Competency mapping, Competency framework, Competencies among pharmacist
INTRODUCTION The term competency was initially used in 1972

by David Mc Clelland1 who described that the real
The concept of competency mapping has been vital to
predictors of a job performance are a set of underlying
organizations around the world. Apart from the different
personal characteristics or performances. According to
fields that have adopted competencies, the healthcare
sector has slowly been catching up with competency Mulholland 1994, Wright 1998; competency is defined
mapping and developing frameworks. Although many as the minimum standard necessary to perform a job2,3.
research studies have been conducted, only a few
With plans to improve the structure, processes, and
competency frameworks have been implemented in
the healthcare sector. A few fields who have adopted outcomes, competencies have also become a contributory
the framework includes nursing, laboratories and factor in the development of the employees’ performances
pharmacies. in an organization. Development of competency
frameworks have been widely used in every sphere but is competency factors that have to be studied among the
still growing in the Indian healthcare industry. pharmacists were identified. With the identification of
factors, a questionnaire was formulated. The data was
Lack of standards in healthcare has led to poor collected with a customized questionnaire wherein
performance (WHO, 2006)4. Thus, various performance the items(questions) were classified under five broad
standards came into the picture. Eventually, competency categories namely, Demographic profile, Technical
frameworks were being designed to meet the Competency, Behavioral Competency, Leadership
standards in various fields within the healthcare sector. Competency and Organization Specific Competency
Encouragement of healthcare professionals to achieve in a 5-point likert scale. Open Ended questions were
the standards with the framework will help in continuous included in the questionnaire. Each employee was
quality improvement. The main aim of this study was given the questionnaire by the researcher in person and
to identify the factors influencing competencies required collected to avoid bias and to address any clarifications
by the pharmacists to achieve their utmost level of in the questions.
performance. The factors which were identified were
narrowed down further according to the hospital’s Sampling: The total population who were 153
requirements and nature of the organization. pharmacists were taken for the study.
OBJECTIVES FINDINGS
zz To study the job roles and responsibilities of the From the outcome of the study, it was noted that
pharmacists to understand the present level of 61.4% were males and 38.6% were females. And out of
knowledge, attitudes and skills these respondents the maximum numbers of individuals
zz To investigate the factors influencing roles were undergraduates i.e. 79.1%. Majority of the
and responsibilities with respect to technical employees (38.6%) belong to the age group of 31 to 40
competencies, behavioural competencies, years. The total percentage of the employees who are
leadership competencies and organization specific permanent is 85.6%.
competencies
All the ‘R’ values for technical, behavioral,
zz To analyse the identified factors and leadership and organization specific competencies are not
zz their impact on effectiveness of technical, above 0.7 and there is no concern for multicollinearity.
behavioural, leadership and organization specific This means that all the variables are measuring its own
competencies in the department question and there is no need for grouping them as there
are no similarities or homogeneity among the items.
zz To analyse the effectiveness of the identified This shows that all the items (competencies) taken for
competencies and suggest suitable recommendations the study can be considered.
for the organizational growth
Hypotheses Testing: Hypotheses testing was done using
MATERIALS AND METHOD two-way analysis of variance(ANOVA).
The study was quantitative and adopted a descriptive Ho: Null Hypothesis: There is no significant
research design in a Tertiary Care Hospital. The research relationship among the technical, behavioral, leadership
was conducted in the department of pharmacy for a and organization specific competencies.
period of six months.
H1: Alternate Hypothesis: There will be a significant
Data Collection: Face-to-face interview, checklists relationship among the technical, behavioral, leadership
and department procedure manual were used to study and organization specific competencies.
and understand the roles and responsibilities of the
Since the p value is lesser than 0.05, null hypothesis
pharmacists.
is rejected and alternate hypothesis is accepted which
Through literature survey i.e. research papers, means that there is a significant relationship among
journals, books along with expert advice, the various the technical, behavioral, leadership and organization
specific competencies. Thus, these competencies are precautions by double checking before dispensing the
independent of each other. medications; their immediate boss is considerate, has
empathy and respects others; the respondents agreed
Ho: Null Hypothesis: There is no significant that the organization encourages team work to achieve
relationship between occupation and technical, organizational goals and good interpersonal relationship.
behavioral, leadership and organization specific
competencies among pharmacists.
DISCUSSION
H1: Alternate Hypothesis: There will be a significant
In this research study, the factors influencing
relationship between occupation and technical,
competency of pharmacists in a tertiary care hospital
behavioral, leadership and organization specific
were analyzed. The most popular languages of the
competencies among pharmacists.
patients who visit the tertiary care hospital are Hindi,
Since the ‘p’ value is higher than 0.05, the test is English, Bengali, Malayalam, Tamil and Telugu.
not significant. Therefore, null hypothesis is accepted Implementation of a competency based system will
and alternate hypothesis is rejected which means that encourage individuals to achieve performance standards
there is no significant relationship between occupation and contribute towards continuous quality improvement.
and technical, behavioral, leadership and organization
Competency Practice Based Research: Competencies
specific competencies among pharmacists. Therefore,
in the current study, have been classified into four main
there is a possibility to increase the quality of the
domains for the overall development of the individual.
employees through these competencies irrespective of
The domains which were identified are technical
the occupation of the pharmacists.
competencies, behavioral competencies, leadership
Thus, it can be concluded that the identified competencies and organization specific competencies.
competencies after analysis can be used for the According to the Organization for Economic Co-
development of a customized competency framework operation and Development (OECD) framework,
for the pharmacy. “Sustainable development and social togetherness depend
critically on the competencies of all our population–with
From the two-way analysis of variance and competencies understood to cover knowledge, skills,
hypotheses testing, it was found that there is a significant attitudes and values.” Core competencies were divided
relationship among the main competency domains. into three main groups: delivery related competencies,
Whereas, null hypothesis was accepted only in case of interpersonal competencies and strategic competencies 5.
occupation (Permanent Employee, Probation Employee, Kumari and Sita, (2010) have examined the importance
Temporary Employee, Trainee) of Pharmacists. of different aspects of competency domains which
are: talent acquisition, talent development and talent
Table 1.1: Competencies which stood out among the retention 6. Whereas, this research study has brought
Pharmacists about a wholistic approach in the development of the
individual to achieve patient centered care.
In the process of grouping competency, factors in

accordance with the organization’s perspective has been
included. All the items taken for the study are independent
of each other and can be incorporated into the analysis
of factors influencing competencies. The outcome of
the analysis of variance shows that there is a possibility
of improvement in the employees’ quality through
the identified competencies. The hypotheses testing
From the table 1.1, the mean values that were shows that there is no significant relationship between
analyzed, the highest mean values were for the following occupation and technical, behavioral, leadership and
competencies: The pharmacists are conscious and take organization specific competencies among pharmacists.
From the literature survey that has been carried out so RECOMMENDATIONS
far, this research study has analyzed various categories
of employees with respect to age, gender, qualification There is a need for management to encourage the
and occupation in accordance to the various competency employees to share their views to the top management
domains. about their needs and grievances.
zz Modules for training employees in languages
There exists a strong linear relationship among
such as Hindi, Bengali, Telugu, Malayalam is
the various competencies that were identified. All the
recommended for the employees to communicate
‘R’ values for technical, behavioral, leadership and
better with the patients. Workshops on development
organization specific competencies were not above 0.7
of interpersonal relationships is of vital importance
which indicates a strong linear relationship which is in
as the maximum number of respondents have stated
accordance with research acceptance limits. Research
lack in this area.
studies have shown that there exists a strong correlation
between the competencies and employees’ performance zz Although a survey questionnaire was used for
levels. Therefore, this confirms that competencies collection of data through the feedback from the
comprise of the knowledge, skills and attitudes of respondents, including participants who represent
individuals to improve individualistic performance 7. the academic side and professional practice across
the various disciplines in the health sector will add
The male pharmacists are more in number than more value to the study.
the females in the country which is also evident from
the current research study. In one of India’s largest zz The inputs from this research for the development
pharmaceutical company, Dr. Reddy’s labs, out of 17,000 of the competency framework can be used in the
employees, only 15% of females are present8. Therefore, other health disciplines also.
from this study it is evident that there still exists a zz Since the study was for a short period of time, survey
variation in the male to female ratio in the industry. questionnaire for self-assessment was adopted for
the study. Further other qualitative techniques such
The importance of this study was that the identified
as interviews, focus group discussions, Delphi
and analyzed competency factors can be used for
techniques etc. can be used for the study.
individual and organizational growth. The gaps identified
among the competencies can be used to develop training zz Based on this study, the research can delve deeper
modules for better performance of the employees. into identifying competencies at various levels
According to Bhojraj et al, (2016) the study states the within the department and across various other
current facts of the pharmacy situation in India wherein departments within the hospital.
for optimal functioning of pharmacists the necessary
knowledge, skills and abilities should be considered. FUTURE DIRECTIONS
As there are more number of pharmaceutical colleges
arising in the country, the outcome of pharmacists The questionnaire which was formulated can be used
with the necessary competence and motivation is less9. to assess the employees over a period of 6 months or one
Therefore, to address this, a competency based education year after training has been incorporated with respect
system will help by exposure of the right competencies to effective interpersonal communication and language
that is necessary for growth and development in the field. training in Bengali, Telugu, Malayalam and Hindi.
In addition to it, the customized competency CONCLUSION

tool which has been developed can be used across
various health organizations by making changes to the The main outcome of this research was to identify
technical competency domain in accordance with the factors influencing competencies for pharmacists. From
job description. The rest of the domains can be retained. the analysis through descriptive statistics i.e. through
Thus, this tool provides a platform for the organization mean and inter correlation, it was found that the items
to develop individual competencies across the health present in the four variables i.e. technical competencies,
disciplines. behavioral competencies, leadership competencies and
organization specific competencies, were independent of 4. Wiedenmayer K, Summers RS, Mackie CA,
each other and there was no concern for multicollinearity. Gous AG, Everard M, Tromp D, World Health
All the correlations were positive and showed that there Organization. Developing pharmacy practice: a
is a possibility of the employees’ competence to improve focus on patient care: handbook. 2006.
through the various variables that were identified. The
5. Rychen DS. Key competencies for the knowledge
identified competency factors will help every individual
society: A contribution from the OECD Project
employee to assess their own competencies and further
Definition and Selection of Competencies
to work towards their own development and contribute
(DeSeCo). InEducation–Lifelong Learning and
towards the organizational goals.
the Knowledge Economy Conference, Stuttgart,
Conflict of Interest: Nil Germany 2002 Oct 10.
6. Kumari A, Sita V. Role of Competencies in
Source of Funding: It was self-funded.
Human Resource Management: A study in Indian
Ethical Clearance: Taken from MSRUAS Research Organizations. 2010.
Committee. 7. Havidz Aima, Rizki Adam et al. Model of
Employee Performance: Competence Analysis
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than for” intelligence.”. American psychologist. 8. C.H. Unnikrishnan. Bridging the gender inequality
1973 Jan;28(1):1. gap in the pharma sector. Live mint [newspaper
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management. 1994 Jul 1;2(4):161-6. assurance in pharmacy education; Transforming
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DOI Number: 10.5958/0976-5506.2018.00617.4
Demographic Profile of Blood Donors: A Study of a Tertiary

Care Medical College Hospital Ambala Facility Based Study
Nazuk Razdan1, Randhir Kumar2, Anu Bhardwaj3

1
Assistant Professor Community Medicine MMMCH Solan, 2Assistant Professor, 3Professor,
Community Medicine, MMIMSR Mullana
Abstract
Introduction: An integrated strategy for blood safety is required for the provision of safe and adequate
blood. Recruiting a sufficient number of safe blood donors is an emerging challenge. The shortage of blood
in India is due to an increase in the demand, with fewer voluntary and limited number of replacement blood
donors. A study on the Demographic profile of Blood Donors: A Study of a tertiary care medical college
Hospital Ambala facility based study was done.
Material and Methods: A hospital based cross-sectional design was conducted among 800 blood donors.
The statistical analyses were done by using the SPSS software. The associations between the demographic
factors were analyzed by using the Chi square test.
Results: Mean age of replacement group was 28 ± 7.392%. Majority (82.4%) knew about their blood group.
Conclusion: Creating an opportunity for blood donation by conducting many blood donation camps may
increase the voluntary blood donations.
Keywords: voluntary, replacement, blood donors, age, religion
INTRODUCTION platelets rather than whole blood is important. But, non-

availability of sufficient basic blood units is a problem
Blood is the only oxygen transporter in the body throughout the country.
and is crucial in saving lives. Even years of extensive
research failed to find a true substitute for blood and The hospitals rely on the relatives of a patient to
blood components may not be available for many donate the necessary blood as there are not enough
years.1 Therefore, blood donation by humans will continue voluntary blood donations to help the needy patients.
to be the major source for blood and blood components. Maximum blood donation in our blood banks is on
Blood donation is truly ‘a gift of life’ that a healthy replacement basis. Blood banks pressurize the doctors,
individual can give to others in their community, who are the nurses and the relatives of the patient and urge them
sick or injured. In any blood bank blood and the component to send replacement donors to maintain their stock. This
units available for everybody’s requirements should be is not a good practice as the relatives of the patients
sufficient. With the advent of modern transfusion medicine are compelled in to finding donors. Professional blood
the therapeutic use of specific portions–components of donors are brought to donate blood in guise of being
blood, e.g. factor VIII concentrates, packed red cells or replacement donors. This is a very risky situation as
professional donors constitute a group with high-risk
Corresponding Author: behavior leading to greater chances of transfusion-
Nazuk Razdan transmitted diseases.2
Assistant professor, Like in any developing country in India too, there is a
Department of Community Medicine. dependency on family replacement and remunerated
Maharshi Markandeshwar Medical College and Hospital, donors. Though the World Health Organization
Kumarhatti, Solan advocates that member states should establish national
blood transfusion services that will operate on the Study tools: A self designed, pre-tested, semi-
basis of voluntary, non-remunerable basis3, family/ structured, open and close ended questionnaire was used
replacement donors still provide more than 45% of the for collecting relevant information
blood collected in our blood banks.4 Data analysis: The data were analyzed using SPSS
version 21. Percentages and means were calculated
MATERIAL AND METHOD for the data. Chi- square test of significance was used.
A p value of <0.05 was considered to be statistically
Study Area: The study was conducted in the Blood
significant.
Bank in the Department of Pathology of Maharishi
Markandeshwar Institute of Medical Sciences and
RESULTS
Research, Mullana, district Ambala, Haryana.
In the present study it was found that male were
Study Population: The participants coming to the
more in both the group. Mean age of replacement group
department of Blood Bank. These participants were both
was 28 ± 7.3925 and for voluntary group it was 27 ±
voluntary and replacement donors.
8.3068. Majority belongs to 21-30 year of age in both
Inclusion criteria: Willing to give consent for the study the group as seen in figure I.
and heamoglobin ≥12gm%
Exclusion criteria: Age <18years and >65years, Weight

<45kgs, Suffering from any disease or on medication,
Professional/Commercial/Paid donors.
Study period: For a period of 12 months i.e. from

January 2015 to December 2015.
Study design: A hospital based cross-sectional design
Method of sampling: Systemic random sampling Figure I: Distribution of Donors According To Their
Age
technique was used for sample collection.
Figure II shows sex wise distribution of Replacement
Sample size: The sample size was decided taking into
& Voluntary donors. Majority (89.4%) of study subjects
account the n=4pq/L2
in replacement group were males and females were
Where, n= Minimum sample size required, p= 10.6%, similarly in voluntary group also the majority
Expected prevalence rate, q=100-p, L=Allowable (92.2%) were males and females were 7.8%.
error (10 %). Literature review reveals that the overall
prevalence was 35.65%, in a study by Manikandan
et al (2013)5 in Tamil Nadu. So keeping this study into
consideration, the sample size was calculated assuming
a prevalence of 35% and the sample size for the study
came out to be 743 and the sample size was rounded off
to 800 donors.
Sampling technique: Approximately 2000 donors

attend the Blood Bank in a year. Considering sample
Figure II: Distribution of Donors According to Their
size of 800, sampling fraction was calculated, therefore,
Gender
in the current study every 3rd donor was included for the
study, and till the sample size completed. However, 6.6% Table 1 represents religion wise distribution of
of the blood donors refused to participate and therefore, Replacement and Voluntary group donors. Majority
a total 747 donors participated in the study. (66.1%) of study subjects were Hindus and belonged to
replacement group, followed by Sikhs (16.5%), Muslims (10.4%), Others (7.1%) respectively, similarly in voluntary
group also the majority (63.0%) were Hindus, followed by Sikhs (21.4%), Others (12.4%), Muslims (3.1%)
respectively. The difference was found to be statistically highly significant.
TABLE 1: Distribution of Donors According To Their Religion
Replacement Voluntary Total

Religion
n = 425 % n = 322 % n = 747 %
Hindu 281 66.1 203 63.0 484 64.8
Muslim 44 10.4 10 3.1 54 7.2
Sikh 70 16.5 69 21.4 139 18.6
Others 30 7.1 40 12.4 70 9.4
χ2=21.622, df=3, p value < 0.001
Table 2 shows distribution of donors according to their educational status among Replacement and Voluntary
group donors. Majority (51.8%) of study subjects in replacement group have studied up to graduation, followed
by secondary school 29.9%, similarly in voluntary group the majority (38.5%) have studied up to graduation with,
followed by secondary school with 38.5%.
TABLE 2: Distribution of Donors According to Their Educational Status
Replacement Voluntary Total

Educational Status
n = 425 % n = 322 % n = 747 %
Illiterate 15 3.5 5 1.6 20 2.7
Primary 8 1.9 5 1.6 13 1.7
Middle School 4 0.9 3 0.9 7 0.9
High school 43 10.1 40 12.4 83 11.1
Secondary School 127 29.9 124 38.5 251 33.6
Graduate 220 51.8 140 43.5 360 48.2
PG 8 1.9 5 1.6 13 1.7
χ2=10.446, df=6, p value 0.107
About their diet, majority (57.6%) of study subjects In the present study, majority (90.6%) of donors
in replacement group and 53.7% in voluntary group were were males as compared to the females 9.4%, the
non-vegetarians. About their smoking behaviour 53.9% reasons for less percentage of female donors could be
of study subjects in replacement group and 64.3% in temporary deferral conditions like low haemoglobin,
voluntary group were non-smokers and 73.2% of study low weight, etc. These findings were found similar to
subjects in replacement group and 71.4% in voluntary the studies done by Uma et al (2013) and Kasraian et
group were non-alcoholic. at (2015), where majority of donors were found to be
males (93.0% and 93.74% respectively) as compared to
DISCUSSION females which were 7.0% and 6.26% respectively.8,9
On analyzing the socio-demographic data, it was In another studies done by Shenga et al (2008),
seen that the majority of the donors who participated Singh et al (2015) and Siromani et al (2016) distribution
in the present study belonged to the age group of 21-30 of donors belonged to Hindu community (44.7%, 66.0%
years (54.6%) which was similar (35.48% and 41.7%) to and 78.3% respectively) followed by Budhist, Muslims
the studies done by Choudhury et al (2014) and Shidham and others which was found similar to the present study
et al (2015).6,7 where Hindus were 64.8%, followed by Sikhs and
others. This may be because Hinduism is the dominant to the achievement of goal of 100% non-remunerated
religion in India.10,11 voluntary blood donation.
Abderrahman et al (2014) and Nigatu et al (2014), Ethical Clearance: The study was approved by
in their studies showed that the majority of respondents Institutional Ethics Committee. The present study did
were living in the rural areas (83.2% and 55.4% not impose any financial burden to the participants and
respectively) which was found similar to the present an informed and written consent was taken
study which was 60.0%.12,13
Conflict of Interest: Nil
In the present study, majority of donors were married
(50.5%) which was similar to the studies conducted by Source of Funding: Self
Kulkarni et al (2014) and Shenga et al (2008) which was
73.6% and 89.5% respectively.14,10 REFERENCES
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2. Shenga N, Thankappan KR, Kartha CC,
In the present study, the distribution of donors
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(33.3%) which was found similar (28.01%) to the study 2010; 3: 21–25.
done by Unnikrishnan et al (2011).16
3. The Melbourne declaration on 100% voluntary
In the present study, the majority of donors belonged non-remunerate donation of blood and blood
to class I (79.8%) of socio-economic status according components,” Composed at World Blood Donor
to modified BG Prasad classification 2016 which was Day. Melbourne, Australia, 2009.
found similar (49.0%) to the study done by Kurian et al 4. National AIDS Control Organization: Voluntary
(2016).17 Blood Donation Program –An operational guideline;
Most of the blood donors in the present study were Ministry of Health and family Welfare 2007:9
non-vegetarians (56%) and 44% were vegetarians, 41.6% 5. Manikandan S, Srikumar R, Ruvanthika PN.
of the donors were smokers while 27.6% were alcoholic A study on Knowledge, Attitude and Practice
whereas in the studies done by Ahuja et al (2009) and on Blood Donation among Health Professional
Ray S et al (2005) the results were quite opposite as Students in Chennai, Tamil Nadu, south India.
the majority of donors were vegetarians 92% and 65%, IJSRP. 2013;3(3).
while 38% and 5.9% were smokers and 37.6% and 5.2% 6. Choudhary P, Chakrabarti JS, Choudhary PS.
were alcoholic. Cultural factors might be responsible for Frequency and distribution of blood groups in
these differences.18,19 blood donors of Tripura. The Health Agenda
.2014;2(2):57-61.
CONCLUSION 7. Shidam UG, Lakshminarayanan S, Saurabh S,
Roy G. Knowledge and Attitude Regarding Blood
It is important to create opportunities regarding
Donation in Rural Puducherry, India. Natl J
blood donation but it is equally important to spread the
Community Med. 2015; 6(1):64-8.
awareness of voluntary blood donation. Awareness or
knowledge can only change behaviour, if the facilities 8. Uma S, Arun R, Arumugam P. Knowledge,
for adopting such practices are readily available. attitude and practice towards blood donors in
Availability of “Blood Donor Diary” at every blood Chennai; J ClinDiagn Res. 2013;7(6):1043-1046.
bank containing the details of prospective blood donors 9. Kasraian L, Negarestani N. Rates and reasons for
could also go a long way. Non- monetary incentives for blood donor deferral, Shiraz, Iran. A retrospective
blood donation like Appreciation Certificates may lead study. Sao Paulo Med J. 2015;133(1):36-42.
10. Shenga N, Pal R, Sengupta S. Behavior disparities regarding blood donation. Annals of Medical and
towards blood donation in Sikkim, India. Asian Health Sciences Research. 2014;4(1):90-94.
Journal of Transfusion Science. 2008;2(2):56-60. 15. Dubey A, Sonker A, Chaurasia R, Chaudhary
11. Siromani U, Thasian T, Isaac R, Selveraj KG and R. Knowledge, attitude and behavior of people
Mammen JJ. Knowledge, Attitude and Practices in North India regarding blood donation. Blood
of blood donors towards Voluntary Blood transfuse. 2014:12(1):21-27.
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12. Abderrahmana BH, Salehb MYN. Investigating
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Donation among the General Public in a Selected
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DOI Number: 10.5958/0976-5506.2018.00618.6
Analysis of Factors Affecting Stunting Events in

Underwrapped in Cempaka Velocity Mining Area Kota
Banjarbaru in Year 2017
Husaini1, Lenie Marlinae2, Ratna Setyaningrum2, Dian Rosadi2, Anggun Wulandari2, Nida Ulfah2, Hastaniah3
1
Magister Public Health Science Program Study, Medical Faculty, Lambung Mangkurat University
2
Public Health Program Study, Medical Faculty, Lambung Mangkurat University 3Student of Magister
Public Health Science Program Study, Medical Faculty, Lambung Mangkurat University
Abstract
Poor nutrition status can result in stunting in children. Children with stunting conditions, will become a
human adult with low quality. If this condition occurs in children aged 0-2 years, then most likely the child
can not reach the expected potential height, the child will experience brain development is not perfect. Based
on riskesdas in 2013, prevalence of baduta stunting nationally is 37.2%, while prevalence of baduta stunting
in South Kalimantan is 45%. Based on the results of research Rahayu, et al., (2013) in Cempaka, Banjarbaru
found that prevalence baduta stunting is 50.9%. These data indicate that the stunting problem belongs to a
very poor category of public health because of the prevalence of stunting at ≥ 40%. This research is an analytic
observational study with cross-sectional approach. The subjects of this study were all children under five and
parents of children under five living in the mining area of Cempaka Urban Village. The results showed that
there was no correlation between father education, maternal education, maternal employment status, number
of family member, income, with stunting incident in Toddler in Kelurahan Cempaka Kota Banjarbaru. As
for suggestions that can be given is the need for monitoring the nutritional status of children under five with
follow-up as a preventive form of stunting incidents, supplementary feeding for improved nutritional status,
and stunted toddlers identified should receive more intensive attention from health workers.
Keywords: stunting, education, employment, number of family members, income
INTRODUCTION under five is mother’s upbringing pattern. Parenting

directly affects the consumption of toddlers1
The development of a nation aims to improve the
welfare of every citizen. The measure of the quality In Indonesia, there are still four major nutritional
of human resources can be seen from the human problems that need to be overcome with nutrition
development index (HDI), while the size of the welfare improvement program, that is protein energy problem
of the community can be seen, among others, from the (PEM), vitamin A deficiency problem, nutritional
level of poverty and nutritional status of the community anemia problem, and iodine deficiency problem. Viewed
(IBRA, 2007). The main problem faced by the Indonesian from the etiology, the nutritional status of the population
nation today is the low quality of human resources (HR). is influenced by various complex factors, such as: social,
The problem of lacking protein energy (PEM) as one economic, cultural, health, natural environment, and
of the major nutritional problems occurring in baduta people who are related to each other. The occurrence
(under five years) (Husaini, et al., 2003). Nutrition status of economic crisis, there has been an increase in
means a state of physical health of a person or group malnutrition cases, and even cases of malnutrition in
of persons determined by one or two combinations of Indonesia that can actually be overcome early with
regular monitoring every month2
specific nutritional measures. Suhardjo (1986: 15) says
that nutritional status is a state of the body caused by Poor nutrition status can result in stunting in
consumption of food absorption and use. One of the main children. Children with stunting conditions, will become
factors that influence the nutritional status of children a human adult with low quality. If these conditions occur
in children aged 0-2 years, it is likely that children can baduta stunting is 50.9% each (Rahayu A, et al., 2013).
not reach the expected height of potential, children will These data indicate that nutritional problems (stunting)
experience imperfect brain development, resulting in are included in public health problems with very poor
difficulties in meeting academic value3. category because of the prevalence of stunting by ≥ 40%
(Agency for Health Research and Development, 2013).
The period of the first two years of life is a time The magnitude of this prevalence shows that nutritional
very sensitive to the environment and this period is very problems, especially the problem of malnutrition is
short and can not be repeated again, then the baduta included in the category of severe problems, so it is
period is called the “golden period” or the “Window important to do research to determine the factors that
of Opportunity or critical period” (critical period). affect stunting.
The toddler period is a period of rapid growth and
development, and is the foundation that determines the
quality of the next generation4. METHOD
Basic on Riset Kesehatan Dasar (Riskesdas) 2007 This study is an analytic observational study that
stated that the prevalence of baduta stunting in Indonesia aims to analyze the factors that influence the stunting
is 36.8%. In 2010, the prevalence of baduta stunting status of children under five in the mining area of
was 35.6%. In 2013, prevalence of baduta stunting was Kelurahan Cempaka Kota Banjarbaru. The research
37.2%, which means an increase compared to 2010 and design used a cross-sectional approach that collects data
2007. Prevalence of baduta stunting in 2013 based on on dependent variable and independent variable is done
the data can be said public health problem with bad at one time point of the phenomenon being studied is
category, because stunting prevalence of ≥ 30%5. during one period of data collection. The independent
Data from Riskesdas 2007, stated that prevalence variable (independent variable) in this research consist of
of baduta stunting in South Kalimantan was 41.8% .In parent education, parent job, family member number, and
2010, prevalence of baduta stunting in South Kalimantan family income. While the dependent variable (dependent
was 35.3%. In 2013, the prevalence of baduta stunting in variable) in this research is stunting status. The subjects
South Kalimantan was 45%, which means an increase of this study were all children under five and parents of
compared to 2010 and 2007. The prevalence of baduta children under five living in the mining area of Cempaka
stunting in South Kalimantan in 2013 based on the Urban Village. In this analysis the statistical test used is
data can be said to be a very bad public health problem
a chi-square test with 95% confidence level, since the
because of the prevalence of stunting by ≥ 40%5.
variables studied are nominal and use more than two
Based on the results of research Rahayu, et al., (2013) groups of unpaired samples. However, if the test is not
in Cempaka, Banjarbaru found that the prevalence of met then use alternative test that is fisher exact test test.
RESULTS AND DISCUSSION

1. Univariate Analysis
Table 1: Frequency Distribution of Factors Affecting Stunting Occurrence in Toddlers in Cempaka Mining Areas
No. Variable Category Frequency Percentage (%)

1. Education of Father Low (≤ SMP), High (> SMP) 28, 2 93,3, 6,7
2. Education of Mother Low (≤ SMP), High (> SMP) 27, 3 90, 10
3. Job Status of Mother Not Work, Work 27, 3 90, 10
4. Number of family members Large (> 4 peoples), Small (≤ 4 peoples) 5, 25 16,7, 83,3
5. Family income Low (< 1.500.000), High (≥ 1.500.000) 23, 7 76,7, 23,3
6. Stunting status Stunting, Not Stunting 7, 23 23,3, 76,7
Total 30 100
Based on table 1, it is known that the education number of family members, the family has a small
history of the father who has a low education of number of family members of 25 people (83.3%)
28 (93.3%) of respondents. Low education in and there are 5 people (16,7%) who are in big
question is no school, did not complete primary family environment. The amount of family can
school, finished primary school and finished affect the consumption of family members. The
junior high school. While mothers who have low growing number of family members and not offset
education as many as 27 (90%) of respondents. by rising incomes will lead to a more uneven
Parents’ education, especially from fathers, has a distribution of food consumption7
role in getting more jobs and more income for the
Based on income status, it is known that families
family. This will also affect the family’s ability
with low income are 23 (76.7%) of respondents.
to meet every household’s needs, including the
Family income affects the provision of family
need to meet nutritious consumption. The level of
meals. In addition, family income can affect the
parental education influences parents’ knowledge
parenting pattern of children, so it also affects
of nutrition and parenting patterns6.
the nutrition of children under five in the family.
Based on the employment status of the mother of Poor child nutrition will have an impact or affect
toddlers, mothers who do not work as many as 27 child growth. Nutritional status can be influenced
(90%) of respondents. Working moms will find it by the direct factors of food intake and infection
easier to get more information than just at home and not directly in the form of food security in
as housewives. Mothers who do not work and just the family, child care patterns and the right health
stay home alone, they can get health information environment. Food consumption also affects the
one of them through television7. Based on the nutritional state of a person8.
2. Bivariate Analysis:
Table 2. Correlation between independent variables with stunting events
Stunting Status
No. Variable Category P-value
Stunting Not Stunting
Low (≤ SMP) 7 (25%) 21 (75%)
1. Education of Father 1,000
High (> SMP) 0 (0%) 2 (100%)
Low (≤ SMP) 6 (22,2%) 21 (77,8%)
2. Education of Mother 1,000
High (> SMP) 1 (33,3%) 2 (66,7%)
Not Work 4 (14,8%) 23 (85,2%)
3. Job Status of Mother 0,009
Work 3 (100%) 0 (0%)
Large (> 4 peoples) 1 (20%) 4 (80%)
4. Number of family members 1,000
Small (≤ 4 peoples) 6 (24%) 19 (76%)
Low (< 1.500.000) 6 (26,1%) 17 (73,9%)
5. Family income 1,000
High (≥ 1.500.000) 1 (14,3%) 6 (85,7%)
Based on the result of statistical test to know the college and college dad have never been involved
correlation between father education and stunting in child feeding activities. In addition, the
incidence in toddler, it can be seen p-value = 1,000 education level of the father also does not reflect
(> 0,05) which means Ho accepted so there is no his nutritional knowledge9.
correlation between father education to stunting
Based on the result of statistical test to find out
event in balita. This is in line with research
the correlation between mother education with
conducted by Aryu Candra (2010) that there is
stunting event in balita, it can be seen that p-value
no correlation between father education with
= 1,000 (> 0,05) which means Ho accepted so
stunting events. This condition can be influenced
there is no relation between mother education
because the father is usually outside the home so
with stunting incident in toddler in Cempaka
that parenting is entirely left to the mother. Both
Mining. In line with research conducted by there
is no correlation between education level with = 1,000 (<0,05) which means Ho accepted so
stunting status (Ni’mah C & Muniroh L, 2015). there is no relation between family income with
This may be because the TB / U indicator reflects stunting incident in balita at Cempaka Mining
past nutritional history and is less sensitive to Area . This research is in line with research of
changes in nutritional input where the mother’s Princess A (2012) which states that there is no
role is so important. Unlike the weight that can relation between family income with stunting
rise, fixed or decreased while the height can only event with p-value 1,000 (Anindita, 2012). This
rise or stay within a certain period. Under normal can be because the income received is not entirely
circumstances, height increases with age. High spent on staple food, but for other needs. A high
level of maternal education does not guarantee level of income does not necessarily guarantee
good nutritional status in infants, as income levels
children avoid malnutrition because the level of
may not necessarily be allocated sufficiently for
higher education does not mean that mothers have
food purposes. Although family income is low,
sufficient knowledge of good nutrition10.
but good childcare, the stunting will be reduced13.
Parental education is not a risk factor for stunting
events because of the many factors that can lead
CONCLUSION
to stunting children, such as parenting and family
care, as well as the history of other infections and There is no correlation between father education,
family food intake. Research in Tangerang in 2011 maternal education, maternal employment status,
found that father education is closely related to number of family members, income, with stunting
changes in stunting child height at 6-12 months of incident in Toddler in Kelurahan Cempaka Kota
age to be non-stunting at age 3-4 years (Rahayu, Banjarbaru. As for suggestions that can be given is the
2011). Parents with better education tend to have need for monitoring the nutritional status of children
knowledge and ability to implement knowledge
under five with follow-up as a preventive form of
better than parents with low education. But it also
stunting incidents, supplementary feeding for improved
does not close the possibility of poorly educated
nutritional status, and stunted toddlers identified should
parents are able to raise children better than those
receive more intensive attention from health workers.
who have a high education and good work11.
Based on the result of statistical test to know Ethical Clearance: this study approved and received
the relation between status of job of mother ethical clearance from the Committee of Public Health
with stunting incident in toddler, it can be seen Research Ethics of Medical Faculty, Lambung Mangkurat
that p-value = 0,009 (<0,05) which means Ho is University, Indonesia. In this study we followed the
rejected so there is relation between status of job guidelines from the Committee of Public Health
of mother to stunting incident in toddler in mining Committee of Public Health Research Ethics of Medical
area Cempaka (Fikrina, 2017). These results are Faculty, Lambung Mangkurat University, Indonesia
in line with research conducted Novita S (2013) for etchical clearance and informed consent. The
that there is a correlation of mother work with informed consent included the research tittle, purpose,
stunting on p-value 0.04 (Siahaan, 2013). Based participants’s right, confidentiality and signature.
on the result of statistical test to know the relation
between the number of family member and the Source Funding: This study done by self funding from
occurrence of stunting in toddler, it can be seen the authors.
that p-value = 1,000 (<0,05) which means Ho
accepted so there is no relation between family Conflict of Interest: The authors declare that they have
size and stunting incident in balita. This research no confict interest.
is in line with research of Novita S (2013) that
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DOI Number: 10.5958/0976-5506.2018.00619.8
Analysis of Impact of Use of Incident Thickness in Pregnant

Woman in Area of Malaria (Gunung Raja Mentawe Village
Districts of Tanah Bumbu South Borneo)
Lenie Marlinae1, Syamsul Arifin2, Nida Ulfah1, Sudayat Sudarmawan3, Siti Aina Putri Warsono3
1
Public Health Program Study, Medical Faculty, Lambung Mangkurat University; 2Magister Public Health
Science Program Study, Medical Faculty, Lambung Mangkurat University; 3Student of Public Health
Program Study, Medical Faculty, Lambung Mangkurat University
Abstract
Malaria is an infectious disease caused by parasites. Plasmodium that lives and breeds in human red blood
cells. The disease is naturally transmitted through the female Anopheles mosquito bites. Transmission of
malaria is similar to infectious disease transmission in general that is determined by factors called host
(human and Anopheles mosquitoes), agent (parasite plasmodium) and environment (physical, chemical,
biological and social). Malaria is a world health problem, especially for tropical countries and subtropics,
the World Health Organization (WHO) says 40% or more than 2,400 million people live in malaria endemic
areas and estimates of prevalence between 300-500 million clinical cases each year, reported deaths of
1-1.5 million people per year. Malaria infection especially in pregnancy is very detrimental to the mother
and fetus it contains, because this infection can increase the incidence of morbidity and mortality of mother
and fetus. Complications of malaria in pregnant women such as anemia, hypoglycemia, cerebral malaria,
pulmonary edema, placental infection, acute renal failure, puerperal sepsis and post partum bleeding, can
even lead to death. The mortality rate of malaria in pregnant women with complication of hypogklikemia
is 45-75%, whereas malaria of celebral have mortality 20-50%. South Kalimantan is among the top 10
provinces with the highest API. One of the districts in South Kalimantan that includes malaria endemic
area is Tanah Bumbu Regency with an API of 7.4%. In Kabupaten Tanah Bumbu there are 2 sub-districts
that are still malaria endemic namely Mentewe sub-district (API 12,2%). Respondents from this study were
pregnant women who used insecticide-treated bed nets. The results showed that the use of insecticide treated
bed nets in pregnant women was influenced by the attitude of pregnant mother (sig.0,033), while knowledge
(sig 0,614), body weight (sig.0,163) and maternal anemia status (Sig 0,362) against the use of mosquito nets
Keyword: Malaria, mosquito nets, pregnant women
Introduction pregnant women, ie malaria in pregnancy causes 5-12%

of total low birth weight infants and contributes 75,000
Malaria is an infectious disease caused by to 200,000 to infant mortality1
Plasmodium parasites that live and multiply in human red
blood cells. The disease is naturally transmitted through Malaria infection especially in pregnancy is very
the bite of Anopheles female mosquitoes. Malaria is a harmful to the mother and fetus it contains, because
world health problem especially for tropical and sub- this infection can increase the incidence of morbidity
tropical countries, the World Health Organization and mortality of mother and fetus. The mortality rate
(WHO) says that 40% or more than 2,400 million people of malaria in pregnant women with hypoglycemic
live in malaria endemic areas and estimates of prevalence complication is 45-75%, whereas cerebral malaria has
between 300-500 million clinical cases each year, with 20-50% mortality1
the reported mortality rate reaching 1-1.5 million people
per year. Malaria is one of the infectious diseases Year 2013 The number of cases of malaria in the
that contribute to infant and under-five mortality, and world as many as 198 million cases with an incidence
rate of 30% and a mortality rate of 40%. Association of bed, as recommended by the World Health Organization
SoutheastAsian Nations (ASEAN) including Indonesia (WHO) since November 2004. Based on research data
stated the number of malaria cases of 28 million with from R & D Center P2B2 Tanah Bumbu in 2016 the use
the number of deaths of 584 thousand people, especially of insecticide-treated bed nets in Mentewe Sub-District
children under five (78%) each year with 42.6 million of Tanah Bumbu Regency resulted in a positive impact
on malaria cases, namely the decrease in the number
babies born from mothers at risk of malaria falciparum and
of malaria cases with API 10.2%. This is supported
/ or malaria vivax. Pregnant women are exposed to the risk by the results of research conducted by Aisyah (2014)
of malaria every year around 125 million worldwide and which states that .here is a relationship between the use
there are 200,000 infant deaths due to malaria infection in of insecticide treated bed nets with the incidence of
pregnancy. The Asia-Pacific region contains 54.4 million malaria. According to Soro (2014) results, 12 households
pregnant women at risk of malaria with deaths ranging (35.3%) of non-adherent respondents used insecticide
from 75,000-200,000 infant deaths each year2 treated mosquito net, while in the group of KK obedient
in using inseccide treated mosquito net, as many as 30
Malaria morality in a region is determined by Annual
families (100%) experienced the incidence of malaria5
Parasite Incidence (API) per year. API is the number of
malaria positive cases per 1,000 population in one year. Materials and method
National API trends in 2011 to 2015 continue to decline
(from the API of 1.75% in 2011 to 0.85% by 2015). This This study design was observational analytic with
demonstrates the success of malaria control programs croos sectional design. The populations in this study
undertaken by central, local, community and related were all pregnant women. Samples were determined
partners. Looking at provinces by 2015, it appears that using accidental system in research period.
eastern Indonesia still has the highest API figures. The
2015 API figure in South Kalimantan is 0.68% (as much
as 0.68% of the malaria positive population per 1,000 Findings
population in South Kalimantan during 2015). Malaria Table 1: Results of Univariate Analysis
positive rates in Indonesia in vulnerable groups such as
pregnant women and children aged 1-9 years are quite No. Variable Category Frequency %
high (1.9%) compared to other age groups3 1. not so good 4 13,3
Knowledge
Good 26 86,7
South Kalimantan is among the top 10 provinces with 2. Negative 10 33,3
the highest API. One district in South Kalimantan that Attitude
Positive 20 66,7
includes malaria endemic area is Tanah Bumbu Regency 3. Less 16 53,3
with an API of 7.4%. In Tanah Bumbu District there Weight Normal 8 20,0
are two sub-districts which are still malaria endemic, Excess 8 26,7
Mentewe sub-district (API 12,2%) and Teluk Kepayang 4. Status of Light 8 26,7
(API equal to 7,7%) including positive pregnant mother Anemia Normal 22 73,3
and infant. The rise of gold mining in the region became
one of the factors causing the development of malaria Based on table 1 can be seen knowledge of
vector. This is because the mining activity caused the respondents at most is good that is as much as 26 people
holes of excavation of mine which became the breeding (86,7%), respondent attitude at most is positive as much
place of malaria vector4 20 people (66,7%). Status of anemia of the respondents
One of the malaria preventive measures that can be at most is normal as many as 22 people (73.3%). The
carried out in accordance with the causes of malaria cases weight of respondents at most in the category less as
is by using insecticide treated bed nets or bed nets in much as 16 people (53.3%).
Table 2: Results of Logistic Regression Estimation on Variables Affecting Respondents in Behavior of

Insecticide Netting Used
B S.E. Wald Df Sig. Exp(B)
Weight .758 .544 1.946 1 .163 2.134
Status of Anemia .516 1.049 .242 1 .623 1.675
Step 1a Knowledge -.809 1.603 .254 1 .614 .445
Attitude 2.863 1.339 4.570 1 .033 17.519
Constant -3.152 2.124 2.202 1 .138 .043
From table 2 it can be seen that only attitude variable other factors that cause the formation of such behavior,
(sig.0,033) has real effect on behavior of inseccide for example because of lack of family support, especially
treated mosquito net, while knowledge (sig 0,614), BB husband, or habit factors and so forth. The number or
(sig 0,163) and maternal anemia status (sig 0,3623 ) did type of mosquito repellent exposure can be used and
not significantly influence the use of mosquito nets. chosen so that the practicality becomes a consideration
not to use insecticide treated mosquito net.
Discussion The results of the same study were conducted by
Respondents in this study mostly did not experience Rianto (2009) which showed that there was a relationship
anemia (73.3%). Respondents were dominated by of mother attitude with the use of insecticide treated bed
non-primary school graduation (66.7%). Despite low nets (p = 0,000). Mothers who have a positive attitude
educational backgrounds, the respondents’ knowledge means supporting the use of mosquito nets. The findings
of malaria, including knowledge about malaria are in accordance with the opinion Notoatmodjo, (2007),
understanding, causes, mode of transmission, malarial attitude is a closed reaction of a person to the stimulus
signs, malaria prevention, and malaria treatment were or object. Attitudes of various levels, namely receiving,
categorized as good. Most respondents’ attitudes toward responding, appreciating and responsible. As Green
malaria are categorized positive (66.7%). (2005) explains that behavioral changes can occur from
predisposing factors in which one of these predisposing
Based on the bivariate analysis there is only one factors is a person’s attitude.
variable that is the attitude variable that has a real
effect on the behavior of the use of insecticide treated To anticipate this and to achieve the main objectives
bed nets. In terms of use of insecticide treated bed nets, of health education in shaping health behavior, the steps
most respondents did not use the mosquito net (56.7%), and efforts that can be taken by health institutions other
whereas the use of mosquito net was one of the efforts than distribution of inseccide treated bed nets are ANC
to prevent malaria transmission. The use of insecticide- services regularly, continuous consultation and includes
treated bed nets can reduce the contact between vectors continuous health promotion and promotion program
and humans, so it can be a protective tool for the by providing knowledge about the importance of using
community against malaria transmission6. mosquito nets for pregnant women in particular and
carrying out prevention efforts of mosquitoes as a whole
Human behavior is the result of all kinds of and integrated7
experience as well as human interaction with the
environment manifested in the form of knowledge, Conclusion
attitudes and actions. In other words, behavior is the
response or reaction of an individual to the stimulus that The use of insecticide treated bed nets in pregnant
comes from outside or from within himself. Behavior women was influenced by the attitude of pregnant
of the community can influence the success of using mother (sig.0,033), while knowledge (sig 0,614), body
insecticide-treated bed nets, because inseccide-treated weight (sig.0,163) and maternal anemia status (Sig
bed nets are only used at night while while not sleeping, 0,362) against the use of mosquito nets
many people interact with the causes of mosquito
bites Anopheles sp so that even when sleeping at night Ethical Clearance: this study approved and received
already using mosquito net insecticide but still there ethical clearance from the Committee of Public
is a possibility to be exposed to malaria due to the Health Research Ethics of Medical Faculty, Lambung
community’s6. Mangkurat University, Indonesia. In this study we
followed the guidelines from the Committee of Public
The results showed that pregnant women who have Health Committee of Public Health Research Ethics
a positive attitude towards the use of insecticide treated of Medical Faculty, Lambung Mangkurat University,
bed nets. The attitude process is still in the stage of Indonesia for etchical clearance and informed consent.
receiving, responding and appreciating, but not yet in The informed consent included the research tittle,
the responsible and behavioral stages so that the current purpose, participants’s right, confidentiality and
attitude condition has not implicated the behavior. Many signature.
Source Funding: This study done by self funding from 4. Dinas Kesehatan Kabupaten Tanah Bumbu.
the authors. Laporan Tahunana Dinas Kesehatan tanah
Bumbu, 2015
Conflict of Interest: The authors declare that they have
no conflict interest. 5. Ayu RA, Susanna D. Pemakaian kelambu
berinsektisida pada anak usia 0-4 tahun terhadap
References kejadian malaria. 2014. Jurnal Kesehatan
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DOI Number: 10.5958/0976-5506.2018.00620.4
Organ Failure and Quality of Life: A Study among Patients

Undergoing Maintenance Hemodialysis
Nishtha Mishra1, Abdul Azeez E. P.2

1
M. Phil. Research Scholar, School of Social Work, TISS, Mumbai; 2Assistant Professor in Social Work,
Amity Institute of Behavioural and Applied Sciences, Amity University, Gurgaon, Haryana
Abstract
Background: Organ failure becomes a complicated health issue which creates a significant threat to a large section
of the population. The burden of disease is very higher among the patients with an organ failure. The present paper
looks into the quality of life and depression among the patients undergoing maintenance hemodialysis.
Methods: Patients who were above 18 years and who have a history of 6 months dialysis are selected as
samples for the study. The total samples for the study were 64. The information was directly collected from
the patients in the hospital setting itself through the interview.
Results: It is evident from the study that diabetes remains one of the prominent reason for kidney related
problems. Different levels of depression are evident among the participants of the study. This study underlines
that the Quality of life remains a challenge for the patients undergoing hemodialysis. A strong association has
found between socio-demographic variables, illness related measures and sub-dimensions of the quality of life.
Keywords: Organ Failure, Quality of life, Hemodialysis.
Introduction of psychosocial problems creates potential risks to the

mental health as well as the physical health of the patient.
The incidents of renal diseases and other organ Depression is one of such concern widely seen among
failure issues become very common in the recent times. the patients with end-stage renal diseases. Current pieces
Epidemiology of such issues has risen ever before in the of pieces of evidence implicate the higher magnitude of
history. The changes in the lifestyle and occurrence of depression among different groups5, 6, 7.
co-existing diseases are viewed as the crucial reason for
the same. The occurrence of a life-threatening disease It is evident from the available literature that patient
not only affects the patient but will have significant on end of stage renal disease is vulnerable to mild and
implications for the family too. Azeez1 reports that severe mental health problems. This could be a potential
organ failure has significant implications on the familial, reason for poor prognosis. Organ failures, especially renal
economic, physical, psychological and social dimensions diseases are potential threat to have low quality marital,
of life. Kidney related problems are one among the familial, cognitive functioning and sexual relations8, 9, 10.
major health challenges persists considerably in the The consequent results of physical and co-existent mental
category of organ failure. A large number of patients are health issues among the renal patients have a significant
diagnosed with kidney (renal) related problems every impact on the overall quality of life of the patients. It is
year and become vulnerable. Apart from being the state evident from the everyday clinical practice and current
of physical vulnerability, kidney patients often required literature that poor quality of life is a very real among
to avail extra medical care, especially dialysis in most the patients who are diagnosed with renal diseases and
cases. The physical complications of the renal failure undergoing maintenance hemodialysis11, 12. A number of
and its consequent treatment modalities are substantial factors, directly and indirectly, influence the quality of
reasons for creating poor psychosocial well-being. life of the patients undergoing hemodialysis. Along with
Psychosocial issues are often identified with the patients psychosocial, familial and economic factors, treatment-
undergoing maintenance hemodialysis2, 3, 4. The presence related factors also play a crucial role in the quality of life
of the patient. Duration of the illness, treatment modalities them the aims of the study along with the potential
adopted yet, caregiving and other demographic variables benefits or threats.
are very influential on the quality of life.
TOOLS
Materials and Method
Apart from the detailed socio-economic data sheet,
The present study was conducted among two other standardized tools were administered to
the patients who are undergoing maintenance explore the core variables under investigation.
hemodialysis at Muljibhai Patel Urological 1. KDQOL-SFTM: KDQOL Version: 1.3, a generic
Hospital, Nadiad, Gujarat, India. The hospital health-related questionnaire developed by the Ron
is exclusively treating patients with Urological D et al (1994). The KDQOL-SFTM, Version 1.3 has
been widely used in the studies with End Stage
problems. Samples for the study were chosen
Renal Diseases patients. The tool contextually
purposively among the patients undergoing measures the Quality of Life of patients with renal
hemodialysis. Patients who were above 18 years diseases.
and who have a history of 6 months dialysis
2. PHQ-9: This tool is widely used for diagnosing
only selected as samples for the study. The total depression among the Kidney Patients undergoing
samples for the study were 64. The information maintenance hemodialysis. The tool is developed
was directly collected from the patients in the by Kroen et al (2001). The nine items of the PHQ-
hospital setting itself. An informed consent was 9 are based on the nine diagnostic criteria for
taken from the patients and researcher explained major depressive disorder in the DSM-IV.
Results
Table 1: Socio-demographic Profile
Sex Frequency Age Group Frequency

Male 46 (71.9) 20- 40 Years 8 (12.5)
Female 18 (28.1) 41 to 60 years 30 (46.9)
Above 60 26 (40.6)
Marital Status Frequency Education Frequency
Married 48 (75) Illiterate 2 (3.1)
Unmarried 6 (9.4) Primary 5 (7.8)
Widow 5 (7.8) Secondary 20 (31.3)
Widower 5 (7.8) Higher Secondary and above 37 (57.8)
Education Frequency Income Frequency
Unemployed 26 (40.6) Below Rs. 10000 20 (31.3)
Farming 4 (6.25) Rs.10001 to Rs.30000 26 (40.6)
Government service 9 (14) Above Rs.30000 18 (28.1)
Private Sector 8 (12.5)
Retired 17 (26.5)
(N = 64)
Men constitute the majority of participants with 72 Nearly Half (46.9%) of the respondents belongs to the age
percent. This was a real reflection of the patients admitted group of 41 to 60 years, almost same percent (40.6%) come
to the hospital for dialysis as men account larger in number. under the age category of above 60 years. As a positive
indication, respondents in the youthhood (below 40 years) around 41 percent of them were unemployed, a major
constitute a minority of respondents (12.5%). portion of them was jobless due to illness and others
were housewives. Around 27 percent of the respondents
A majority of the participants in the study were reported that they are retired from service and 14
married (75%) while almost 10 percent of the respondents percent are government employees. It was evident that
are still unmarried. A major portion of the respondents 41 percent of the respondent are earning below Rs.
had a Higher secondary or above qualification while 31 10000 per month while less than one-third (31.3%) of
percent of the respondents had secondary education. the respondents are earning between Rs. 10001 to Rs.
Only three percent of the participants were illiterate. 30000. Around 28 percent of the respondents are earning
The employment status of the respondents indicates that more than Rs. 30000 per month.
Table 2: Disease related information
Duration of illness Frequency Frequency of Dialysis Frequency

Up to 2 years 20 (31.3) Once in a week 1 (1.6)
3 to 7 years 27 (42.2) Twice in a week 16 (25)
Above 8 years 17 (26.6) Thrice in a week 47 (73.4)
Care Giver Frequency Usage of Wheel Chair Frequency
Family Member 60 (93.8) No 31 (48.4)
Others 4 (6.3) Yes 33 (51.6)
Causes of Disease Frequency Insurance Frequency
Don’t know 7 (10.9) No insurance 28 (43.8)
Hypertension 21 (32.8) Mediclaim 21 (32.8)
Diabetes 19 (29.7) Reimbursement 4 (6.3)
Other 17 (26.5) Other 11 (17.2)
(N = 64)
Patient participated in this study reported that Kidney Disease whereas 29.7 percent reported Diabetes
42.2% of them are victims of the illness between 3 to as a cause of their Kidney Disease. Around 27 percent
7 years while 31 percent become within 2 years of time of the respondents stated that they are not aware of the
period. Around 27 percent of the patients have started cause of the kidney failure. Diabetes and hypertension
their treatment before eight years. When asked about remained the crucial reason for kidney disease among
the dialysis frequency, 73.4 percent of the respondents the samples of this study too.
reported that they are undergoing maintenance
hemodialysis thrice a week whereas 25 percent reported Table 3: Level of Depression
that twice in a week. It is evident that majority of the
patients are in need of availing dialysis very regularly. Level of Depression Frequency Percent
No Depression 4 6.3
Showcasing the scenario of Indian caring system,
around 94 percent of the participants are reported that Minimal Depression 32 50
they are being cared by one of their family members Mild Depression 11 17.2
while 6 percent reported that caregiving was provided Moderate Depression 3 4.7
by someone else. In most of the cases, when probed, it
Severe Depression 6 9.3
was a nurse. It is evident that a majority (51.6%) of the
patients undergoing maintenance hemodialysis are using (N = 64)
a wheelchair. The researcher tried to explore the probable
reasons for the Kidney disease. It is reported by 32.8% The impact of being a kidney patient and undergoing
of the respondent that Hypertension is the cause of their dialysis has evident from the results of the study. It is
reported that half of the respondents (50.0%) are having helpless and hopeless. This further leads to depression
Minimal Depression while 17 percent of respondents and other mental health problems.
are having Mild. Around 10 percent of the respondents The same negative trend has also evident in the
are identified with Severe Depression. The state of case of Quality of life. A majority of the respondents are
being subjected to dialysis has made many of them feel identified with the poor quality of life.
Table 4: Gender, depression and different dimensions of quality of life
Gender N Mean Std. Deviation t P

Male 46 5.33 5.420
Depression 1.974 .053*
Female 18 8.33 5.636
Male 46 79.1667 12.35253
Symptom 2.242 .029*
Female 18 70.7176 16.31792
Quality of Social Male 46 76.5217 24.89441

.073 .942 (NS)
Interaction
Female 18 77.0370 26.98072
(*Significant, = p<0.05) (NS: Not Significant)
It is evident from the present study that there The present study indicates that frequency of
are significant differences among male and female dialysis doesn’t have any influence on the different sub-
participants in some variables. Depression was seen dimensions of the quality of life and depression. Patients
to be more in Female when compared to Males. The t in different categories of frequency have shown an almost
same level of quality of life and depression, a statistically
ratio for Depression is significant (t=1.974, p=0.05)
relevant difference was not traced. In the same manner,
which indicates that there is a significant difference in
age group also doesn’t make much difference in the
depression among Males and Females. Symptoms are case quality of life among the respondents. The case of
another variable that shows a significant difference in income and quality of life also remains same as lower or
the grounds of gender. Remaining sub-dimensions in the higher income doesn’t make a significant difference in
quality of life have shown no significant difference. the quality of life of the patients.
Table 5: Duration of dialysis, depression and other variables in quality of life
Duration of Dialysis N Mean Std. Deviation F P

Up to 2 Years 20 5.70 5.507
3 to 7 Years 27 6.33 6.403
Depression 4.308 .018*
Above 8 Years 17 6.47 4.543
Total 64 6.17 5.605
Upto 2 Years 20 66.7188 18.92123
3 to 7 Years 27 72.6852 19.83239
Effect of Kidney Disease 3.190 .048*
Above 8 Years 17 68.5662 18.06937
Total 64 69.7266 18.97905
Upto 2 Years 20 44.3750 37.10870
Burden of Kidney 3 to 7 Years 27 43.2870 35.56405
4.118 .021*
Disease Above 8 Years 17 51.1029 36.59289
Total 64 45.7031 35.89272
Upto 2 Years 20 80.3333 22.63103
3 to 7 Years 27 72.0988 25.28721
Cognitive Function 5.859 .005*
Above 8 years 17 85.0980 17.40521
Total 64 78.1250 22.92442
Contd…
Up to 2 years 20 75.0000 22.77528

Quality of Social 3 to 7 Years 27 78.2716 27.46202
4.954 .010*
Interaction Above 8 years 17 76.0784 25.82622
Total 17 86.2729 23.00134
Up to 2 years 20 81.6648 22.23037
Social Support 3 to 7 years 27 85.8007 16.47701 5.689 .005*
Above 8 years 17 86.2729 23.00134
Total 17 84.6337 19.98893
Discussion depression. A large number of them have the feeling

of helplessness and hopelessness while facing with the
It is evident from the study that duration of dialysis has complexities of organ failure and frequent dialyzes. The
an impact on the other variables. The respondents’ group level of depression has shown a significant relationship
which is on dialysis more than 8 years is having a Mean with other variables. As like much previous literature,
(M= 6.47), higher depression in comparison to two other the present study also indicates higher depression
groups. The same trend is visible in the case of ‘effects of among females while compared to males. The duration
kidney diseases’ too. The respondent receiving dialysis of dialysis and depression is also established a strong
since 3 to 7 years are having a Mean = 72.68, which depicts connection. Patients with higher duration had a high
that they have much bothered with the effects of kidney level of depression while comparing to the patients with
disease in comparison to two other groups. lower duration.
Duration of dialysis made a significant impact A considerable percentage of patients who are
on the patient’s perception on the ‘Burden of kidney undergoing maintenance hemodialysis reported a lower
diseases’. The respondent receiving dialysis since more level of quality of life. Variations also found in connection
than 8 years have a Mean= 51.10 which results that they
with the different sociodemographic and illness-related
are having the maximum burden of Kidney Disease.
variables. The severity of symptoms is high among
Further, the respondent group undergoing dialysis up to
females than males. Other gender-related variables
2 years, having Mean= 44.37 which shows that they are
don’t show much difference. Duration of dialysis is a
feeling less burden of kidney disease while comparing to
variable that has a significant connection with the overall
other groups. Cognitive functioning is another variable
quality of life and its dimensions. Patient with higher
that shows significant variation among the respondents
dialysis duration reported higher effects and burden of
according to the duration of illness.
kidney diseases. It is evident that Cognitive functions
This study underlines the physiological and also decreases when the duration of dialysis increases.
psychological problems are very commonly identified The same trend is visible in the case of quality social
with the patients undergoing maintenance hemodialysis. interactions. Patient with fresh dialysis history reported
Care and Caregiving become a complicated issue among higher social interaction while comparing to a patient
the patients undergoing hemodialysis. Activity limitation with long history of dialysis. Patient’s felt higher social
is common among the patients and half of them are using support in the initial years of dialysis while comparing
a wheelchair. Showcasing the poor health insurance to other categories.
system in India, it is evident from the study that more
than 40 percent of the patients do not have any insurance. Conclusion
This creates a significant financial burden on the patient,
Replicating the previous researchers, this study also
especially when a proportionate of them is unemployed.
reveals that end-stage renal disease patients receiving
Psychological variables in the study also manifest the dialysis treatment have a lower quality of life than people
negative implications of the organ failure. A considerable in general population. The patients receiving longer
number of patients are identified with severe and mild years of dialysis are shown a much better quality of life
than patients with a new history. This is an indication 4. Shulman R, Price JD, Spinelli J: Biopsychosocial
which highlights the patient’s ability to cope-up with aspects of long-term survival on end-stage renal
the life realities rationally. Further investigations could failure therapy. Psychol Med 19 : 945 –954, 1989
focus on the factors contributed to the higher quality
5. M. Israel, “Depression in dialysis patients: a review
of life among patient with long history of dialysis.
of psychological factors.,” Canadian Journal of
Like many other studies, this study also underlines the
Psychiatry, vol. 31, no. 5, pp. 445–451, 1986.
presence of depression among the patients. Psychosocial
intervention programmes for the patients and their 6. J. Chilcot, D. Wellsted, and K. Farrington,
families have to be mandated for professionals and “Depression in end-stage renal disease: current
institutions. This would help in minimizing disease and advances and research,” Seminars in Dialysis,
treatment related psychosocial complexities. vol. 23, no. 1, pp. 74–82, 2010.
Conflict of Interest: The author declares that there is no 7. Watnick S, Kirwin P, Mahnensmith R, Concato
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Urological Hospital, Gujarat, India. 9. Murray AM, Tupper DE, Knopman DS, et al.
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patients. Kidney Int 59 : 1599 –1613, 2001 Treatment J Clin Med Res; 3(3):132-138, 2011
3. Wai L, Burton H, Richmond J, Lindsay RM: 12. Kalantar-Zadeh, Kamyar, and Mark Unruh.
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1981 nephrology, 367-378, 2005
DOI Number: 10.5958/0976-5506.2018.00621.6
Legal Challenges in Blood Transfusion Process in India
Rubi Talukdar1, Prabir Kumar Pattnaik2

1
Research Scholar, 2Professor, Siksha "O" Anusandhan (Deemed to be University) National Institute of
Law, Khandagiri, Bhubaneswar, Odisha, India
Abstract
In recent times, the technical and legal standards of blood transfusion in US and European nations have
undergone significant change but in India, the quality and standardization of blood transfusion have not
changed much and thereby the patients are exposed to risks. The present paper considers incidents of blood
transfusion process errors in India, identification of causes of errors, and presents an overview of Indian laws
relating blood transfusion and the judicial approach towards errors in blood transfusion process.
Keywords: Blood Transfusion, Errors, Law, Judicial approach, Drugs and Cosmetics Act
Introduction place due to anemia, 42 percent is due to surgery, and

26 percent for acute hemorrhage and 16percent is for
Blood transfusion is a contested health care service pregnancy. 74 percent of adult blood transfusions are
and it is a most preferred practice under emergent inappropriately done without following the government
situations. Since 1975, the World Health Assembly transfusion guidelines. The possible nearby reason for
has been focusing on the global need for blood safety these inappropriate transfusions are due to unnecessary
and has passed several resolutions [1] for that purpose. transfusion for volume replacement and for iron-
In 2016, the Global Status Report on Blood Safety deficiency anemia cases [3]. The BBC News reported
and Availability [2] points out that there exist significant that at least 2,234 Indians have contracted HIV while
variations in the availability, safety and use of blood and receiving blood transfusions in hospitals during 2015-
blood components between developed and developing 16[4]. In the state of Kerala a heart patient dies allegedly
countries. Blood transfusion safety has been a major after wrong blood transfusion [5].The incidence of death
concerned in low and middle income countries, where due to wrong blood transfusion are also not uncommon
the risk of transfusion-transmissible is high and in in India [6]. Further, one can find several litigations
the absence of proper blood screening facilities such connected with transfusion errors.[7]
risk is often maximized. Therefore, the report calls
for strengthening the national blood collection and Causes of Error: The transfusion chain includes proper
screening systems so as to ensure sufficient and safe donor selection, blood collection, component separation,
blood supplies worldwide, especially in low and middle infection screening, issue, cold chain transport and final
income countries. transfusion to patient. In India, transfusion errors take
place due to (i) Error in screening the Donors (ii) Pre-
Reports of Error in Blood Transfusions in India: It analytical errors and (iii) Errors due to inadequacy in
is reported that in India 60% of blood transfusion take legal standardization.
Corresponding Author: Error in screening the Donors: It is estimated that in

Rubi Talukdar India, about 30,000 patients are annually infected due
Research Scholar to unsafe blood transfusion. The viruses range from
Siksha ‘O’ Anusandhan National Institute of Law HIV-AIDS, Hepatitis-B or Hepatitis-C[8]. Carney [9] and
Siksha "O" Anusandhan (Deemed to be University), Ishrath Humairah [10] enumerate how ‘Blood Factories’
Khandagiri, Bhubaneswar-751030, Odisha, India operate and thrive in India. The Ministry of Health and
Phone: 9583762995 Family Welfare, Government of India reports that during
Email: [email protected] 2014-15 the blood supply has improved in India but it
still faces a deficit of 10 % [11]. India, with its population for the operation of blood bank such as technical staff,
of 1.25 billion people, needs 12 million units of blood equipments, accommodation etc. State Drugs Controllers
annually but collects only 9 million that amount 25% were empowered to issue the licenses for blood banks.
deficit [12]. The commercialization of blood is a big The standards for ‘Whole Human Blood’ were dissuaded
‘underworld’ market. This market not only attracts new in Indian Pharmacopoeia.[17]
and professional donors but also entertains unqualified
donors indiscriminately without proper screening. The Due to the wide spread pervasiveness of HIV
Supreme Court of India attempted to ban professional AIDS, in 1989, Government of India (the Ministry
blood donation and promote replacement donation of Health and Family Welfare) issued a notification
system [13]. At times, over confidence on relative or under the Drugs and Cosmetics Rules and made the
replacement donors can cause errors. HIV seroprevalence test HIV 1and 2 antibodies of Whole Human Blood as
is generally higher in blood sellers and even in the so mandatory requirement before transfusion . The Rules
called replacement or relative donors than amongst from 122F to 122P explain the various procedure of
regular voluntary donors.[14] The gap between demand making applications by a blood bank, fees to be paid for
and supply not only precipitates corrupt practices in grant/renewal of license by the applicant and conditions
transfusion chain but also promote reckless collection of of license to be followed by the applicant after grant/
blood samples. renewal and conditions of license to be followed by the
applicant after grant/renewal of license. However, the
Pre-analytical Errors: In the total testing process, Supreme Court order extensively revised the rules on
pre-analytical phase is the most accessible part and 5.4.1999. The National Blood Policy in 2002 closely
this phase is considered as the greatest threat to the followed the inclusion of hepatitis C testing in blood;
laboratory professionals. Satyavati V.Rana [15] reports other improvements included the standardization of
the types of pre-analytical errors that includes (a) blood storage centers, National Plasma Policy, and
Patient Identification and Preparation (b) Sample recently the baseline assessment of all blood banks in
Collection Procedures, Handling, and Processing: India in 2016.
proper venipuncture technique, order of draw, proper
tube mixing, and correct specimen volume (c) Judicial Approaches towards Errors in Blood
Specimen Transport (d) Errors in Laboratory Tests and Transfusion: In Common Cause v. Union of India and
(e) Other Errors: (Missing sample and/or test request, Others [18] the Supreme Court of India stated that “Blood
contamination from infusion route, insufficient samples, is an essential component of the body which provides
and inappropriate containers). sustenance to life. There can be no greater service to the
humanity than to offer one’s blood to save the life of other
Errors due to inadequacy in Legal Standardization: fellow human-beings. At the same time blood, instead of
The pre-analytical activities, management of unsuitable saving life, cannot lead to death of the person to whom
specimens and reporting policies are not fully the blood is given if the blood is contaminated. Medical
standardized, nor harmonized worldwide [16]. errors with respect to blood transfusion are dependent on
several aspects which have been discussed earlier. But,
Blood Transfusion Services and Indian Law: Blood
most medical errors are either treated as civil or criminal
transfusion services in India are primarily regulated
negligence”.
by the Drugs and Cosmetics Act, 1940 and its
subsequent amendments. The Central Govt. through Judicial Interpretation of Error: In agreement of the
Drugs Controller General of India has formulated a A.F. Ferguson Report,1990 the Supreme Court of India
comprehensive legislation to ensure better quality control took notice of levels of errors in blood transfusion process
system on collection, storage, testing and distribution and observed that many unauthorized Blood collection
of blood and its components. Human blood is covered centers indiscriminately collect blood through untrained
under the definition of ‘Drug’ under Sec. 3 (b) of Drugs and unqualified technicians and without specialized
and Cosmetics Act, 1940. The Central Government of screening and store them in unhygienic conditions. [19]
India in the year 1967 accomplished a separate provision
Schedule F Part XII B of the Drugs and Cosmetics Human beings ordinarily make judgment either on
Rules. This part includes various requirements essential the basis of their sensorial data which they perceive or
on the sensorial data that are stored in memory. Incorrect collected from an unauthorized blood collection center
processing of sensorial and stored data can lead us to which pretended to be an official blood bank.
commit error. For example, cognitive biases can lead to
systematic deviations from a standard of rationality or Due to lack of screening facilities the recipients
good judgment. undertake risk. In a case it was reported that in the
absence of Antizen Test conducted through Polymer
Medical Professionals can commit error if, Chain Reaction (PCR) method, the HIV+ virus cannot
(a) There is error in inductive reasoning or be identified during the Window Period. Therefore, the
certificate given by the blood bank about the quality of
(b) There is error in deductive reasoning
blood becomes redundant.
The term ‘Error’ is often interpreted as mistake,
It is internationally well-accepted that even after
accident, or misfortune .A mistake is an omission made
screening through a reliable test like the ELISA test,
not by design, but by mischance [20]. Ordinarily, an
there is still a possibility of the Hepatitis virus not
accident means an unintended and unforeseen injurious
being detected in the blood if it is in the early stages
occurrence; something that does not occur in the
of incubation which may have happened in the instant
usual course of events or that could not be reasonably
case. In this connection, we note that for screening of
anticipated.[21] On the contrary, negligence means a
blood, two tests are in use: (i) ELISA test; and (ii) Radio
material deviation from the normal standards due to
Immunoassay test. It is also worth noting that ELISA
breach of duty.
test is not considered conclusive in detecting the HIV
In PoonamVerma v. Ashwin Patel and Others [22] viruses and its results usually have to be confirmed by a
the Supreme Court of India considered several forms of subsequent test like the Western Blot Test.[31]
negligence. It is true that ‘no sensible professional would
intentionally commit an act or omission which would At times, doctors and technician are harassed by
result in loss or injury to the patient as the professional patients and police on the allegation of negligence.
reputation of the person is at stake’[23]. However, the Apex court observed that without obtaining
a credible medical opinion from an expert, Investigating
As a consumer a patient reasonably expects Officer is not justified in submitting the charge sheet
reasonable degree of knowledge and skill from his against the doctor [32]. This ruling brought relief towards
doctor [24]. The degree of knowledge and skill of doctors many doctors from police action.
might differ but must not fall below minimum standard.
[25]
However,’ law does not require of a professional It is settled law that the hospital is vicariously
man that he be a paragon combining the qualities of liable for the acts of its doctors and the State would be
polymath and prophet’ [26].A doctor cannot assure cure also vicariously liable for the damages on account of
[27]
.Sometimes a doctor does take risk [28] but such risk negligence of its doctors or other employees[33].
must not be reckless. At times both doctors and patient
In Dr. K. Vidhyullatha v. R. Bhagawathy [34] it was
suggest for alternatives from several options [29].But,
viewed that there could be no doubt that administering
each alternative must be assessed from the minimum
blood of ‘A’ positive group to a patient having ‘O’ positive
safety standards.
blood group would certainly amount to deficiency in
In blood transfusion process never trust either donor service and the acute renal failure occurred due to intra-
or the recipient. Sometimes, documents on donors and vascular haemolysis.
recipient can be deceptive. Unauthorized collection of
unscreened blood and reckless transfusion can cause In Post Graduate Institute of Medical Education and
disaster. In Ravjibhai Ramabhai Sondarwa and Others Research, Chandigarh v. Jaspal Singh and others [35] the
v. State of Gujarat and Others [30] the Court considered Supreme Court of India observed that the where internal
the cases of 23 minor children who used to get treatment imbalance of liver and kidney and haemoglobin levels
for severe Thalassemia in Government hospital were deteriorated after wrong blood transfusion the doctors of
infected with HIV+ due to reckless blood transfusion the Hospital cannot disown absolve from their liabilities.
Conclusion bloodsafety/Expert_Consensus_Statement_Self-
Sufficiency.pdf [accessed on 15th September 2017]
Precaution is better than undertaking risk. Law
always expects professionals to follow minimum 2. World Health Organization, Global Status
prescribed standards right from collection to transfusion report on Blood Safety and Availability 2016,
of blood. The health technology in India has considerably Available from: http://apps.who.int/iris/bitst
improved, but the benefits of technology are yet to ream/10665/254987/1/9789241565431-eng.
percolate to the rural level. pdf?ua=1 [accessed on 16th September 2017]
3. Bray T J, Salil P, Weiss H A and Porter J D.
In order to minimize errors in blood transfusion
Transfusion medicine in India: A survey of current
both doctors and technicians must observe inter alia few
practice. Transfusion Medicine. 2003; 13(1): 17-23
important things in mind. (i) Doctors and technicians
should ensure their professional competency and update 4. India hospital transfusions infect thousands with
training (ii) Doctor must record the justification of HIV. BBC News 2016 May 31. Available from:
transfusion (iii) Donor and recipient should be properly http://www.bbc.com/news/world-asia-india-
identified and their informed consent be obtained and 36417789 [accessed on 20th September 2017]
recorded.(iv) Donor and recipient’s blood should be 5. Reghukumar N. Kerala: Heart patient dies
screened with minimum prescribed standard and be allegedly after wrong blood transfusion. News18
recorded.(v)Prescribed classification of blood products 2013 November 26. Available from: http://www.
should be record (vi) The blood products under news18.com/news/india/kerala-heart-patient-
prescribed standards be stored and transported with 652835. html [accessed on 22th September 2017]
proper records (vii) Issue and receipt of blood products
6. Odisha: Woman dies after getting wrong blood
be recorded (viii) Cross check status of blood of the
type during transfusion in govt. hospital. Firstpost
recipient before transfusion and monitor during and after
2016 December 15. Available from: http://www.
transfusion.(ix) procedural details of transfusion should firstpost.com/india/odisha-woman-dies-after-
be recorded. getting-wrong-blood-type-during-transfusion-
We donate blood to give someone a second chance in-govt-hospital-3156856.html [accessed on 15th
and let us not spoil the objectivity of philanthropy by September 2017]
wrong transfusion. 7. P.G.Inst.of Medical Education and Others v. Jaspal
Singh and Ors, (2009) 7 SCC 330; M. Chinnaiyan
Conflict of Interest: No conflict of Interest
v. Sri Gokulam Hospital AndAnr. III (2007) CPJ
Source of Funding: Self 228 NC; Dr. Sunil Thakur v. Gorachand Goswami
and Others, National Consumer Disputes
Ethical Clearance: This manuscript entitled as “Legal Redressal Commission NCDRC, First Appeal
Challenges in Blood Transfusion Process in India” has No.175 of 2006 in S.C. Case No. 61/O/2001,
been prepared by Rubi Talukdar and Prabir Kumar Decided on 29.01.2013.
Pattnaik for review and publication in the Journal “Indian
8. Unsafe blood transfusion infects around 30k
Journal of Public Health Research and Development”. annually: Dr. Harish Warbhe. The Times of India
This manuscript has neither been submitted to any city 2016 November 4. Available from: http://
other journal nor being considered by any publisher for timesofindia.indiatimes.com/city/nagpur/Unsafe-
publication. blood-transfusion-infects-around-30k-annually-
Dr-Harish-Warbhe/articleshow/55233542.cms
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Administration and Human Resource (2009)7SCC330
DOI Number: 10.5958/0976-5506.2018.00622.8
Substance Use among Students in a Private Medical College,

Southern India-A Cross Sectional Study
S. Rajini1, C. Kameshvell1, Kannan1, Alli2, V. Tamilselvi3

1
Associate Professor, Department of Community Medicine, 2CRRI, 3Statistician, Department of Community
Medicine, Sri Lakshmi Narayana Institute of Medical Sciences, Pondicherry
Abstract
Introduction: Substance abuse and its associated problems are a global concern. A recent WHO estimate
shows a burden of worldwide psychoactive substance use of around 2 billion alcohol uses, 1.3 billion
smokers and 185 million drug users. The doctors are vulnerable to substance abuse/addiction due their ready
accessibility to the substance of abuse.
Aims & Objective: To study the prevalence, duration, reasons and type of drug use among medical students.
Materials And Methods: A cross sectional study among 300 randomly selected medical students was carried
out in private medical college during August to September 2016. After seeking administrative approval and
verbal consent of the participants, questionnaire was prepared, distributed and data were collected from
the students (of 1st year to 5th year).Questionnaire was designed to elicit information on the use cigarettes,
alcohol, illegal purchase of drugs as well as reasons and age at first use.
Results: Among 300 participants 86% were males and 14% were female students. The prevalence of substance
abuse among medical students was about 52% and among them 57.85% of them was staying in hostels. 40%
and 36% of them started using it as for experimentation and for fun respectively and 17% of them used for
stress relief. The present study also reveals that above 65% were well aware of their side effects.
Conclusion: The problem of substance abusers among medical students should gain attention and it’s time
to evolve on comprehensive intervention approach to promote a healthy and safe life style practices.
Keywords: Prevalence, substance use, alcohol, cigarette, medical students.
Introduction uses,1.3 billion smokers and 185 million drug users.[3]The

doctors are vulnerable to substance abuse/addiction due
Use of tobacco, alcohol, and other substances is their ready accessibility to the substance of abuse. There
a worldwide problem and affects many children and is higher percentage use of alcohol, tranquilliers and
adolescents. [1] Early initiation of substance use is usually psychedelics among medical students and a dependence
associated with a poor prognosis and a lifelong pattern rate is 5%. [4] Medical students are significantly more
of deceit and irresponsible behavior. [2]Substance abuse likely to use prescription stimulant medications to boost
and its associated problems are a global concern. A academic performance. Medical training is a demanding
recent WHO estimate shows a burden of worldwide endeavour; students often are pushed to limit to succeed
psychoactive substance use of around 2 billion alcohol and must find ways of copying and adapting. Three
fourths of medical students reported that they believe
Corresponding Author: stimulants could enhance cognitive performance and
Dr. S. Rajini, had used them typically for performance enhancement
Associate professor, Department of Community Medicine, [5].
Substance use changes the way people approach and
Sri Lakshmi Narayana Institute Medical sciences, experience interactions. The adolescents’ psychological
Pondicherry. and social development is compromised as in formation
Mobile: 9865233325 of a strong self identity. Half of the students who drink
have reported binge drinking, according to the report and analyzed. Among the participants majority were
by national institute on alcohol abuse and alcoholism. male students 86% (257) and (43) 14% were female
Baldwin et al (1991) investigated the problem among students. 64.6% of the students were following Hindu
senior medical students at 23 medical schools in USA religion, 12% Christianity and 9% were Muslims. 87%
and reported the frequency of life time use of variety of of the study participants were hostlers and 13% were
substance as follows alcohol 98% cannabis 66% tobacco day scholars. Among them 57.85% of the hostlers and
55% cocaine 32% amphetamine 22% tranquilliers 25.64% of the day scholars are substance users. The
19%. Adolescence is the critical period when the first variety of substances used by the students was alcohol
initiation of substance use takes place. Among the youth, 31.66%, cigarette 20% and drugs 2% respectively. The
students are particularly involved due to increasing study showed only 48% of the students was non users of
academic pressures. The encouragement by peer groups, any type of substances.
the lure of popularity and easy availability of many such
substances like alcohol, tobacco (cigarettes and gutkha) Table 1: Gender wise distribution of substance use
and other drugs make a teenager an easy prey. In India (n = 300)
approximately 5500 children and adolescents start using
tobacco products daily, some as young as 10 years old. Smoke Alcohol Drug
Gender
The majority of users have first use tobacco prior to Yes No Yes No Yes No
the age of 18 years [6]. Present study was undertaken to Female 8 35 12 31 0 43
estimate prevalence of substance abuse medical students. Male 52 205 83 174 6 251
Total 60 240 95 205 6 294
Materials and Methods Chi Square: Chi-Square: Chi-Square:
0.061 0.328 1.024
A cross sectional study was done among 300 df: 1 df: 1 df: 1
randomly selected medical students which were carried p-value: p-value: p-value:
out in a private medical college during August to 0.805 0.567 0.311
September 2016. After seeking administrative approval
and verbal consent of the participants, a pre-tested It was observed in the present study that
and pre-designed questionnaire was used to collect consumption of alcohol is more in male students when
the data. The data was collected from the randomly compared to smoking. This may be because; smoking
selected students( 1st year to 5th year).Questionnaire was is strictly prohibited in the college and hostel campus.
designed to elicit information on the use of cigarettes, No statistical significance was observed when compared
alcohol, self prescription of drugs, including sedative, with gender and drug usage.
hypnotics ,minor and major opiates and illicit drugs
such as cannabis, cocaine, heroin and others as well as Table 2: Resident wise distribution of substance use
reasons for use and age at first usage. The subjects were (n = 300)
asked whether they had used the substance during their
Smoke Alcohol Drug
lifetime. The participants had to provide information on Stay
Yes No Yes No Yes No
how often they use its quantity and type of consumption.
Day
The students were asked to choose the reason for 6 33 4 35 0 39
Scholar
substance use from a list including to obtain due to peer
Hostler 54 207 91 170 6 255
pressure, relaxation, for fun, and experimentation. The
Total 60 240 95 205 6 294
results were analyzed using suitable statistical package
and chi square test was used per the requirements. Chi-Square: Chi-Square:
Chi-
9.496 0.915
Square:0.597
df: 1 df: 1
Results df: 1
p-value: p-value:
p-value: 0.440
0.002 0.339
The present study was carried out in a private
medical college of south India. 300 medical students Statistical significance was observed by the place of
were randomly selected and the data was collected stay and alcohol consumption of the students.
Table 3: Year wise distribution of substance use Regarding the usage of the substances, it was
(n = 300) reported 27.5% and 28.9% were regular use of alcohol
and smoking respectively. These findings were supported
Year of Smoke Alcohol Drugs
Study by DN Sinha, on prevalence of regular use of smoking
Yes No Yes No Yes No
among male students to be 43%.[9]
1st Year 10 102 40 72 1 111
2nd Year 30 87 30 87 4 113 Many studies done in India [10-12] and other countries
3rd Year 9 32 15 26 1 40 show similar prevalence of substance use among the
4th Year 5 8 4 9 0 13 medical students of various years. [13-15] The main
CRRI 6 11 6 11 0 17 predisposing factor for increase of substance use upto
Total 60 240 95 205 6 294 50% is due to the stress undergone by the medical
graduates. Same observation was made by P Kumar and
The present study shows, drug usage is common
D Basu, were the drug usage was mainly to overcome
among first and second year students of the course.
stress. [4]
Regarding the usage of the substances, 27.5% and
28.9% were regular use of alcohol and smoking The present study shows more than 70% of the
respectively. Two percent of the students who used were substance users know well about their side effects. The
only occasional users. Majority of the substance users
findings were similar to the study done by Gopiram et al,
were using them only for the duration of past 6months
among adolescents and young adults. [16]
to 1 year. This may be because, the students stay away
from their parents during recent period only. The present
study shows 40% of the substance users were doing it Conclusion
for experimentation and 36.4% were using it for fun as
Despite of knowing the harmful use of the substance
shown in table 4.
use, it has been noticed that the adolescents initiate and
Table 4: Reason for substance use among the still continue to use. To conclude, psychological stress
participants seems to be the major cause for substance use. Health
planners and educationalists have to be informed, for
Reason For Substance Use Number % the corrective action which should be taken on time
For Fun 124 36.4 to reduce the morbidity and decrease the usage of
Experimentation 136 40 substances among the medical students.
Stress Relief 58 17
Forced By Friends Or Others 22 6.4 Conflict of Interest: Nil
Questions were asked about the feeling after the use Source of Funding: Self
of the products. Nearly 40% of all substance users say
no feeling and same percentage of individuals says that, References
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a Paediatric Concern. Indian J. paediatr 1999; students. Med J Armed Forces India 2003; 59 :
66:557-67. 209-11.
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Students in District Dehradun. Indian Journal of and drug use in UK University Students. Lancet
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14. Melani AS, Verponziani W, Boccoli E, Trianni
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abuse among the undergraduate medical students smoking habits, attitudes and beliefs among nurse
in Calcutta. JIMA 1999; 97:20-21. and medical students in Tuscany. Eur J Epidemiol
2000; 16 : 607-11.
9. Sinha Dhirendra N. and Gupta Prakash C. —
Indian Journal of Public Health. 48 (3): pp 123- 15. Deressa W, Azazh A. Substance use and its
125, JulySept 2004. predictors among undergraduate medical students
of Addis Ababa University in Ethiopia. BMC
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internees. Indian J Psychiatry 1996; 26 : 128-32. 16. Gopiram P, Kishore MT. Psychosocial attributes
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11. Mannapur B, Dorle AS, Hiremath LD, Ghattargi
adults: A comparative study of users and non-
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psychological stress in undergraduate medical
DOI Number: 10.5958/0976-5506.2018.00623.X
Nutritional Status of Children Residing at

an Orphanage in Puducherry
K. Kannan1, S. Rajini2, Kameshvell C2, G. Jayalakshmi3, Jenith4, Karthikeya4

1
Assistant Professor, 2Associate Professor, Department of Community Medicine, 3Dean, 4CRRI,
Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry
Abstract
Introduction: Orphanages are a vulnerable group in any socio-economic setting simply because they are
deprived of one or both of their primary care givers. The level of vulnerability they face however increases
significantly with the level of poverty. The practice of placing deprived children having minimum or no
emotional and material resources, in orphanages has since long been prevailing in socio-economically poor
Asian countries.
Aims: To assess the nutritional status of children residing at an orphanage.
Methodology: A cross section study was conducted with 75 children with pre structured questionnaire
including clinical examination and biometric assessment.
Result: Mean age of children residing at orphanage was 11.2 3.1 years, while 58.7 percentage children
were male. The malnutrition was graded by calculating Z score for BMI - Age. It was found that no children
having severe malnutrition, but 5.3 percent children were diagnosed as moderate and 18.7 percent children
were diagnosed as mild. Children were mainly seems to be deprived socially, rather than physically. Apart
from, these children have scabies 12% and Hook worm infestation 5 %, anemia about 8 % and refractory
error 3%.
Discussion: A study conducted by Sadik (2010) shows low intake of both micro and macro nutrients except
protein by orphanage children in Ghana. Nutritional status indicated that 10% and 15% of the children were
severely stunted and wasted respectively. Similar findings were reported by Bhuvanesh Shukla et al (2011),
DrNaheedVaida (2013)
Conclusion: About 24 percentage of children residing at orphanage have mild or moderate malnutrition,
even though none of them are severely malnourished based on BMI.
Keywords: Nutritional status, Orphanage, BMI
Introduction setting simply because they are deprived of one or both

of their primary care givers. The level of vulnerability
An orphanage is an institution dedicated to the care they face however increases significantly with the level
and upbringing of children who have lost their parents. of poverty(1). The evidence from the pediatric and child
Orphans are a vulnerable group in any socio-economic psychiatry literature makes clear that orphanages are
Corresponding Author: neither an effective nor a humane mode of assistance
Dr. K.Kannan, Assistant Professor, to infants and families. After the independence the
Department of Community Medicine, government of India has launched number of schemes
Sri. Lakshmi Narayana Institute of Medical sciences, for welfare of orphan and destitute children. Such as
Puducherry. “Scheme for welfare of orphan and destitute children’’
Mobile: 9786028602 The sole motive of this program is to prevent destitution
Email: [email protected] of children. Under this provision the destitute and
orphan children are provided shelter, in order to provide included all the 75 children available during examination
good healthy atmosphere and good nutrition. Most day. Anthropometric measurements were collected based
common problems faced by orphans include loss of on standard methods(9). Age of the subjects under study
home, high dropout rate from school, lack of health care was determined by interrogation and confirmed through
and problems with immunization, social downfall, child probing if the birth certificate or the health cards were
labors and drug abuse. unavailable. Measurements of weight and height were
obtained from all subjects. The subjects were weighed
It has been seen worldwide that every person, wearing minimal cloths and bare footed. Three weight
every family, every institution recognizes the need for measurements were obtained using a bathroom weighing
looking after its children. Particularly orphans, destitute scale and the average was calculated and recorded to the
or abandoned children who are looked after primarily nearest 0.5kg. the height was measured with a wooden
through child care institution run by government and measuring board without shoes and the average was
non-government organization and in some cases through calculated and recorded to the nearest 0.1cm Clinical
fosters families. The national nutrition survey (1995- finding were recorded on Individual Case sheet by a
1996) report illustrates that about 62% of the children General Physician and a Pediatrician. Diet History was
aged 6-9 years are malnutrition’s, 43.4% of the children recorded by using 24hrs recall method followed by health
are stunted but not wasted and 9.3% of the children are education. Children those who need investigations and
wasted but not stunted. In addition, 9.1 % of the children follow up were referred to the Institution, and children
are both stunted and wasted (2). In the developing world, who need simple medication were provided on the spot.
43% of the children are stunted and 9% are wasted (3). Mass Deworming was instructed though the warden,
Directly or indirectly malnutrition contributes to more on the day of examination after Dinner. Data was then
than 60% of 10 million child deaths each year(4). analyzed by using Microsoft Office Ex-cell 2010 and
Hence the present study is a humble effort to generate SPSS software version 20. Descriptive analysis was
relevant information and data on health and nutritional done by using Percentage and Frequencies.
status of destitute children living in the establishment
voluntary body in Puducherry. Result
Figure 1: Depicts the gender distribution of study

Aims And Objectives subjects that is about 59% were male and remaining
zz To assess the nutritional status of the children 41 where female children. Table 1 describes the
dwelling at an orphanage characteristic features of our study samples. It shows the
mean age of study subject as 11.2 years with standard
zz To identify the morbidity pattern among orphan
deviation of 3.1 years. Mean duration of stay was found
children
about 68.8 months with Standard deviation of 34.7
(approximately 5 years of mean stay at home). Whereas
Methodology the mean height and weight was recorded as 130.84cm
After obtaining IEC clearance, we obtained (SD-16.51) and 31.43 Kg (SD 10.15) respectively
permission to conduct Cross sectionalstudy at a
Private orphanage through proper channel. The Home
for orphan children situated around 5 kilometer from
the Institution. Prior to the examination day, the
researcher arranged the logistics at the Home including
Registration, Anthropometric Measurement and clinical
examination and also a Pharmacy. Date was fixed on 3rd
Sunday November 2016 based on the convenience of
Fig 1: Gender-wise distribution of study subjects
the facilitators at orphanage. On the day of examination
out of 120 children, 75 children were available since The malnutrition was graded by calculating Z score
remaining pupils were attending their schools, so we for BMI – Age and it was found that no children having
Grade III malnutrition, but 5.3 percent children were were severely malnourished i.e. underweight, stunted
diagnosed as Grade II and 18.7 percent children were and wasted respectively(8)
diagnosed as Grade I(Fig 2). Children were mainly
seems to be deprived socially, rather than physically. Bhuvanesh Shukla in his study on to Assess Physical
Health Status of Children at Selected Orphanage
in Salem, Chennai – India reported that Orphanage
children skin problems shows that 3.84% of them had
skin patches, 1.96% of them had skin rashes, 7.70%
of then had infected wound and 3.84% of them had
other skin problems. Most of the (83%) children had
dandruff, 25% of them had pediculosis. children’s has
Fig 2: Prevalence of anemia among study subjects 4.8% blindness and only 1.96% of them had Bitot’s spot.
Orphanage children show that 50% of them had dental
Apart from, these children have scabies 12% and carries, 33.50 of them had gingivitis and 4% of them had
Hook warm infestation 5 %, anemia about 8 % glosistis. Orphanage children show that 57.70% of them
and refractory error 3%.(Fig 3) were malnourished. Dandruff and pediculosis are most
common in children. Mouth conditions are very poor
in orphanage, mal nutrition is prevailing among orphan
children.
Conclusion
Our study concludes that the nutritional status was

not that bad when compared with different standards.
Fig 3: Health Issues among Study Subjects Even though none of them are severely malnourished
based on BMI about 24 percentage of children residing
at orphanage have mild or moderate malnutrition.But
Table 1: Description of study subjects
still we would like to recommend for periodic medical
Distribution of study sample checkup for early diagnosis and for a balanced diet
Variable Mean SD distribution to reduce the complication and prevalence
Age in year 11.2 3.1 of malnourishments.
Height in cm 130.84 16.51
Ethical Clearance: Obtained before the commencement
Weight in Kg 31.43 10.15 of study
Duration of stay in month 68.8 34.7
Source of Funding: Self
Discussion Conflict of Interest: Nil
A study conducted by Sadik (2010)(5) shows
low intake of both micro and macro nutrients except References
protein by orphanage children in Ghana. Nutritional 1. UNICEF, “Nutrition–South Africa Humanitarian
status indicated that 10% and 15% of the children Crisis–Presentation at the UN/SADC Stakeholders
were severely stunted and wasted respectively. Similar
Meeting”, Johannesburg, pp 11–12, (2003)
findings were reported by Bhuvanesh Shukla et al(2011)
(6)
, DrNaheedVaida (2013)(7) 2. Jahan, K., and Hossain, M. 1998. Nature and
Extent of malnutrition in Bangladesh. Bangladesh
Another study at Bangladesh by A.K.ObidulHuqet National Nutrition Survey, 1995-96. Institute
al has stated thatNutritional statuses of the orphans are ofNutrition and Food Science, Universityof
very poor. About 12.0%, 14.3% and 6.3% of the orphans Dhaka, July, Part-1:116. 11.
3. Park, K., 2005. Parks Textbook of Preventive 7. DrNaheedVaida et al.” Nutritional Status of
and Social Medicine.18th ed. Jabalpur: Children Living in Orphanages in District
BanarasidasBhanot. Budgam, J&K “International Journal of
Humanities and Social Science Invention Volume
4. WHO., 2002. Child Health Research: A
2 Issue 2 ǁ February. 2013ǁ PP.36.
Foundation for Improving Child Health, World
Health organization,Geneva. 8. A.K.Obidul Huq1,et al “Health Care Facilities
and Nutritional Status of Orphans Residing
5. A.Sadik,( 2010) “Orphanage Children in Ghana:
in Selected Orphanage in Capital City of
Are Their Dietary Needs Met”, Pakistan Journal
Bangladesh”Int.J.Curr.Microbiol.App.Sci(2013)
of Nutrition: 9(19), 844-852.
2(10): 118-125.
6. Shukla.Band,Shukla.D (2011) “Study to Assess
9. WHO., 2006. Child Growth Standards based
Physical Health Status of Children at Selected
on length/height, weight and age. World Health
Orphanage in Salem, Chennai-India” International
Organization. ActaPaediatrica. 450: 76-85.
Research Journal: 1(2): 1-7.
DOI Number: 10.5958/0976-5506.2018.00624.1
Study on Prevalence of Whatsapp Addiction among Medical

Students in a Private Medical College, Pondicherry
S. Rajini1, K. Kannan2, P. Alli3, V. Tamilsevi4

1
Associate Professor, 2Assistant Professor, Department of Community Medicine, 3CRRI, 4Statistician,
Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry.
Abstract
Background: The world is dynamically changing due to the advancement in the mobile technology. These
days it is almost impossible to avoid the presence of Mobile Apps. Whatsapp is one among the major change
in mobile apps communication in the recent past, it users is growing very fast. Whatsapp addiction syndrome
is a part of internet addiction disorder. This study focuses on the prevalence of whatsapp addiction among
medical students.
Aim and Objective: To study the prevalence, pattern, reasons, advantages and disadvantages of whatsapp
addiction among medical students.
Methods: This is a cross sectional descriptive study which was done among the medical students present
in the medical college. The pretested questionnaire is used for collecting the data. Questions regarding the
duration of usage, reasons, to whom, its advantages and disadvantages are asked. The data was collected and
analyzed by using suitable statistical methods.
Results: Of the 200 medical students who took part in the study, 108 (54%) were male and 92 (46%) were
female. The prevalence of whatsapp addiction among medical students is 51%. Reason for whatsapp usage
is for chatting with friends is 87% .The benefit of using whatsapp is easy way of communication is 30.5%.
The drawback of whatsapp use is no face to face interaction is 24.5%. Inspite of knowing the harmful effect
of whatsapp usage, 32.5% of them are using it and unable to control it.
Conclusion: The whatsapp addiction problem among medical students should gain attention
and it is time to evolve a comprehensive intervention approach to promote a healthy and safe
whatsapp use.
Keywords: Whatsapp addiction, medical students.
Introduction use in their everyday lives. Several people are heavily

dependent of the usage of such applications for their day
The world is dynamically changing due to the to day activities. [1]
advancement in the mobile technology. These days it
is almost impossible to avoid the presence of mobile WhatsApp is one among the major change in
applications or called Mobile Apps. Most of the People mobile apps communication in the recent past, it users
can praise the various mobile applications that they is growing very fast on mobile phones and also on the
computers.[2]
Corresponding Author: Whatsapp was created by Jan Koum and Brian Acton
Dr. S. Rajini, Associate professor, in 2009 for easy communication and faster multimedia
Department of Community Medicine, messaging. Communication through mobile phones
Sri. Lakshmi Narayana Institute of Medical sciences, has become easier, faster and cheaper with the help of
Puducherry whatsapp messenger. It is cheaper when compared to
Mobile: 9865233325 the normal phone messaging. Whatsapp messenger is a
Email: [email protected] cross platform mobile messenger which is being worked
through internet data plan. Whatsapp provides users to questionnaire was then administered to 200 students.
send and receive media’s like audio, video and images.[3] Students not available during the study and not willing
to participate were excluded from the study. Questions
Addiction is considered by WHO as dependence,
regarding the duration of usage of whatsapp, reasons,
as the continuous use of something for sake of relief,
to whom, its advantages and disadvantages are asked
comfort, or stimulation, which often causes cravings
The data is collected by asking the students to fill
when it is absent. [4] Mobile phone addiction /abuse/
the profoma. The data is analyzed by using suitable
misuse is one of the forms of compulsive use of “a
statistical methods.
mobile phone” by youth across the world. A new kind
of health disorder in this category among smart phone
Results
users, “WhatsApp’s addiction/ abuse/ misuse” is now
challenging health policy makers globally. Medical Of the 200 medical students who took part in the
students are also affected by this high smartphone study, 108 (54%) were male and 92 (46%) were female.
engagement.[5] The prevalence of whatsapp addiction among medical
students is 51%.
Whatsapp addiction syndrome is a part of internet
addiction disorder. Internet addiction disorder may be In the present study 8%, 15%, 21%, and 56%
broadly defined as “the inability of individuals to control of students felt irritable, depressed, happy and calm
their internet use, resulting in marked distress and/or respectively, when not using whatsapp.(refer figure 1)
functional impairment in daily life”. One of the study The benefits of using whatsapp was told by students
conducted in South Korea on Internet addiction disorder were, easy way of communication, building friendship,
showed that Internet addiction disorder influence long distance communication, improve interpersonal
suicide related behavior. Gray matter volumes of the relationship and fast & speedy way of communication
dorsolateral prefrontal cortex (DLPFC), rostral ACC, as shown in table 1.
the supplementary motor area (SMA), and white matter
focal anisotropy (FA) changes of the posterior limb of
the internal capsule (PLIC) were significantly correlated
with the duration of internet addiction in the adolescents
with internet addiction syndrome.[6]
The application is highly addictive and creates

a great impact on regular users, and apart from that it
becomes difficult to control and cure. They can do the
positive and negative with what’s app.[3] This study focus
on the prevalence of whatsapp addiction among medical
students. Figure 1: When Not Using, How Do You Feel?
Materials & Method Table 1: Benefits of Using Whatsapp

This is a cross sectional descriptive study which Variables Number Percentage
was done among the final year and CRRI students of Long Distance
44 22
the medical college. The Pre – tested, self administered, Communication
anonymous questionnaire were provided to the individual Interpersonal Relations 28 14
students. Verbal consent and ethical committee clearance Building Friendship 49 24.5
was obtained from the students and management Fast & Speedy 18 9
respectively, before handing over the questionnaire. Easy Way of
61 30.5
Communication
They were requested to fill the Performa with full
assurance about the confidentiality and anonymity that The students responded as drawback of using
data would be used only for scientific purpose. The whatsapp were, no face to face interaction, ignoring
people around them, less interaction with the society, more than 300 Rs. (14%). Whatsapp usage per day by
unwanted relations and reduced attachment with parents. medical students was 0-1 hour (28%), 1-2 hours (29.5%),
( refer table 2) The whatsapp is mainly used for chatting 2-3 hours (23.5%) and more than 3 hours (17.5%).
(66%), current updates (17%), photo & video sharing
(14%) and others (3%) respectively as in figure 2. The Discussion
participants reported, the usage of Whatsapp is mainly
to chat with their friends (87%), relatives (8%), and with Globally there have been a lot of advances in the
group (5%). (Refer figure 3) field of technology and communication. Now-a-days
many electronic gadgets are available with lots of
facilities along with internet connectivity which has
Table 2: Drawbacks of Using Whatsapp
changed the way of communication and lifestyle. Use
Variables Number Percentage of Whatsapp can be a boon or a bane. The relationships
Unwanted Relations 39 19.5 created in this virtual world of Whatsapp builds new
friendships and improve communication among people.
Less Interaction with Society 40 20
At the same time participants in this study also opined
No Face to Face Interaction 49 24.5
that the use of Whatsapp also leads to lesser face to face
Ignoring People around Us 44 22 interactions, lesser understanding, false impressions,
Reduced Attachment with materialistic and unwanted relations. [7] This was justified
28 14
Parents by the findings of the present study.
Students were asked the reasons why they most often

use whatsapp on their mobile phones. The researchers
were amazed at their responds. The results shows that
majority of the students use the application for chatting
with friends on different issues rather than academic
work on campus, and this is represented by 72% of the
total number of respondents. This also indicates the link
between usage of the application and poor academic
performance among the majority of the students. The
more friends a student has on whatsapp, the more time
he/she spends on the application” according to most
students interviewed. A student who has a lot of friends
Figure 2: Whatsapp is Mainly Used for on whatsapp is most likely going to be responding to
more people and thus spending more time chatting.
The study looked at students engaged in the use of the
application for other purposes including academic work,
general information, and family. [8] In our study, Purpose
of using whatsapp responded by students were for their
personal work (73%), education (11%) and for other
purposes (15.5%).
In another study 43% of students use whatsapp for

chatting, 24% of them for sharing photos and videos,
and 30% of them for current updates and remaining 3%
for other purposes. [3] But the present study shows, 66%
Figure 3: Whatsapp is Mainly Used to Chat with
of students use whatsapp for chatting, 14% of them for
Purpose of using whatsapp were for their personal sharing photos and videos, and 17% of them for current
work (73%), education (11%) and for other purposes updates and remaining 3% for other purposes.
(15.5%). Monthly data recharge done by students was
In our study, students use Whatsapp mainly for 87%
approximately 0-100 Rs. (28%), 100-300 Rs. (58%) and
chatting with friends and 8% of them with their relatives,
5% of them in groups. Similar findings were reported 2. Naveen Kumar and Sudhansh Sharma;“Survey
by Karthikeyan, in his study that students use whatsapp Analysis on the usage and Impact of Whatsapp
mainly for chatting with friends 83% and 7% of them Messenger”, Global Journal of Enterprise
with their relatives, 5% of them in groups respectively.[3] Information System. Volume-8, Issue-3, July-
September, 2016.
In a study done at Coimbatore, 54% of them use
below 100 rupees for monthly data recharge 33% of 3. V. P. Karthikeyan1 , Tony Varghese Olassayil2
them use up to 300 rupees and the remaining 13% uses and Sanal Jacob3,“A study on Impact of whatsapp
more than 300 rupees monthly for data recharging. [3] But among College Student’s In Coimbatore District”
in our study monthly data recharge done by students was Indian Streams Research Journal | Volume 4 |
approximately 0-100 Rs. (28%), 100-300 Rs. (58%) and Issue 12 | Jan 2015
more than 300 Rs. (14%). 4. WHO. Management of substance abuse:
Dependence Syndrome. [Last updated on 2014
In a study done among college students at
Mar 26; Last cited on 2014 Mar 262] WhatsApp
Coimbatore, 29% of students use 0-1 hours daily, 30%
- Wikipedia, the free encyclopediahttps://en.m.
of them use 1-2 hours daily, 19% of them use 2-3 hours
wikipedia.org/ wiki/ WhatsApp.
daily and remaining 22% use more than 3 hours in a
day.[3] But our study shows whatsapp usage per day by 5. Shettigar MP, Karinagannanavar A. Pattern
medical students was 0-1 hour (28%), 1-2 hours (29.5%), of whatsapp usage and its impact on medical
2-3 hours (23.5%) and more than 3 hours (17.5%). students of Mysore Medical College and research
institute, India. Int J Community Med Public
Conclusion Health 2016;3:2527-31.
6. Yuan K, Qin W, Wang G, Zeng F, Zhao L, Yang X,
The prevalence of whatsapp addiction is high, were
et al. Microstructure Abnormalities in Adolescents
in more than half of the study group show some form
with Internet Addiction Disorder PLoS ONE.
of whatsapp addiction pattern. The whatsapp addiction
2011;6(6): e20708.
problem among medical students should gain attention
and it is time to evolve a comprehensive intervention 7. Sankalp Raj Choudhary, Mohmmed Irfan
approach to promote a healthy and safe whatsapp use. H. Momin, S. L. Kantharia. ”Facebook and
Whatsapp: Beneficial or Harmful?”. Journal of
Conflict of Interest: Nil Evidence based Medicine and Healthcare; Volume
2, Issue 17, April 27, 2015; Page: 2306-2311.
8. Johnson Yeboah ,George Dominic Ewur: The
Impact of Whatsapp Messenger Usage on
References
Students Performance in Tertiary Institutions in
1. Jang YJ, Kim CW. The Evolution of Smartphone Ghana Journal of Education and Practice ISSN
Market and the Effect by Android. Journal of 2222-1735 (Paper) ISSN 2222-288X (Online)
KIISE. 2010; 28(5):48–56. Vol.5, No.6, 2014
DOI Number: 10.5958/0976-5506.2018.00625.3
Prevalence of Stress in Young Urban Population in a City of

Northern India
Samir Chattopadhyay1, Sushil Kumar Singh2, Arvind K. Shukla3

1
Professor, 2Junior Resident, 3Asst Prof, Department of Community Medicine, Subharti Medical College,
Meerut, Uttar Pradesh.
Abstract
Stress is not a mental disorder itself but rather an early sign & symptom of under lying psychological
condition. Not all stress is bad. Some amount of stress is necessary for optimal functioning; However
chronic stress can lead to metabolic dysfunction. Stress has been linked to inappropriate eating, overweight,
obesity for a long time. However it is not clear whether the stress causes metabolic dysfunction or itself is
an effect of metabolic dysfunction.
A community based Cross-sectional study was conducted to find out the prevalence of stress among the
young 18-40yrs of urban population and its association with overweight, obesity. 150 study subjects, aged
18 to 40 years of both sexes were recruited using simple random sampling. Data was collected using WHO’s
STEPS criteria and using modified close ended questionnaire. Pearson’s Chi-square test & Fisher’s exact test
was applied for finding the statistical association.
Overall prevalence of psychological stress was high. As much as 28.4% of males & 24.2% of females were
having “severe stress” and 60.2% males & 64.5% females were having “moderate stress”, whereas the
prevalence of obesity was 38.6% in males & 45.2% in females. But the association between stress & obesity
was not statistically significant.
Conclusion: The prevalence of both ‘psychological stress’ & ‘obesity’ was high among the study participants.
However, the association was not statistically significant
Keywords: Psychological stress, Obesity, overweight, BMI.
Introduction Association between stress and obesity has been

suspected for many years. Scientific evidence in support
According to American psychological association of such link also has been established.[2]
stress can be defined as “any uncomfortable emotional
experience accompanied by predictable biochemical, Studies have established the relationship between
physiological and behavioural changes”. Sometimes chronic stress, HPA (Hypothalamic-pituitary-adrenal
stress can be beneficial providing boost & energy to axis) and obesity. In addition of typical traits of over
get through situations, but extreme stress can have nutrition, sedentary life style and sleep deprivation,
health consequences affecting immune, cardiovascular, chronic exposure to environmental stress potentially
neuroendocrine & central nervous system.[1] contributes to the development of obesity.[3]
Taub-Dix, RD of New York city, a weight loss expert

Corresponding Author: has noted that very often, when people are stressed they
Dr Sushil Kumar Singh may eat inappropriately. If that causes them gain weight,
Junior Resident that can cause even more stress.[2]
Department of Community Medicine,
Subharti Medical College, Meerut, Uttar Pradesh There are considerable evidence from population
Mobile: 9412823176 based and clinical studies indicating significant and
Email: [email protected] positive association of high uncontrollable stressful
event and chronic stress states with adiposity, BMI their lives. The questions in the PSS ask about feelings
and weight gain. This relationship also appears to be and thoughts during the last month.[8]
strongest among individuals who are overweight and
those binge eat.[4] Data was analysed using Statistical Package
for Social Sciences (SPSS) software version 19.0.
Some studies found poor mental health (depression, . Pearson‘s Chi square test was applied to find out
anxiety) and childhood physical abuse , sexual and significance of association between independent and
verbal abuse associated with overweight and obesity dependent variables.
among university students/young adults. Numerous
epidemiologists linked social stress with obesity and Results
metabolic dysfunction. However they found it difficult
to determine whether stress contributes to development Socio-demographic distribution of the 150 study
of metabolic dysfunction or is a result of metabolic participants showed, 58.7% were males with mean age
dysfunction itself.[5] 30.7(± 7.03) years while 41.3% were females with mean
age 29.8 (± 8.22) years. 24% of them were graduate/post-
Aim graduates, followed by 22% intermediate/post high school
diploma holders, 14.7% high school certificate holders,
The study was carried out to find out the prevalence 12.7% middle school certificate holder, 12% primary
of stress among the young 18-40yrs of urban population school certificate holder and 12.7% were illiterates. Only
and its association with overweight/obesity. 2% were professionals/honours graduate (Table 1).
Materials & Method Table 1: Distribution of Study participants

according to their demographic profile
A community based cross-sectional study was
conducted in semi-urban population of Meerut, to assess Variables n = 150 %
the burden of diabetes. Sample size was calculated to 18-19 years 22 14.7%
be 150 adults of 18-40 years of both sexes. 150 families 20-24 years 17 11.3%
were selected randomly from total 350 registered Age 25-29 years 20 13.3%
families of the UHTC. Home visits were made. Only 30-34 years 29 19.3%
one subject was selected from each family randomly by
35-40 years 62 41.3%
using lottery method.
Male 88 58.7%
Sex
Data was collected by using a pre-tested, semi Female 62 41.3%
structured questionnaire using WHO’s STEPS criteria. Hindu 148 98.7%
Religion
Information was collected regarding socio-demographic Others 2 1.4%
profile, educational status, socio-economic status. Professional/
Modified Kuppuswamy’s classification of socio 3 2%
Honours
economic status was used for assessing the socio Graduate/Post-
economics status of the study subjects.[6] 36 24%
graduate
Intermediate/
Anthropometric measurements (height, weight)
Post High school 33 22%
were recorded & body mass index (BMI) was
diploma
defined according to WHO’s criteria for Asian adults Education
High school
underweight (<18.5 kg/m2), normal (18.5 -22.9 kg/m2), 22 14.7%
certificate
overweight (23-24.9 kg/m2) and obese (>25 kg/m2).[7]
Middle school
Perceived Stress Scale (10 item version) was used to 19 12.7%
certificate
assess subjective stress in participants under study. It is
Primary school
a measure of the degree to which situations in one‘s life 18 12%
certificate
are appraised as stressful. Items were designed to tap
Illiterate 19 12.7%
how unpredictable and uncontrollable respondents find
Contd… 45.3% of the participants were Housewives/

Unemployed(mostly females), followed by 21.3%
Professional 6 4%
doing clerical job, 11.3% skilled workers and 10%
Semi-professional 9 6% professional and semi-professionals. Majority (46%) of
Clerical/Shop the participants belonged to upper-middle class, 30.7%
32 21.3%
owner belonged to lower-middle class, 21.3% belonged to
Skilled worker 17 11.3% upper-lower middle class and only 2% were from upper
Occupation
Semi-skilled class (Table 1).
8 5.3%
worker
Unskilled worker 10 6.7% The prevalence of obesity & overweight was quite
Unemployed/ high in this study, 38.6% males & 45.2% females were
68 45.3% obese, but this relation between sex & BMI was not
Housewife
Upper 3 2% significant. Also, the prevalence of stress was high, with
Socio- Upper middle 69 46% 28.4% males & 24.2% females were having “severe
economic stress” and 60.2% males & 64.5% females were having
Status Lower middle 46 30.7%
“moderate stress”. But this association was statistically
Upper lower 32 21.3%
not significant (Table 2).
Table 2: Prevalence of body mass index & psychological stress in males and females
Variables Males (n = 88) Females (n = 62) Total (n = 150)
BMI
Underweight 5 (5.7%) 5 (8.1%) 10 (6.7%)
Normal 26 (29.5%) 20 (32.3%) 46 (30.7%)
Overweight 23 (26.1%) 9 (14.5%) 32 (21.3%)
Obese 34 (38.6%) 28 (45.2%) 62 (41.3%)
χ2 = 3.074, df = 3, p = 0.380
Psychological stress
No stress 10 (11.4%) 7 (11.3%) 17 (11.3%)
Moderate stress 53 (60.2%) 40 (64.5%) 93 (62.0%)
High stress 25 (28.4%) 15 (24.2%) 40 (26.7%)
χ2 = 0.350, df = 2, p = 0.839
Among the obese persons, 27.4% participants were underweight participants the prevalence of both ‘severe
having ‘severe stress’ & 62.9% were having ‘moderate stress’ & ‘moderate stress’ was high respectively. But
stress’, while among the overweight participants, 15.6% this association between BMI and “psychological stress”
were having ‘severe stress’ & 68.8% were having was not significant. (Table 3).
‘moderate stress’. Similarly, among the normal &
Table 3: Association of psychological stress and body mass index (BMI)
Psychological stress
Variables Total
No stress Moderate stress Severe stress
BMI N % N % N % N %
Underweight 1 10% 4 40% 5 50% 10 100%
Normal 5 10.9% 28 60.9% 13 28.3% 46 100%
Overweight 5 15.6% 22 68.8% 5 15.6% 32 100%
Obese 6 9.7% 39 62.9% 17 27.4% 62 100%
Total 17 11.3% 93 62.0% 40 26.7% 150 100%
χ = 5.290, df = 6, p = 0.507
2
Discussion References
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in young adult males,8% & 13.1% respectively.[12]
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The relation between ‘psychological stress’ & 5. Peltzar K, Pingpid S, Samuels AT, Ozcan N
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[Internet]. 2016;69(2):329-36.DOI: http://dx.doi.
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DOI Number: 10.5958/0976-5506.2018.00626.5
Effects of Socio-Demographic Factors on Prelacteal Feeding

Practices among the Lactating Mothers in Meerut City
Pawan Parashar1, Kiran Garg2, Sameer Chattopadhyay3, Arvind K. Shukla4, Sartaj Ahmad5
1
Professor (Community Medicine), 2Consultant CMO Office Gaziabad UP India, 3Professor, (Community
Medicine), 4Assistant Professor (Biostatistics), 5Associate Professor (Medical Sociology), Department of
Community Medicine, Subharti Medical College, Meerut, UP. India
ABSTRACT
Background: In many countries across the world, the practice of giving new born babies other substances (pre
lacteal feeding) even before lactation is a common cultural practice. Prelacteal feeding is an underestimated
problem in a developing country like India, where infant mortality rate is quite high.
Aim and objective: To know the prevalence and effects of socio-demographic factors on prelecteal feeding
practices among the lactating mothers in Meerut city UP.
Material and Methods: A cross-sectional study included 322 women who had a live birth during last one
year. A pre-designed and pre- tested questionnaire was used for data collection.
Statistical Analysis: Data was analyzed using appropriate statistical tests by (SPSS) version 21.0 for
Windows and data were analyzed using the chi-square test.
Results: Study findings showed that 232 (72.05% ) of the mothers had given pre-lacteal feedings to their
newborn. Ghutti (47.8%), honey (13.4%) and others (10.9) like tea, artificial milk, Gur ( Jeggary) etc . had
given as Prelacteal feed.
Conclusion: The problem of prelacteal feeding is still prevalent in India. In our study, (72.05% ) of the
mothers had given pre-lacteal feedings to their newborn.
Keywords: Pre lacteal feeding, Socio-demographic factors , Urban Slum area
Introduction including India which carries potential risk of infection

and aspiration. [7]. WHO/UNICEF strongly discourages
Pre lacteal feeds that are usually given include honey, the traditional practice of pre-lacteal feeding unless
sugar water, ghee or other herbal even before lactation medically indicated.[8]
has been initiated, it is called pre-lacteal feeding, and the
fluids are called pre-lacteal feeds. [1]. It is common in our
Aims and Objective
Indian society due to different customs and misbelieves.
[2,3 ]
According to NFHS-3 (2005-2006); the pre-lacteal To know the prevalence of prelacteal feeding
feeding is most common in Bihar (90.6%), Uttar Pradesh practices and its effects of socio-demographic factors
(86.0%), Rajasthan (71.6%) and Jharkhand (66.3%). [4]. among the lactating mothers in Meerut city UP.
It is also observed in many countries like South Nepal
(55.6% ) and Pakistan (87.6%) . [5,6] Prelacteal feeds
MATERIALS & METHOD
are commonly given in many developing countries
The present cross-sectional study was conducted in
the catchment area of urban health and training center
(UHTC), Multan Nagar which is the field practice area
Dr. Pawan Parashar
of the department of Community Medicine, Subharti
Professor, Deptt. of Community Medicine,
Medical College, Meerut. 322 Lactating mothers having
Subharti Medical College Meerut UP
child 0-12 months were included for the study. The For the collection of data, a personal visit was made
period of study was from September 2013 to August to each selected family after verbal consent. Data was
2014. After obtaining the ethical clearance from the analyzed using appropriate statistical tests by (SPSS)
institutional ethical committee of Subharti Medical version 21.0. For all the tests, a p-value of less than 0.05
College, Meerut, the required sample was taken using was considered significant. Appropriate tables were used
simple random sampling technique. A pre-designed and to show the results.
pre- tested questionnaire was used for data collection.
RESULTS
Table 1: Socio Demographic Characteristic of the Family
Characteristics of the family Frequency Percentage

Nuclear Family 198 61.5
Type of family
Joint Family 124 38.5
Upper 1 0.3
Upper middle 25 7.8
Socio economic status of family Lower middle 128 39.8
Upper lower 144 44.7
Lower 24 7.5
Hindu 280 87.0
Religion of the Family Muslim 40 12.4
Others 2 .6
Table no. 1 shows that 198 (61.5%) mothers belongs Contd…

to nuclear families. while 124 (38.5%) mothers were in
House Wife 311 96.6
Joint families. Majority 144 (44.7%) of women belongs
to upper lower class. Majority of mothers 280 (87.0%) Unskilled 3 .9
belongs to Hindu families and only 40 (12.4%) mothers Skilled 5 1.6
Occupation
were in Muslim families. of mother Clerk 1 .3
Semi
1 .3
professional
Table 2: Socio Demographic Characteristic of The
Professional 1 .3
Mothers
Parity Primipara 89 27.6
Characteristic of the of the
Frequency Percentage Multi para 233 72.4
mothers Mother
≤20 years 25 7.8
Table no. 2 shows that half of mothers167 (51.9%)
Age of 21-25 years 167 51.9 belonged to age group of 21-25 years. 74 (23%) mothers
mother 26-30years 119 37.0 were illiterate. Majority of mothers were house wife
31-35 years 11 3.4 311(96.6%). Only 1(0.3%) mother was professional in
Illiterate 74 23.0 her occupation. Most of the mothers were multipara 233
Primary 50 15.5 (72.4%).
Junior school 52 16.1
Education High school 53 16.5 Table 3: Demographic Characteristic of the Child
of mother Intermediate 41 12.7 Characteristic of the
Frequency Percentage
Graduate & infants
49 15.2
Post Graduate Female 142 44.1
Sex of Child
Professional 3 .9 Male 180 55.9
Contd… Contd…
0-6 Honey and water 43 (13.4%)

100 31.1
Age of the months Other Like Tea, Artificial
Child 35 (10.9%)
6 -12 Milk, Gur ( Jeggary) etc.
222 68.9
months Total 232 (72%)
Below
75 23.3
average Table no. 3 shows that more than half children
Weight of Average 212 65.8
the child at were male 180(55.9%) and 142(44.1%) were
Above
the Time of 32 9.9 female. Most of the children were between 6-12
Delivery average
Not months of age 222(68.9). 75 children (23.3%)
3 0.9
known were below average body weight at the time of
delivery.
Table 4: Prevalence of prelacteal feeding practices
and types of prelacteal feeding Table no. 4 shows that 232 (72.% ) of the
Frequency and
mothers had given prelecteal feedings to their
Variables
Percentage newborn. Ghutti/ (47.8%), honey (13.4%) and others
Types of prelacteal feeding (10.9%) like tea, artificial milk, Gur ( Jeggary) etc.
Ghutti 154 (47.8%) had given as prelacteal feed.
Table 5: Association between Prelacteal Feed Given and Various Characteristic of Family, Mother and Child
Prelacteal Feed Given Total

Variables Yes (N = 232) No (N = 90) (N = 322) Χ2 –Value P-Value
Freq % Freq % Freq %
Female 104 73.2 38 26.8 142 100.0
Sex of Child 0.179 0.673 (NS)
Male 128 71.1 52 28.9 180 100.0
Socio- Upper middle 14 56 12 44 25 100.0
Economic Lower middle 96 75 32 25 128 100.0
6.28 0.98 (NS)
Status of Upper lower 107 74.3 37 25.7 144 100.0
Family Lower 15 62.5 9 37.5 24 100.0
=<25 YEARS 138 71.9 54 28.1 192 100.0
Age of Mother 0.01 0.92 (NS)
> 25 YEARS 94 72.3 36 27.7 130 100.0
Illiterate 53 71.6 21 28.4 74 100.0
Primary 40 80 10 20 50 100.0
Education of Juniour school 39 75 13 25 52 100.0
5.25 0.386 (NS)
Mother High school 40 75.5 13 24.5 53 100.0
Intermediate 28 68.3 13 31.7 41 100.0
Graduate & pg 32 61.5 20 38.5 52 100.0
Religion of Hindu 198 70.71 82 29.29 280 100.0
1.90 0.168 (NS)
Mother Muslim 34 81 8 19 42 100.0
Parity of Primipara 53 59.5 36 40.4 89 100.0
9.54 0.002(SIG)
Mother Multi para 179 76.8 54 23.2 233 100.0
Type of Normal 192 73.6 69 26.4 261 100.0
1.57 0.211(NS)
Delivery Operation 40 65.6 21 34.4 61 100.0
Contd…
Place of Home 102 79.7 26 20.3 128 100.0

6.15 0.01(SIG)
Delivery Institutional 130 67 64 33 194 100.0
Education of Illiterate 113 73.4 41 26.6 154 100.0
0.036 0.850 (NS)
Mother In Law Literate 15 71.4 6 28.6 21 100.0
Once 45 73.8 16 26.2 61 100.0
Child Sick Last Twice 41 69.5 18 30.5 59 100.0
3.43 0.33 (NS)
Six Month More than 2 93 76.9 28 23.1 121 100.0
Nothing 53 65.4 28 34.6 81 100.0
Diarrhoea 39 83 8 17 47 100.0
Pneumonia 38 69.1 17 30.9 55 100.0
Reason Child
Fever 51 66.2 26 33.8 77 100.0 7.31 0.06 (NS)
Sick
Two or more
51 82.3 11 17.7 62 100.0
reason
Table no. 5 shows that that prelacteal feeding was found not statistically significant. (79.7%) of
practice was found (72.05%) of respondents. Mothers mothers gave prelecteal feed who had delivery at home
who had female child, 73.2% gave prelecteal feed to their which was more than those who had delivery in a
babies in comparison to those mothers who had male hospital (67.0%). The association was found statistically
child 71.1%. The association was found not statistically significant.
significant. (44.0%) mothers of upper middle class of
families had good practice of not given prelecteal feed to (73.4%) of illiterate mothers in law advised
their babies. The association was found not statistically prelecteal feed to their grandchild as compared to literate
significant. Mothers who were less than 25 years of age, mothers in law (71.4%). The association was found not
(71.9%) of them gave prelecteal feed to their babies in statistically significant. Children who became sick for
comparison to mothers who were above 25 years of age more than two times in last six months, (76.9%) of them
(72.3%). There is no association between age of mothers had received prelecteal feed after birth in comparison to
an d prelacteal feeing practices . Mothers who were those children who became sick once and twice (73.8%
primary passed & illiterate (80.0% & 71.6%) of them and 69.5% respectively). The association was found not
gave prelecteal feed to their babies respectively. While statistically significant.
mothers with high school, intermediate, graduate, & post Children who had two or more reason for their
graduation qualification, (75.5%, 68.3% & 61.5%) of sickness, (82.3%) of children who had two or more
them had given prelecteal feed to babies. The association reason for their sickness had received prelacteal feed
was found not found statistically significant. in comparison to the children who had only one reason
Prelecteal feed was given by 81.0% mothers who for their illness. This association also was not found
belonged to Muslim religion,while mothers who were statistically significant.
hindu 70.71% given prelecteal feed. The association was
Discussion
found not statistically significant.
In our study prelecteal feeding practice was found
Mothers who were multipara, 76.8% of them gave
(72.%) among mothers. A study done by Satapathy et al.
prelecteal fed to their babies than primipara mothers
(1984) reported that practice of prelacteal feeding was
(59.55%). With increase in parity, there is increase
found (73%) among mothers in South Orissa.[9]
in prelecteal feeding practices. The association was
found statistically significant. Mothers who had normal In our study, Ghutti (47.8%), honey (13.4%) and
delivery, (73.6%) of them gave prelecteal feed to their others (10.9) like tea, artificial milk, Gur ( Jeggery) etc .
babies. It means that in institutional deliveries less had given as prelacteal feed. A study done by Gupta P. et
prelacteal feeding practices was adopted. The association al (2012) revealed that mugli ghutti/gripe water 55.1%,
and boiled water 49.4%, cow/buffalo’s milk 4.7%, and In our study, mother in laws who were less educated,
honey 22.6% percent had given as Prelacteal feed.[10] less informed about the current practice of the breastfeeding
were the main influence (73.4%) for the prelacteal feed.
This study shows that among mothers who had A study done by Khanal et al. (2011) revealed that the
female child, (26.8%) did not give prelacteal feed to mother in laws who were less educated, were the main
their babies in comparison to those mothers who had advocator (59.1%) for the prelacteal feed.[16].
male child (28.9%) which is also documented in studies
by Gupta RK. et al.(2012).[11] This study shows that (76.9%) children who became
sick for more than two times in last six months had
Lower socioeconomic group (37.5% ) found to be received prelecteal feed after birth. Prelacteal feeding is
practicing prelacteal feed to their baby as compared discouraged because it limits the infant’s frequency of
to the upper lower & lower middle class in our study. suckling and exposes the baby to the risk of infection.
. A study done by Salve Dawal et al. (2014) revealed
[17]
In Ethiopia children who received prelacteal feeding
that lower socioeconomic group found to be practicing were 1.8 times more likely to be stunted than children
prelacteal feed to their baby as compared to the 11(42%) who were not subjected to prelacteal feeding.[18]
out of 26 in the upper socioeconomic class. Mothers who This study shows that (82.3%) children who had two
were less than 25 years of age, (28.1%) of them did not or more reason for their sickness had received prelecteal
give prelecteal feed to their babies. The age group with feed. It is a common misbelieve that milk comes only on
highest number of respondent that practiced prelacteal the second or third day of life.[19]
feeding was 21-25 years (59.4%), while the age bracket
of respondents with least practice of the prelacteal feed
CONCLUSION
was 35-40 years.[12]
This study revealed that there are very common
In our study, no statistical significant of mother prelacteal feeding pattern among infant in urban area of
& prelecteal feed practices was observed. A study Meerut. These practices of prelacteal feeding do affect
conducted by Raval et al. (2011 found that (85.2%) the growth parameters of a child. False beliefs and myths
illiterate mothers practiced more prelacteal feeding than attached to child’s feeding deeply rooted in all strata of
literate mothers (50.9%).[13] community; need to be replaced by sound and scientific
messages. It is suggested that mothers should be educated
This study shows that the prelecteal feed was given
about adverse effects of prelacteal feeds. BCC should be
by (81.0%) mothers who belonged to Muslim religion,
targeted for tackling these traditional practices.
which were more than 70.71% mothers of Hindu
religion. A study done by Ahmad S et al.(2014) reveled Source of Funding: Nil
that (32.00% ) mothers initiated breast feeding after 24
Conflicts of Interest: None
hours.[14]
Ethical Clearance: Permitted by the Ethical committee
This study shows that among mothers who had
normal delivery, (73.6%) of them gave prelecteal feed to
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DOI Number: 10.5958/0976-5506.2018.00627.7
A Cross Sectional Study to Estimate Prevalence and Maternal

Risk Factors with Term Low Birth Weight Babies
Sridhar. D1, A. Sai Ram2, P. Narasimha Reddy3

1
Assistant Professor;Community Medicine;ESIC Medical College,Sanath Nagar, Hyderabad;
2
Assistant Professor; 3Professor, Community Medicine;Kamineni Institute of Medical Sciences,Narketpally
Abstract
Background: WHO defined Low birth weight (LBW) as birth weight less than 2500gms.Intra uterine
growth retardation (IUGR), preterm birth or combinations of both are the common causes of LBW. In India
two thirds of LBW cases are due to small for date. Infants with IUGR have greater morbidity and mortality
than the appropriately grown infants. Also LBW is a major determinant of malnutrition in infancy, as 40%
of LBW babies are malnourished at 1 year of age.
Methodology: 300 subjects were randomly selected from the department of obstetrics and paediatrics for
measuring the prevalence of LBW and to correlate it with maternal risk factors.
Results: Prevalence of term LBW babies was found to be 36.30%. Mean birth weight was 2.52 kg. Lower
socio economic class led LBW babies 82(52.9%), upper lower class 24(28.6%), and lower middle class
3(4.9%). Majority of the LBW babies were born to short stature(<145cms) mothers, which was statistically
significant.
Keywords: low birth weight, maternal risk factors, maternal morbidities
Introduction infants. LBW is also a major determinant of malnutrition

during infancy, as 40% of LBW babies are malnourished
WHO defined Low birth weight as birth weight less at 1 year of age. These babies have 2.3 times increased risk
than 2500grms.1 In developing countries like India LBW of mortality due to infections compared to normal birth
is a serious problem. According to WHO, 20 million weight babies after controlling the confounding variables.
LBW patients are born each year, of which 95% are It is also a significant determinant of infant and childhood
from developing countries, while India alone accounted morbidity, particularly neuro developmental impairments
around 40% i.e., 8 million infants. Of the 37 per 1000 such as mental retardation and learning disabilities.4
IMR, LBW constituted 28%, while mortality rate in
LBW babies being 57%.2 Recent evidence indicates that obesity, type 2
diabetes, and cardiovascular diseases are more common
LBW is caused by Intra uterine growth retardation among adults who had IUGR at birth. Studies suggest
(IUGR) or preterm birth or combination of both, majority that these may represent an example of “programming,”
of them in developing countries being due to pre term in which an insult, when applied at a critical or sensitive
birth. While in India two thirds of LBW are due to small stage in development, may result in a lifelong effect
for date.3 on the structure or function of the organism. There are
Infants with IUGR have greater morbidity and numerous factors contributing to LBW, including both
mortality than do appropriately grown, gestation matched maternal and foetal factors.
Material and method

Dr. Sridhar D. Objectives:
Assistant Professor, Community Medicine, To measure the prevalence of LBW
ESIC Medical College, Sanath Nagar, Hyderabad To correlate LBW with maternal risk factors
A hospital based cross sectional study was conducted using new Ballard scoring system. Chi square tests
on randomly selected 300 subjects in the department of were performed to evaluate the association of various
obstetrics and paediatrics. All live babies born at term and maternal risk factors with LBW.
singleton pregnancy were included. Pre-term and Post-
term babies, Intra-uterine deaths, Still-births, multiple RESULTS
pregnancies, newborns with congenital malformations
were excluded from the study. Of the 300 babies born during the study period,
prevalence rate of term LBW babies was found to be
After taking Informed consent from all study
36.30% with mean birth weight of 2.52 kg.
subjects, pre tested questionnaire was introduced.
Haemoglobin levels were recorded 15 days prior to Socio demographic factors: Table No 1
delivery. Birth weight was measured within 1hr of birth
with an electronic weighing machine. Preterm babies are Prevalence of LBW babies was noticed more in exteme
excluded by assessing gestational age with the help of age groups (<19 yrs and >35yrs), Muslim and illiterate
USG scan reports, EDD, and examination of the baby mothers. All these parameters were statistically significant.
Table No. 1: Socio demographic factors versus LBW
Birth weight Birth weight

P value
<2.5Kg >2.5Kg
<19Yrs 33(62.30%) 20(37.70%)
Maternal age 19-35Yrs 72(30.00%) 168(70.00%) <0.05
>35Yrs 4(57.10%) 3(42.90%)
Hindu 43(37.7%) 71(62.3%)
Muslim 51(48.6%) 54(51.4%)
Religion <0.05
Christian 15(20.0%) 60(80.0%)
Others 0(0%) 6(100.0%)
Illiterate 35(43.8%) 45(56.3%)
Mother’s Primary School 66(41.3%) 94(58.8%)
<0.05
Education High school 7(17.5%) 33(82.5%)
Intermediate 1(5.0%) 19(95.0%)
Agricultural worker 44(63.8%) 25(36.2%)
Daily wage labour 50(51.0%) 48(49.0%)
Occupation <0.05
Service 8(11.1%) 64(88.9%)
Home maker 7(11.5%) 54(88.5%)
<2164 106(66.3%) 54(33.8%)
Family Income 2165-6430 3(2.8%) 109(57.1%) <0.05
6431-10718 0(0%) 28(100.0%)
Lower Middle 3(4.9%) 58(95.1%)
Socio Economic
Upper Lower 24(28.6%) 60(71.4%) <0.05
Class
Lower 82(52.9%) 73(47.1%)
Maternal factors: Table No.2 pregnancy, tobacco/alcohol/toddy consumption during

pregnancy had increased incidence of LBW with
Grand multiparous women, birth spacing <18 months,
significant association. Equal distribution of LBW was
pre-pregnancy weight <40 kg, weight gain during
noted in mothers who received protein and calorie
pregnancy <7 kg, Short stature (<145 cm), mothers
supplementation and who didn’t.
with Hb <7 mg/dl, strenuous physical activity during
Table No. 2: Maternal Factors versus LBW

Birth weight Birth weight
Pvalue
<2.5Kg >2.5Kg
Primi 34(33.7%) 67(66.3%)
Parity Multi para(2-3) 17(18.7%) 74(81.3%) <0.05
Grandmulti para (4 or above) 58(53.7%) 5(46.3%)
<18 MONTHS 63(46.7%) 72(53.3%)
Birth spacing 18-24 MONTHS 30(30.6%) 68(69.4%) <0.05
>24 MONTHS 16(23.9%) 51(76.1%)
<40Kgs 79(94.0%) 5(6%)
Prepregnancy birth weight <0.05
>40Kgs 30(13.9%) 186(86.1%)
<7Kgs 97(82.2%) 21(17.8%)
Weight gain <0.05
>7Kgs 12(6.6%) 170(93.4%)
<145cm 106(83.5%) 21(16.5%)
Height of mother <0.05
>145cm 3(1.7%) 170(98.3%)
<4 105(59.7%) 71(40.3%)
No of antenatal visits <0.05
>4 4(3.2%) 120(96.8%)
<7mg/dl 54(100.0%) 0(0%)
Haemoglobin status of mother 7-9.9mg/dl 33(22.6%) 113(77.4%) <0.05
>9.9mg/dl 22(22.0%) 78(78.0%)
ICDS beneficiary Yes 6(136.5%) 106(63.5%) >0.05
H/O strenuous physical activity Yes 95(48.5%) 101(51.5%) <0.05
Smoking/tobacco chewing Yes 64(91.4%) 6(8.6%) <0.05
Alcohol/toddy consumption Yes 64(66.7%) 32(33.3%) <0.05
Iron&folicacid Yes 62(64.6%) 34(35.4%) <0.05
Abortions 10(35.7%) 18(64.3%)
Still Births 17(51.5%) 16(48.5%)
Bad obstetric history >0.05
Neonatal deaths 9(33.3%) 18(66.7%)
H/O LBW baby 7(30.4%) 16(69.6%)
Maternal Morbidities: Table No.3

Prevalence of LBW is more in mothers who had Tubercolosis followed by other infectious disorders. Highest
percentage of LBW babies were born in mothers with chronic hypertension, pre-eclampsia and eclampsia(47.6%),
followed by other systemic diseases.
Table No 3: Maternal morbidities versus LBW
Birth weight <2.5Kg Birth weight >2.5Kg P value

Fever 7(24.1%) 22(75.9%)
Malaria 9(31.0%) 20(69.0%)
Maternal infections TB 3(75.0%) 1(25.0%) >0.05
UTI 29(34.9%) 54(65.1%)
Bacterial vaginosis 13(35.1%) 24(64.9%)
Chronichypertension,
10(47.6%) 11(52.4%)
Preeclampsia, Eclampsia
Heart disease 8(30.8%) 18(69.2%)
Systemic diseases >0.05
Diabetes,GDM 10(38.5%) 16(61.5%)
Bronchial Asthma 8(33.3%) 16(66.7%)
Sickle Cell Anaemia 8(32.0%) 17(68.0%)
Discussion al.12It can be due to malnourishment and less body stores

of proteins and fats leading to LBW.
In the present study, the prevalence of term LBW
was high i.e., 36.3% compared to Telangana state(8.6%). Less weight gain during pregnancy(<7 kg)and
According to NFHS 3 data prevalence of LBW in India its association to LBW was similar to the findings of
was 21.5%, Andhra Pradesh accounting for 19.4%.2 This Rajashree K et al16, Raghunath D et al.12It can be due
is comparable to results of Noor N et al5 and Juneja et al6. to factors like inadequate intake of nutritious food, hard
This can be attributed to locality and referral hospitals manual labour during pregnancy etc.
receiving high risk pregnancy cases from local and area
hospitals. Short stature (145 cm) association to LBW is similar
to findings of Sumana M et al13, Prudhivi S et al10 and
Association between extreme age group (<19yrs and Agarwal A et al8 but not with Soujanya M et al.11Maternal
>35 yrs) and LBW was similar with findings of Kaur S height though influenced by heritable factors or other
et al7, Aggarwal A et al8 and Dubey M et al9 but was not environmental factors, under nutrition appears to play an
consistent with the study of Prudhivi S et al10. Soujanya important role leading to short maternal height and LBW.
M et al11 showed significant association. Early age at
marriage and illiteracy in women will make them Literacy status of mothers was comparable with the
physically and physiologically immature for reproduction findings of Kaur S et al7, Raghunath D et al12 Sumana M
and hence resulting LBW babies. Women >35 years were et al13 and Prudhivi S et al .10 But Reddy RS et al 18 didn’t
mostly grand multi paras with increased incidence of find any significance. Educated mothers may have an
complications like hypertension, diabetes etc, this may increased awareness about the health care services and
augment the risk of birth of LBW baby in them. pregnancy care.
Muslim religion was significantly associated with Mother’s occupation was comparable with the
LBW babies, similar to the findings of with Dubey M et findings of Rajashree et al16 and Shahnawaz k et al17 but
al9, Raghunath D et al.12 Prudhivi S et al 10 , while Kaur S not with study findings of Reddy RS et al.18 It can be
et al7 found no significance. This may be due to Muslim attributed to an increased physical activity and less rest
population belonging to lower socioeconomic status. when compared with homemakers.
Grand multi and primi paras association was Less family income findings are similar with Reddy
similar with findings of Kaur S et al7, Prudhivi S et al10 RS et al18 and Sunilbala K et al19 but not with the findings
and Dubey M et al9 and not similar with Sumana M et of Dandekar RH et al.20 Low income can cause stress on
al.13Primi paras will have utero placental insufficiency, pregnant women forcing them to work and also can be
structural factors which limit uterine capacity in the the reason for reduced intake of nutritious food during
first pregnancy, so first born infants may be exposed to pregnancy.
a different maternal immune environment, contributing
Socioeconomic class association with LBW was
to relative growth restriction, compared to subsequent
comparable with findings of Sahu KK20, Agarwal A et al8,
pregnancies. Grand multi para had higher incidence of
Raghunath D et al12, Thomre PS et al15 and Bendhari ML
pregnancy related complications leading to LBW.
et al21 and not consistent with Shahnawaz k et al17 .They
Less birth spacing (<18 months) association with have not found significance between socio economic
LBW is consistent with findings of Kaur S et al7, Sumana M status and LBW. Low socioeconomic status indirectly
et al13 and Giri A et al14 but not with findings of Raghunath linked to infections, low birth spacing etc.
D et al.12 This can be explained by the deterioration of
Antenatal visits less than 4 led to significant
nutritional status in the present pregnancy, because of the
association and it is similar to results of Dubey M et al9,
previous delivery and breast feeding.
Thombre PS et al15, Kaur S et al7 but not with Dandekar
Pre-pregnancy weight <40kgs led to LBW and it RH et al.19 Proper anti natal care can decreases modifiable
was similar to results of Prudhivi S et al10 and Thombre risk factors like infections, anemia, hypertension etc
PS et al15 but not with the findings of Raghunath D et leading to decrease in LBW.
LBW significantly associated with maternal severe during pregnancy lead to high incidence of LBW babies
anemia. This is consistent with the findings of Raghunath compared to other maternal infections during pregnancy.
D et al12, Sahu KK20 and Kaur S et al7.Severe maternal Bates M et al25 documented similar findings.
anaemia limits maternal oxygen uptake leading to
decrease in oxygen delivery to foetus and consequently Chronic hypertension, pre-eclampsia and eclampsia
leading to foetal growth restriction. were major variables that led to LBW compared to other
systemic diseases like diabetes, bronchial asthma, sickle
ICDS beneficiaries association was not similar with cell anemia and heart diseases during pregnancy. It is
Dubey M et al.9 They found reduced percentage of LBW comparable to the findings of Kumari PR26 who did not
in mothers who had consumed an extra meal during find significant association between hypertension and
pregnancy. Supplementary meal provided to the mother LBW. Findings of Prudhivi S et al10, Raghunath D et
may not be eaten by the mother alone in the family due al12, Bendhari ML et al21, found significant association
to poor socioeconomic conditions. between hypertension and LBW.
Physical activity of mothers and its association Conclusion: Health education, socioeconomic
with LBW was similar with results of the Kaur S et al7, development, maternal nutrition, and increasing use
Thomre PS et al15 and Sahu KK et al20. Dandekar RH of health services during pregnancy are important in
et al19 couldn’t find any significance. Strenuous physical reducing LBW.
activity can alter the balance in mothers with marginal
nutritional deficiency and can lead to LBW babies. Ethical Clearance: Obtained from Institutional ethical
committee
LBW and smoking/chewing tobacco during
pregnancy showed significant association. This is Source of Funding: self funded
consistent with Giri A et al14, Agarwal K et al8, Dubey Conflict of Interest: Nil
M et al9, Bendhari ML et al21, and Johnson CD et al22
but not with the Raghunath D et al12 and Sahu KK20.
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DOI Number: 10.5958/0976-5506.2018.00661.7
Role of Videofluroscopy in Rehabilitation of Dysphagia−

A Case Study
Kevin Gautham M1, Vijay Kumar K V2, Shankar V3

1
Intern, 2Senior Lecturer, Department of Speech Language and Hearing Sciences, 3Professor,
Department of Neurology, Sri Ramachandra University
Abstract
Dysphagia, described as difficulty in swallowing is a commonly seen post stroke. Individuals with stroke
experience difficulty in cognition, language and swallowing. Not many centres in India offer a comprehensive
dysphagia management due to lack of infrastructures and professionals working in the domain of swallowing
disorders. Visualisation techniques are used to detect aspiration and swallowing disorders. This helps Speech
Language Pathologists (SLPs) to facilitate modification of therapeutic manoeuvres to the need of the patient.
These techniques not only help in planning treatment, but also provide information on treatment efficacy and
decision making on initiating oral feeds. This study focuses on demonstrating the use of Videofluroscopic
swallow study (VFS) in a 57 Year old patient, medically diagnosed with left lateral medullary infarct with
dysphagia. This study throws light on usage of VFS in modifying therapeutic manoeuvres to improve the
patient’s quality of life.
Keywords: Dysphagia ,Videofluroscopy , Therapeutic manoeuvres, Speech Language Pathologist, Quality

of life.
Introduction safe swallow. A home plan was structured and was given
to the patient after a re-assurance from him for regular
A 57 Year old male patient was medically diagnosed follow up. The patient followed up on the last week
with left lateral medullary infarct, along with systemic of March 2017 and showed no signs of improvement
hypertension and aspiration pneumonia. The patient’s in swallowing. He consented to attend speech and
nutritional needs were met through nasogastric tube swallowing therapy twice a week but refused to undergo
since February 22, 2017. The patient was consulted and any formal instrumental evaluation.
clinically examined by the Speech-Language Pathologist
on March 09, 2017. He was observed to have frequent Therapeutics focused on strengthening the base
throat clearing, reduced hyolaryngeal elevation during of tongue, by pushing the tongue against the palate
dry/saliva swallow, presence of a gurgly voice and and Masako manoeuvre (gently biting the tongue and
multiple swallow attempts. His voice was breathy which attempting to swallow dry air). It was initially difficult
suggested the presence of vocal cord palsy. Fiberoptic for the patient to achieve hyolaryngeal elevation using
Endoscopic Evaluation of Swallowing (FEES) was
Masako manoeuvre and complained of inability to do
advised before initiating therapy but was neglected due
the exercise. The base of tongue exercises along with
to the patient’s personal reasons and he was reluctant to
breath holding and breath holding with gentle cough to
attend regular speech and swallow therapy to promote
facilitate vocal adduction were practised for ten sessions.
It was observed that the patient had hyolaryngeal
Corresponding Author: elevation (but clinically reduced in functioning and not
Vijay Kumar K V adequate on three finger test).
Senior Lecturer,
Department of Speech Language and Hearing Sciences After the above mentioned ten sessions of therapy
Sri Ramachandra University the patient was persuaded to undergo a visualisation
Email: [email protected] technique (either FEES or VFS) to understand his
swallow physiology. The advantages of visualisation 7. Breath holding exercises were also done for vocal
were discussed in detail with the patient. The patient adduction to facilitate voicing and preventing
then opted to undergo VFS considering that, FEES is an food to enter the airway.
intrusive procedure. VFS is a radiological examination
for assessing swallowing functions. The examination These exercises were practiced for twelve sessions
of therapy. Apart from therapy sessions, the patient was
was done on June 02, 2017 by using soft solids and
advised to maintain a record of practise sessions at home.
liquids (banana and water respectively mixed with
The patient practised these exercises and manoeuvres 4 –
Barium Sulphate). The examination was carried out in
6 times a day. After twelve sessions, when hyolaryngeal
lateral and anteroposterior view.
elevation was clinically observed, oral trails of soft
On examination; lip closure, tongue elevation, solids and puree (pongal and thick curd) were tried
chewing and anteroposterior movement of tongue were using supraglottic swallow modified to the left side was
present (for soft solids and liquids). There was a delay in recorded on June 29,2017. It was observed that he was
the oral transit time. Oral residue (pocketing), multiple tolerating oral trials. It was also brought to the notice of
swallow, coughing (during and after swallowing), and SLPs few oral trial of liquid was attempted successfully
reduced hyolaryngeal elevation were observed. at patient’s home. The patient was assessed with VFS
again on July 18, 2017 to document the prognosis
It was also noted that the patient also had premature attained by him over the modification of the therapeutic
spillage. In the pharyngeal phase, pooling was observed manoeuvres. On examination, the patient was given
in the valleculae and pyriform sinus. Relaxation of liquids and semi-solids (water and pongal; south Indian
cricopharyngeus muscle was not observed. Efforts were dish, respectively). First, the water was mixed with
made by the patient to regurgitate. Aspiration for liquids Barium Sulphate and was attempted. The patient did not
was also an important finding in this individual. find it difficult to swallow and no signs of aspiration or
any oral/ pharyngeal residue/ pooling were observed.
The results of VFS study were discussed with the Secondly, pongal was given and it was observed that the
patient and the treatment was planned based on the patient was able to have a safe swallow without multiple
same. The therapeutic manoeuvres were modified to swallow trials and residue/ pooling.
benefit the patient’s recovery. The following exercises
Based on the evaluation, the patient was asked
and manoeuvres were taught to the patient, each of them
to continue the swallowing manoeuvres and also
having rationale behind it.
accommodate semi-solid and puree (rice/pongal and
1. Shaker’s manoeuver was carried out to facilitate curd) to the diet by oral intake in smaller proportions for
relaxation of the criocopharyngeus muscle. It also breakfast. He was advised to slowly increase the portion
helps in increasing its flexibility and improving in of the food for intake every week. From only breakfast,
strength. the patient began oral feeds for lunch. Liquids were also
advised to be included in the diet by oral intake. In the
2. Masako manoeuver was prescribed to strengthen following weeks, the patient could take semi solid, puree,
the pharyngeal muscles. and liquids. Until then he was advised to use NG tube for
3. Mendelsohn’s manoeuvre was prescribed to medicines. He was then asked to start taking medication
facilitate hyolaryngeal elevation. orally after discussing with the primary physician. The
patient showed improvements in therapy and started
4. Pitch glide to facilitate pharyngeal movement. to intake his food orally everyday (which include his
5. Effortful Swallow helps in increasing the posterior breakfast, lunch, dinner, hydration and medication). The
movement of the tongue. This manoeuvre is to Nasogastric tube was removed on July 31, 2017after
overcome the pooling in the valleculae. careful assessment of SLP and Neurologist.
6. Supraglottic swallow was done due to aspiration

Discussion
during swallowing. Voluntary holding of breath
adducts the vocal cords, hence gaining control Dysphagia is seen in both acute ischemic and
over aspiration before and during swallowing. haemorrhagic strokes. The occurrence of dysphagia
varies depending on time of evaluation, and the possible only after assessing swallowing physiology
measures used. It is estimated that 37 to 78% of using visualisation technique. Speech-Language
stroke patients encounter dysphagia [1,2].Aspiration Pathologists play an important role in rehabilitation of
pneumonia is a common threat to medical, allied health dysphagia. Videofluroscopic swallow study also helps
professionals and patients post stroke. This can cause in decision making on nasogastric tube removal and
greater morbidity, mortality, and increased hospital initiating safe oral feeds after rehabilitation.
stay [3,4]. Dysphagia screening protocols are clinically
used to detect dysphagia and aspiration at bedside [5,6].
Although this conveys the information of a patient
at risk of aspiration, these bedside evaluations fails to
provide information on silent aspiration, swallow transit
time, pooling in valleculae and pyriform sinus etc.
These information are important for a Speech Language
Pathologist (SLP) to modify the treatment manoeuvers
to facilitate safe swallow.
A good visualisation technique provides this

Figure 1: Lateral view demonstrating signs of
information to SLPs who work in the field of swallowing dysphagia
disorders. VFS is a commonly used instrumental
evaluation of swallow among oropharyngeal dysphagia Figure 1 demonstrates the presence of aspiration,
patients. This provide details on the nature and severity pooling in valleculae and pyriform sinus.
of swallowing difficulty and deliver baseline of
dysphagia therapy[7] .Several manoeuvers, exercises
and stimulation are provided to patients to modify
physiology of swallowing in individuals with dysphagia.
Manoeuvers like Mendelsohn’s, Shaker’s, Masako and
facilitatory approaches like head tilt/ head turn during
swallow, suraglottic swallow are carefully selected
based on the swallowing physiology. Hence the study
aims to document the role of VFS in the management of
dysphagia by tailoring the manoeuvres and exercises to
the need of the patient to facilitate safe swallow.
Figure 2(a) Anteroposterior view
Management of Dysphagia is a ‘Team Event’
including many professionals contributing in the
treatment of the given patient [8] .Speech Language
Pathologists play a central role in assessment and
management of dysphagia with the help of visualisation
techniques like VFS. Modification of therapeutic
manoeuvres demonstrate good prognosis and safe
swallow among individuals with dysphagia. For over
three decades VFS is considered gold – standard in the
assessment of dysphagia. Considering the limitation
like portability and vitals of patient, one may use this
instrument for dysphagia assessment on individuals who Figure 2(b) Lateral view
are medically stable and mobile [9] .
Teaching point: Videofluroscopic swallow study has Figure 2 a and b confirms the findings of no
showed to be efficient and could be incorporated in aspiration, no pooling in valleculae and pyriform sinus,
rehabilitation of dysphagia. Modification of therapy is no oral or pharyngeal residue.
Table 1: Result of VFS evaluation of swallow (Pre- Conflict of Interest: The authors have no conflict of
therapy) interest in this publication.
Parameters of Swallowing
Declaration: This article has not been published in any
Lip Closure Present journal. This was carried out as a part of student clinical
Oral propulsion of bolus Present case presentation. This study did not receive funding
from any agencies.
Velum closure (Posterior Pharyngeal
Inadequate
Walls)
Lid action of References
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DOI Number: 10.5958/0976-5506.2018.00628.9
System Modeling for Forecasting of Diabetes Prevalence
Vinaytosh Mishra1, Cherian Samuel2, S K Sharma3

1
Research Scholar, 2Assistant Professor, 3Professor, Industrial Management Department of Mechanical
Engineering Indian Institute of Technology (BHU), Varanasi, INDIA
Abstract
The computer simulation models can help understanding the progression of a chronic disease like diabetes.
These models allow researchers and decision makers to forecast disease progression and resource required for
managing it. The simulation tools presently used for planning and evaluating the health policy are inadequate
for capturing the dynamic complexity of chronic disease involving the large delays between causes and
health consequences. The paper develops and uses system dynamics for diabetes system modeling. The
system dynamics approach is able to address the complexity of the chronic disease like diabetes. The study
further forecasts the prevalence of diabetes by the year 2030, using the case of an ancient city of Varanasi.
Keywords: Chronic Disease Modeling, System Dynamics, Healthcare, Diabetes Prevalence
INTRODUCTION below summarizes the result of INDIAB study Phase-I

completed in the year 201113.
Diabetes is rising as an epidemic in many parts of
the world. The rate of growth of diabetes has earned a Table 1: Prevalence of Diabetes in Year 2011
tag of world’s diabetes capital of India. In the year 2014,
there were 387 million individuals with diabetes, and this Region Prevalence Confidence Interval
number is estimated to become 592 million by 20351. The Tamil Nadu 10.4% (95% CI: 9.0-11.0%)
major reasons for this increasing prevalence of diabetes Jharkhand 5.3% (95% CI: 4.5-6.1%)
are a sedentary lifestyle, increased urbanization and
increased life expectancy. The South Asian population is Chandigarh 13.6% (95% CI: 12.8- 15.2%)
genetically at high risk of developing diabetes2-3. Multiple Maharashtra 8.4% (95% CI: 7.5-9.3%)
complications like retinopathy, nephropathy, neuropathy,
cardiac risk and diabetes foot occur with the progression Source: ICMR–INDIAB study (2011)
of the disease. The cost of diabetes management The second phase of the INDIAB study completed
increases many folds with multiple complications4. The in July 2013 is more comprehensive and includes fifteen
close monitoring and awareness are critical in diabetes states of the country. The overall prevalence of diabetes
management. For planning a prevention program, we
in all 15 states of India was estimated as 7·3% (95% CI
need to forecast the resource requirement. The tools like
7·0–7·5). The Figure 1 below suggests that state with
system dynamic can help in predication and capacity
higher GDP has a higher prevalence of diabetes. The data
planning for diabetes management.
below made us believe that the prevalence of diabetes is
Diabetes Mellitus: Diabetes mellitus (DM), commonly dependent on the economic growth of the region14.
known to as diabetes, is a group of metabolic disorders
in which there is a persistent increased level of glucose
in the blood. It is a chronic disease that occurs either
when the pancreas does not produce enough insulin
or when the body cannot effectively use the insulin it
produces. The prevalence of diabetes in India ranges
from 5–17%, with a higher percentage, is reported in the
southern part of the country and in urban areas5-12 .As
per INDIAB study done by Indian Council of Medical
Research diabetes, the northern regions report a higher Figure 1: Prevalence of diabetes and GDP per capita
prevalence of diabetes than southern regions. The table by state
The National Urban Survey conducted across the and natural for addressing the dynamic complexity of
metropolitan cities of India reported similar trend: health care system.
11.7 per cent in Kolkata (Eastern India), 6.1 per cent in
Kashmir Valley (Northern India), 11.6 per cent in New The researchers have used System Dynamics model
Delhi (Northern India), and 9.3 per cent in West India for developing tools for chronic disease prevention
(Mumbai) compared with (13.5 per cent in Chennai and control. The research adopts the diabetes and
(South India), 16.6 per cent in Hyderabad (south India), Prediabetes stock and flow model developed by Homer
and 12.4 per cent Bangalore (South India)15. et al for development of model for predicting the state
of diabetes in Varanasi by year 2030. A focus group of
There have been researchs to predict the prevalence eight experts (clinicians and researcher) was constituted
of diabetes in a different part of the country, but there for the estimation of parameters and system components.
is lack of any comprehensive study to measure the The size of eight participants is appropriate for the study
prevalence of diabetes in Varanasi and surrounding as a group with higher than eight members, is hard to
areas. The government and healthcare providers still use handle18.
conventional methods of evaluating and managing each
aspect of the disease separately. The tools presently used Model Structure: The suggested in studies group
are diagrammatic logic models and epidemiological strived to achieve a diabetes system models having19 :
forecasting models. These tools are not capable of 1.Generic enough to be adaptable for another chronic
addressing the dynamic complexity of diabetes. The silo disease.
approach to management is not appropriate for managing
2. Realistic enough to reproduce the historical data
the disease involving a long delay between causes
derived from other epidemiological studies.
and the health events. It is time to adopt an integrated
system-wide approach in prevention and management of 3. Comprehensible enough to test various policy
diabetes. This paper attempts to address this gap. scenarios.
4. Broad enough to include various policy measures
METHOD considered during the third meeting.
The method used in this research is computer 5. Doesn’t require guess work beyond what focus
simulation method known as System Dynamics. The group agrees upon.
simulation is a method that allows experiment on the
The study adopts a model (Homer et al, 2004) as
system through a computer based model of the system16.
described in Figure 2 as preliminary stock and flow
System dynamics model has unique ability to mimic
model after various iteration of the focus group we were
the real world scenario. It can address the complexity,
able to finalize the customized stock and flow model for
nonlinearity, and feedback loop structure attached to the
the population being studied19. (Undx: undiagnosed; Dx:
healthcare system17. The system dynamics (SD) model is
diagnosed; PreD: prediabetes; D: diabetes)
used for the study because it is simple, powerful, useful
Figure 2: Preliminary Diabetes and Prediabetes Population Stock and Flow Structure
The system can be divided into two parts namely 4. Add DT to simulation time.
upstream (prevention related variables) and downstream 5. Stop iterating when Time >= StopTime
(treatment related variables).Using the secondary
research and input of the Focus Group the parameter The year 2017 is taken as year Zero and the step size
values and initialization values very estimated. The used is a year. The numerical integration method used for
proposed system dynamics model uses availability & the model is Euler Method. The reason for selecting the
affordability of preventive care, testing of diabetes and method is its simplicity and availability as inbuilt option
prediabetes, availability of qualified doctors and support in the Vensim tool. The Euler Method uses following
staffs, availability of hospitals, health insurance and steps in processes of calculating the value of stock:
government subsidies as the policy variables. The model
D Stock = DT × Flow at begining at DT
uses following steps in the process:
Stockt = Stock(t − DT) + DStock
Initialization Phase:
1. Create a list of all equations in required order of Stockt = Stock(t − DT) + DT × Flow(t − DT)
evaluation.
Please refer exhibit 1 for the final system dynamics
2. Calculate initial values for all stocks, flows and model for prediction of prevalence of diabetes.
auxiliaries (in order of evaluation).
Iteration Phase: RESULTS

1. Estimate the change in stocks over the interval DT The parameters for the model developed were
(Step size). estimated and the system was tested whether it mimics
2. Calculate new values for stocks based on this the other reliable studies. The validation was done using
estimate. the information collected through secondary research.
3. Use new values of stocks to calculate new values The results of the study are summarized in Table-2
for flows and auxiliaries. below.
Table 2: Results of the Simulation Run
Undx Uncomplic Dx Uncomplic Undx Complic Dx Complic diab

Year Total
diab popn diab popn diab popn popn
2017 50000 50000 25000 25000 152017
2022 85014 166727 20594.4 109643 384000.4
2027 63585.4 219735 16302 204169 505818.4
2030 52985.7 215808 13565.6 235190 519579.3
2032 46904.2 206247 12015 244921 512119.2
2037 34335.3 172042 8816.56 240683 457913.9
2042 24953.1 135325 6415.86 212248 380984
2047 18073.6 102965 4649.84 175220 302955.4
2050 14881.1 86515.6 3829.26 152854 260130
The prevalence of complicated and uncomplicated we will need 520 doctors as well as beds for diabetic
diabetes by year 2030 with be 0.52 million in Varanasi. population alone. Moreover, this infrastructure is needs
At present growth rate (1.19%) the population of to be specialized in diabetes care to provide health care
Varanasi will be 1.46 million by years 2030. This data effectively. As depicted in Figure 3, the prevalence of
gives us the prevalence of diabetes by years 2030 at diabetes in Varanasi will increase and peak by year 2030
35.64 %., which is very alarming. To achieve the doctor and will decrease thereafter.
patient ratio of 1:1000 and bed patient ratio of 1:1000,
Figure 3: Prevalence of Diabetes in Varanasi
Exhibit 1: System Dynamics Model for Prediction of Diabetes Prevalence
CONCLUSION of diabetes at national and regional level. Though the

simulation is done for the city under study, the model
The model described in this paper can help policy can be easily tuned to get a picture at national level. The
makers design strategies for addressing the burden simulation model gives prevalence of diabetes in years
2030 as 0.52 million and 35.64 %. The study suggests tolerance, pre-diabetes, and type 2 diabetes in a rural
involving 520 specialized doctors in management of community of south India: a cross-sectional study.
diabetes. Assuming fifty beds per hospital, the city will Diabetology & metabolic syndrome, 8(1), p.21.
need opening additional nine district level hospitals
(presently two) to support this surge of diabetes cases. 7. Ramachandran, A., Snehalatha, C., Kapur,
The same infrastructure can be utilized for proving the A., Vijay, V., Mohan, V., Das, A.K., Rao, P.V.,
healthcare for other disease as well. Yajnik, C.S., Kumar, K.P., Nair, J.D. and Diabetes
Epidemiology Study Group in India (DESI, 2001.
Ethical Clearance: The study use secondary research
High prevalence of diabetes and impaired glucose
and focus group discussion for data collection. Since, the
tolerance in India: National Urban Diabetes
study uses the data freely available in public domain it
Survey. Diabetologia, 44(9), pp.1094-1101.
don’t need ethical clearance.
8. Barik, A., Mazumdar, S., Chowdhury, A. and Rai,
Source of Funding: Self, there is not any source of R.K., 2016. Physiological and behavioral risk factors
funding to be declared. of type 2 diabetes mellitus in rural India. BMJ Open
Conflict of Interest: Nil, there is not any conflict of Diabetes Research and Care, 4(1), p.p255.
interest to be declared. 9. Ajay, V.S., Prabhakaran, D., Jeemon, P.,
Thankappan, K.R., Mohan, V., Ramakrishnan,
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DOI Number: 10.5958/0976-5506.2018.00629.0
Knowledge, Arv Access and Compliance of Plhiv before and

after Providing Health Education Based on Community Arv
and Adherence Support Group (Caasg) in Bulukumba Regency
Andi Suswani1, AA Arsunan2, Ridwan Amiruddin2, Andi Zulkifli2, S. Ariyanti3

1
Student Doctoral Program Faculty of Public Health UNHAS Makassar, 1Lecturer at High School of
Health Sciences Panrita Husada Bulukumba; 2Professor of Epidemiology Faculty of Public Health
UNHAS Makassar; 3Senior lecturer at Faculty of Nursing UNHAS Makassar
ABSTRACT
HIV and AIDS is a global and very complex disease which in handling the need for active health education
involving People living with HIV (PLHIV). Knowledge, access to ARVs and adherence are very important
factor in maintaining the quality of PLHIV. This study aimed to analyze differences in knowledge, access
to ARVs and adherence before and after the provision of health education interventions based on ARV and
adherence Support Group (CAASG) in existing PLHIV in Bulukumba.
The study design was Quasi Experiment using pre-test and post-test with Control Group Design. The study
group was divided into 2 (two) groups consisting of group I and group II. The group I was given a health
education through lectures and modules, while the group II was given a health education with a leaflet. The
number of samples were 42 respondents consisting of group I with the sample counted 24 people and the
group II with the number of samples were 18 people.
Based on Cochrane test results showed that there are differences of knowledge in treatment groups 1&2 (p1=
0.004, p2= 0.026), difference of ARV access (p = 0.004) and difference of adherence in group 1 and 2 (p1=
0.001, p2= 0.015) and no significant difference in group II for ARV access
It is suggested to maintain the group that has been formed in order to increase knowledge, experience no
barriers to accessing ARVs and have and maintain compliance with the treatment to obtain a better quality
of life for PLHIV in Bulukumba.
Keywords: Health education, HIV and AIDS, knowledge, ARV access, adherence
INTRODUCTION HIV virus reached 0.5 / 1000 uninfected populations, the

highest compared to Myanmar, Malaysia and Vietnam
HIV and AIDS are major health problems and
which only reached 0.3/1000 population3,5.
become one of the world’s most serious health
challenges, to date there are currently about 36.9 million The second largest province of HIV, after Papua
people living with HIV (PLHIV) in the world, 17.1 in eastern part Indonesia, is South Sulawesi6 and
million are unaware of the presence of HIV virus in the Bulukumba is one of the districts in South Sulawesi,
body they needed HIV testing services, 22 million did which ranks third in HIV and AIDS after Makassar and
not get access to antiretroviral treatment including 1.8 Pare -Pare which have number of HIV and AIDS sufferer
million children1-3. In 2030, deaths due to HIV and AIDS
as many as 188 people with the highest percentage in
continue to increase4.
man that is equal to 110 people (60,6%), in woman
Sub-Saharan Africa is the largest contributor to HIV counted 68 (37%) and transvestite counted 4 people
(71%), Asia Pacific (14%). In the Southeast Asian region, (2,42%) with factor the highest risk of transmission in
Indonesian adults aged 15-49 years who contracted the heterosexuals (58.7%), IDU’s (37.1%) and pregnancy/
breast milk (4.19%) with the highest number of cases diploma in the treatment group II. Respondents mostly
in Ujung Bulu sub-district as many as 93 cases (51%) worked with percentages with 20 persons (83.3 %) in
and the lowest in Herlang sub-district (2%). One form the treatment group I and 16 (88.9%) in the 2nd treatment
of prevention in a national strategy undertaken in key group, with the highest married status with unmarried
category as big as 11 people (45.8%) in the treatment
populations is behavioral change interventions7. The
group I and 13 people (72.2%) in the treatment group II.
process of changing one’s behavior can be achieved
The largest mode of transmission through heterosexuals
through health education8,9.
by percentage 45.8 % in group I and 61.1% in group II,
Health education is a process of change in oneself and most had public insurance with 87.5% percentage in
where the process of change that influences one’s group I and 88.9% in group II.
behavior includes the components of knowledge, Table 1: The characteristic of participant in
attitudes, or practices related to the purpose of healthy Bulukumba Regency
life both individually, group and society8,9. The purpose
of this research is to know the effect of health education Characteristic Group I % Group II %
based on Community ARV and Adherence Support Sex
Group to knowledge, access of ARV and medication Male 17 70.8 11 61.1
compliance to PLHIV in Bulukumba in 2016. Female 7 29.2 7 38.9
Age Group
MATERIAL AND METHOD Adolescent 4 16.7 2 11.1
Adult 17 70.8 16 88.9
The study design was Quasi Experiment using
pre-test and post-test with Control Group Design. The Elderly 3 12.5 0 0
study group was divided into two groups consisting of Education
treatment group I and treatment group II. Treatment High 2 20 8 80
group I was given health education through lectures Low 22 68.8 10 31.3
and modules, while the treatment group I l given health Occupation
education leaflets. This research was conducted in Ujung Occupied 20 83.3 16 88.9
Bulu Subdistrict. The population of the study were all Non-occupied 4 16.7 2 11.1
PLHIV in Bulukumba Regency were 189 people. The Marriage status
sample chosen using purposive sampling technique
Single 11 45.8 13 54.2
and collected as many as 42 PLHIV. Univariate data
Married 8 72.7 3 27.3
processing analyzed and presented in the form of a
Divorced 5 71.4 2 28.6
frequency distribution table, using a bivariate test
Mode of transmission
Cochran test and Mc-Nemar.
Heterosexual 11 45.8 11 61.1
RESULTS IDU 7 29.2 5 27.8
LSL 6 25 2 11.1
Characteristic of PLHIV Respondents: Based on Assurance
Table 1, it can be seen that most respondents are in the
Yes 21 87.5 16 88,9
adult age group with the number of 17 people (70.8%) in
No 3 12.5 2 11.1
the group I and 16 people (88.9%) in group II, with the
Total 24 100 18 100
highest percentage of male sex with the number of 17
people (70.8 %) in the treatment group I and 11people Distribution of knowledge changes, ARV access,
(61.1%) in the second treatment group), with the most and PLHIV compliance before and after the provision
senior secondary education being 1 to 3 people (54.2 of community-based ARV & Adherence Support Group
%) in the treatment group I and 7 (38.9%) with nursing health education in each group.
Table 2: The changes of knowledge between intervention groups

KNOWLEDGE
Groups Pre-Test Post-Test I Post-Test II Post-Test III p
High % Low % High % Low % High % Low % High % Low %
Group I 12 50 12 50 14 58.3 10 41.7 15 62.5 9 37.5 20 83.3 4 16.7 0.004
Group II 8 44.4 10 55.6 10 55.6 8 44.4 12 66.7 6 33.3 14 77.8 4 22.2 0.026
Total 20 47.6 22 52.4 24 57.1 18 42.9 27 64.3 15 35.7 34 81 8 19
p = Cochran test
Table 3: The changes of ARC access of PLHIV between intervention groups

ARV ACCESS
Group Pre-Test Post-Test I Post-Test II Post-Test III p
Group I 11 45.8 13 54.2 13 54.2 11 45.8 16 66.7 8 33.3 20 83.3 4 16.7 0.004
Group II 11 61.1 7 38.9 12 66.7 6 33.3 11 61.1 7 38.9 14 77.8 4 22.2 0.261
Total 20 47.6 22 52.4 24 57.1 18 42.9 27 64.3 15 35.7 34 81 8 19
p = Cochran test
Table 4: The changes of compliance of PLHIV between intervention groups
COMPLIANCE
Group Pre-Test Post-Test I Post-Test II Post-Test III p
Group I 7 29.2 17 70.8 14 58.3 10 41.7 13 54.2 11 45.8 18 75 6 25 0.001
Group II 7 38.9 11 61.1 12 66.7 6 33.3 12 66.7 6 33.3 15 83.3 3 16.7 0.015
Total 20 47.6 22 52.4 24 57.1 18 42.9 27 64.3 15 35.7 34 81 8 19
p = Cochran test
Tables 2, 3 and 4 show the test results of Cochran Table 5: The result of Mc-Nemar test from the first
the treatment groups 1 and 2 show the significance of to the 3rd measurement
the knowledge variables (p1 = 0.001, p2= 0.026), the
ARV access variables in the treatment group 1 (p =
Assessment n p
0.004), the adherence variable in the treatment group
1 and 2 (p1= 0.001, p2= 0.015) which means there is Knowledge (baseline) & Knowledge
24 0.625
(post 1)
at least a difference in the level of knowledge, access
to antiretroviral drugs and adherence before and after a Knowledge (baseline) & Knowledge
24 0.25
CAASG-based health education and group support. In (post 2)
the second treatment group showed the significance of Knowledge (baseline) & Knowledge
24 0.008
the variable of ARV access (p = 0.261), which means (post 3)
there was no difference in ARV access before and after Knowledge (post 1) & Knowledge
24 1.000
health education. (post 2)
Knowledge (post 1) & Knowledge
The post hoc analysis test is conducted to find out 24 0.07
(post 3)
which measurement differs regarding the knowledge.
Knowledge (post 2) & Knowledge
Post hoc analysis is done by using Mc-Nemar test. The 24 0.125
post 3)
following table will illustrate the measurement of the
difference in knowledge. Access (baseline) & Access (post 1) 24 0.5
Conted… education using modules can facilitate the reception of

Access (baseline) & Access (post 2) 24 0.63 public health messages8.
Access (baseline) & Access (post 3) 24 0.022
A research showed that after being given a health
Access (post 1) & Access (post 2) 24 0.25 education using learning aids booklets and posters,
Access (post 1) & Access (post 3) 24 0.065 the knowledge and attitude of the intervention group
Access (post 2) & Access (post 3) 24 0.289 increased significantly compared to the control group12.
Compliance (baseline) & Compliance
24 0.016 Learning aids are used on the principle that the
(post 1)
Compliance (baseline) & Compliance knowledge that is present in every human being is
24 0.31 accepted or captured through the five senses. The more
(post 2)
Compliance (baseline) & Compliance senses used to receive something the more and more
24 0.001 clearly the understanding or increase of knowledge
(post 3)
Compliance (post 1) & Compliance obtained, thus the use of learning aids is intended to
24 1.000 exert the senses as much as possible on an object so as to
(post 2)
Compliance (post 1) & Compliance facilitate understanding8.
24 0.219
(post 3)
Access in this study include physical access
Compliance (post 2) & Compliance (distance from home to the health service, the travel
24 0.125
(post 3)
time from home to health care, the cost to get access
p = Mc-Nemar test to antiretroviral services) access to psychological
(shame be shunned from society and have problems in
Based on table 5 it can be seen that differences in communicating with health care providers). Based on
knowledge, access to ARV and adherence are found in information from health personnel who served in the
the measurement between initial measurements and post VCT clinic, Sultan Daeng Radja Hospital in Bulukumba
t measurements 3, where the number of significance stated that the number of PLHIVs in the hospital were
shown in the knowledge variables (p = 0.008), ARV only 13 people, when compared with the number of
access variables (p = 0.022), (p= 0.001). PLHIV based on data from the District Health Office
Bulukumba are 188 people. It means only about 6.91%
DISCUSSION who perform treatment at Bulukumba Hospital which is
the only health facility that provides ARV drugs.
The provision of health education by using a
module for 3 months in the treatment group can increase Some studies suggest that the distance to be a
the knowledge of PLHIV continuously. The results of predictor of LTFU incidence that affects ARV access is
research supported by the theory suggested that the more than 5 km distance from home to health service
longer the information is retained in short-term memory and travel time ≥ 1 hour to place of ARV services. It is
with the help of repetition, the more likely it is to enter likely that people living far from health facilities have
long-term memory, thus becoming more permanent less access to health care. Patients with close proximity
relative. Knowledge will be stored long in memory. So, it to health facilities have a smaller LTFU risk13.
needs an effective repetitive learning method to suppress
The results in Table 4 showed that the proportion
the decrease of one’s knowledge, which is aided by user
of adherence of ODHA in treatment in the group I
of media10.
experienced an increase of 45.8%, while in the group II
The use of media / learning aids such as leaflets increased by 33.3% since the initial measurement until
and modules in the implementation of health education the final measurement, this indicates that the compliance
is expected to increase the attention of PLHIV. This of the treatment group I is greater than the group II.
is supported by Bullet theory which states that the
The results of this study are supported by research
effectiveness of messages using the media can directly
conducted in Mozambique where participant who did not
affect the intended target11, which is in line with the
become a community CASG (ARV Community Support
theory which says that the use of learning media in health
Group) has LTFU higher levels (p=0.04) compared with Sources of Funding: Nil
participants who are members of CASG. The CASG is
an effective strategy for reducing LTFU and improving Conflict of Interest: No conflict of interest in this study
adherence in supporting ART programs14. In line with
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DOI Number: 10.5958/0976-5506.2018.00630.7
Obesity and Pulmonary Functions in Young Non Smoker Male

of Shah Alam, Malaysia
Aniruddha Bhattacharjee1, Ariitharan A/L Thygoo1, S. Rammohan2
1
Department of Physiology, 2Department of Pharmacology, International Medical School, Management &
Science University (MSU), Malaysia
Abstract
Background: The prevalence of overweight and obesity among Malaysian adults has increased due
to their sedentary lifestyle and unhealthy food habits. Other than cardiovascular and metabolic diseases,
obesity is also associated with respiratory impairments. Studies on pulmonary function in relation to obesity
are very few in Malaysia
Aim: To evaluate the effect of obesity on dynamic lung function parameters and to identify the association
of both relative and abdominal obesity indicators with dynamic pulmonary function measurements among
young male non smoker healthy university students of shah alam, Malaysia.
Materials and Method: A Cross-sectional comparative study was conducted in a total of 100 (50 obese and
50 non obese control) adult non-smoker healthy male students aged 18-25 years. Forced vital capacity (FVC),
forced expiratory volume in 1 sec (FEV1), FEV1 as a percentage of FVC (FEV1/FVC%), maximum mid
expiratory flow rate (FEF25-75%) and peak expiratory flow rate (PEFR) were measured using a computerized
spirometer. Body weight, height, waist circumference (WC) and hip circumference (HC) were measured.
Results: All dynamic pulmonary function measurements were significantly lower in obese subjects than non
obese except FVC. Body weight, waist circumference (WC) and waist hip ratio (WHR) exhibited highly
significant (P<0.001) inverse correlation with all pulmonary function measurements except FEF25-75%.
However, BMI, body height had no significant correlation with any spirometric variables .
Conclusion: Obesity has adverse effect on dynamic lung function parameters and central obesity has more
impact on impairment of pulmonary functions than overall relative obesity.
Keywords: Obesity, Pulmonary function test, Body Mass Index (BMI), Waist circumference, Waist hip ratio.
Introduction 18 years and above has increased from 29.4% and 15.1%
in 20113 to 30.0% and 17.7% in 20154. Major respiratory
Over weight and obesity is one of the major complications due to obesity are lowering of respiratory
global healthcare problem1 including Malaysia. In muscle endurance, chest wall compliance and elevated
both developed and developing countries, incidence of work of breathing. Pulmonary function parameters
obesity is increasing in adults2. The sedentary lifestyle are influenced by both relative obesity and body fat
and unhealthy diet of Malaysian university students distribution. Body mass index (BMI) is a measure of
have become important contributing factors to the rise relative adipocity, whereas waist circumference (WC)
of obesity. Based on the report of National Health and and waist hip ratio (WHR) is considered as a measure
Morbidity Surveys (NHMSs) in 2015, the prevalence of of central obesity. Central adiposity may be associated
overweight and obesity among Malaysian adults aged with a modest impairment of lung volumes such as
FVC, FEV1 and TLC in normal and mildly obese men 5.
Corresponding Author: Studies have shown that both obesity itself and pattern
Dr Aniruddha Bhattacharjee of body fat distribution has an independent effect on
Department of Physiology, International Medical School, ventilatory functions6. Most of the previous studies on
Management & Science University (MSU), Malaysia pulmonary function impairment in relation to obesity
Email: [email protected] have used BMI as obesity indicator7.8.However, the
abdominal obesity markers are better predictor of Anthropometric measurement: The body weight
pulmonary function than BMI9. Studies on pulmonary was measured by using a balanced beam scale with an
function in relation to obesity are very few in Malaysia accuracy of ±0.1 kg with the subject wearing minimum
and it is important to evaluate the effect of obesity clothing whereas body height was measured with the
on ventilatory impairment in Malaysian young adult measuring rod attached to the balanced beam with
university student due to their unhealthy food habit and an accuracy of ± 0.50 cm. Waist circumference was
sedentary lifestyle. Therefore, the present study was measured as the smallest circumference between the
aimed to evaluate the effect of obesity on dynamic lung ribs and the iliac crest to the nearest 0.1 cm, while the
function parameters as well as to identify the association participant was standing with the abdomen relaxed, at
of both relative and abdominal obesity indicators with the end of normal expiration. Hip circumference was
dynamic pulmonary function parameters among young recorded as the maximum circumference between the
male university students of shah alam, Malaysia. We iliac crest and the pubic symphysis. Waist hip ratio
hypothesized that upper body fat is a better predictor of (WHR) was calculated by dividing waist circumference
by hip circumference.
reduced pulmonary function than total body adiposity.
Dynamic pulmonary function measurements: The
Materials and Method dynamic pulmonary functions were recorded using a
computerized spirometer. The spirometer was calibrated
Study design: This cross-sectional study was conducted
daily using calibration syringe of 2 liters. The parameters
in the Human Physiology Laboratory of international
measured were FVC, FEV1, FEV1/FVC%, FEF25-75%
medical school, Management and Science University,
Shah alam, Malaysia. and PEFR. All the measurements were conducted in
standing posture with nose clipped 12. These tests were
Selection of subjects: A total of 100 (50 obese and 50 recorded at noon before lunch, as expiratory flow rates
non obese) non-smoking healthy young male subjects are highest at noon 13. Three satisfactory efforts were
were randomly selected from the a student population recorded for each volunteer with at least 5 min rest
of the management and Science University, Shah alam between the consecutive trials as per the standard norm14.
Campus, Malaysia. The study population belonged to
All the anthropometric measurements and recording of
the age group of 18-25 years and with similar socio-
pulmonary function measurements were recorded in one
economic background.
sitting on the same day for each subject.
Body mass index (BMI) was greater than 30 kg/m2
was defined as obese10. A total of 50 such obese male Statistical analysis: Student’s t test and Pearson’s
were identified. An identical number of age-matched product moment correlation (r) was adopted. The level
non-obese with BMI between 18.50 - 24.99 kg/m2 were of significance was set at P<0.01.
taken as control group.
Each subject filled up one questionnaire11 to Results

record their personal demographic data, health status
Table1 compares the demographic and
and consent to participate in the study. Subjects with
symptoms or history of pulmonary diseases , anxious, anthropometric variables of the obese and control groups.
apprehensive, doing regular exercise were excluded The mean BMI ,body weight, waist circumference
from the study. The experimental protocol was explained of the obese students were significantly (p<0.001)
to all the participants. Each subject signed the written higher compared to control group with same age . The
informed consent form. comparison of dynamic
Table 1: Physical and anthropometric characteristics of obese and non-obese.
Obese (n = 50) Non-obese (n = 5 0)

Mean ± SD Mean ± SD p values
Age(Years) 21.2±0.05 21.16 ± 2.17 0.946
Height(cm) 172.16 ± 5.57 173.76 ± 7.83 0.447
Weight ( kg) 92.16 ± 7.18 67.92 ± 5.09 0.000***
Conted…
Body mass index (kg/m2) 31.10 ± 3.74 22.32 ± 2.35 0.000***

Waist circumference (cm) 99.56 ± 6.89 82.08 ± 6.70 0.000***
Waist hip ratio(WHR) 0.80 ± 0.05 0.78 ± 0.15 0.918
***Highly significant P<0.001
pulmonary function parameters of the obese and non obese healthy young male has been depicted in Table 2,
.The mean FEV1/FVC ratio of obese subjects was significantly(p<0.01) lower than non obese control group (Fig2).
The mean FEV1(L), FEF25-75%(L/s) and PEFR(L/s) of obese subjects were much lower than non-obese control group
and the difference was highly significant (p<0.001)(Fig1). However, there was no significant difference in FVC (L)
of obese and non obese subjects.
Table 2: Comparison of dynamic lung function parameters between obese and non-obese.
obese (n = 50) Control (n = 50)

Mean ± SD Mean ± SD P values
FVC(L) 3.25 ± 1.31 3.81 ± 0.78 0.1246
FEV1(L) 2.41 ± 0.73 3.55 ± 0.79 0.0004***
FEV1/FVC (%) 78.62 ± 18.83 91.58 ± 8.36 0.009**
FEF25-75% (L/s) 2.75 ± 1.27 4.29 ± 0.85 0.0002***
PEFR (L/s) 3.52 ± 1.82 6.38 ± 1.59 0.0001***
** Moderately significant P<0.01, ***Highly significant P<0.001
Figure 1: Comparison of dynamic lung function parameters between obese and non-obese (control group)
healthy male of shah alam, Malaysia
Figure 2: Comparison of FEV1/FVC ratio between obese and non-obese (control group) healthy male of
shah alam, Malaysia.
The values of correlation coefficient between different obesity markers and dynamic lung function measurements
have been depicted in Table 3. Based on correlation coefficient values and p values ,body weight ,waist circumference
(WC) and waist hip ratio (WHR) exhibited a highly significant inverse correlation with all pulmonary function
measurements except FEF25-75% . However, BMI and body height had no significant correlation with any spirometric
variables.
Table 3: Correlation of anthropometric obesity indices with pulmonary function measurements in young
healthy male (n = 100) of shah alam, Malaysia (values are correlation coefficient r).
FVC (L) FEV1 (L) FEV1/FVC (%) FEF25-75% (L/s) PEFR (L/s)
Age(yrs) 0.03 0.09 0.04 0.02 -0.03
Weight(kg) -0.37# -0.28* -0.27* -0.09 -0.39
Height(cm) 0.15 0.24 0.09 0.11 0.19
BMI (kg/m²) -0.14 0.17 0.23 0.09 0.15
WC (cm) -0.53# -0.29* -0.37# 0.01 -0.54#
WHR -0.47# -0.41# -0.36# 0.02 -0.52#
# Strongly significant P<0.000, * moderately significant P<0.01
Discussion have direct effects on the pulmonary function, whereas

peripheral obesity would be less likely to have any
Many physiological factors affect lung function. The direct mechanical effect on the lungs. In our study, we
effect of age, gender, ethnicity and smoking status on lung investigated the association between adiposity markers
function has been confirmed 15,16. The effects of obesity with pulmonary function measurements in non-smoker
on spirometric values are not consistent. Some studies healthy young university students. Body weight, waist
showing no effects17,18 and some other studies showing circumference (WC) and waist hip ratio(WHR) exhibited
significant effects 19-21. By this study we tried to evaluate strong significant inverse correlation with all pulmonary
the effect of obesity on different dynamic pulmonary function measurements except FEF25-75%, whereas BMI
functions among Malaysian non smoker healthy adult and body height were not significantly correlated with
university students by comparing lung function of the any pulmonary function parameters , suggesting that
obese to their age matching normal weight control group. central obesity has more impact on the impairment of
Our study showed FEV1(L), FEV1/FVC %, FEF25-75% and dynamic lung function than overall relative obesity.
PEFR of obese subjects were significantly(P< 0.01) lower Our findings support the hypothesis that abdominal
than non obese control group of same age. However, there adiposity markers have better explanatory power than
was no significant (P=0.12) difference in FVC of obese total body adiposity measured as BMI according to the p
and non obese subjects. This may suggest that obesity has value significance and the correlation coefficient values.
an adverse effect on dynamic lung function parameters. Similar findings was observed by Banerjee et al.28 where
Similarly carey et al. 22 showed a reduction in FEV1 but there was no significant association between BMI and
not FVC in obese individual, whereas similar other studies lung function parameters (FVC, FEV1, FEV1/FVC,
23,24
showed a decline in both FEV1 and FVC in obese FEF25-75%) in obese male non-asthmatic subjects in
individuals. This discrepancy between studies regarding India. Our results were consistent with finding by Chen
the effect of obesity on pulmonary function may be et al.29 where WC was inversely associated with FVC
explained by the wide variations in ethnicity of different and FEV1 in both men and women. In our study, we
population in pulmonary function test values or this may found that central obesity markers are better predictor of
be a result of methodological differences in these studies. lung function than BMI, which is supported by a study
Most of the previous studies reported an inverse
30
in western New York where they found that WC was
relation between respiratory function and various a better predictor of pulmonary function than BMI. The
indices of obesity 22,25-27. Central obesity is likely to impairment of pulmonary function by abdominal obesity
may be due to mechanical restrictions of the descent of 1997. WHO Technical Report Series Number
the diaphragm and increase thoracic pressure by thoracic 894. Geneva: WHO; 2000.
and abdominal fat31. Our findings have similarity with
2. Katulanda MA, Jayawardena MH, Sheriff GR &
the findings of Saxena et al.9 where they showed
Constantine DR. Prevalence of overweight and
abdominal adiposity markers such as WHR and WC
obesity in Sri Lankan adults. Obes Rev 2010; 11:
had a strong negative correlation with FEV1. Pouliot et
751-56.
al, also showed that abdominal adiposity markers have
much better explanatory power than total body adiposity 3. Institute for Public Health (IPH) National Health
measured as BMI 32. and Morbidity Survey 2011 (NHMS 2011). Vol.
II: Non-Communicable Diseases. Kuala Lumpur:
Ministry of Health Malaysia; 2011.
Limitations
4. Institute for Public Health (IPH) National Health
There are few limitations in our study. A bigger and Morbidity Survey 2015 (NHMS 2015). Vol.
sample size would have given more concrete evidence. II: Non-Communicable Diseases, Risk Factors &
In our study we have only investigated the dynamic lung Other Health Problems. Kuala Lumpur: Ministry
volumes ,we did not examine static lung volumes. Fat of Health Malaysia; 2015.
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9. Saxena Y, Sidhwani G, Upanyu R. Abdominal
the purpose of improving lung function and therefore
obesity and pulmonary functions in young indian
improving quality of life of obese individuals.
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23. Steele RM, Finucane FM, Griffin SJ, Wareham NJ, best simple anthropometric indexes of abdominal
Ekelund U. Obesity is associated with altered lung visceral adipose tissue accumulation and related
function independently of physical activity and cardiovascular risk in men and women. Am J
fitness. Obesity (Silver Spring) 2009;17(3):578–584. Cardiol 1994; 73: 460–468.
DOI Number: 10.5958/0976-5506.2018.00631.9
Prevalence of Self Medication with Antibiotics among Medical

Students of Barabanki
Ankur Shrivastava1, Nidhi Shrivastava2, Sandhya Mishra3, Pankaj Mishra4, Vijay Kumar Singh5
1
Associate Professor, Department of Community Medicine; 2Assistant Professor, Department of Dentistry;
3
Associate Professor, 4Professor, 5Assistant Professor, Department of Community Medicine, Mayo Institute
of Medical Sciences, Barabanki.
Abstract
Background: Self-medication with antibiotics is becoming a common type of self-care behavior among
the population of many countries. Many international studies have investigated the prevalence and nature of
self medication practices at the population level. In India, some workers have also looked at the population
prevalence of self-medication with antibiotics in general; however the prevalence of self-medication with
antibiotic among medical undergraduates has been studied very less. The interest in studying this practice
among this select group is due to the fact that they are the future prescribers and health educators of the nation.
Aims and Objectives: (1) To estimate the prevalence of self-medication with antibiotics among undergraduate
medical students. (2) To know the factors associated with the practice of self-medication with antibiotics.
Material and Method: The study was a cross-sectional pre-tested questionnaire-based study carried out
among medical students of Mayo Institute of Medical Sciences, Barabanki, Uttar Pradesh, in January 2018.
The information from the returned questionnaire, was entered and analyzed using SPSS Version 16 statistical
software and MS Exel.
Result: A total of 147 medical students participated in the study, 17 questionnaire were found to be
incomplete, hence 130 medical students were the study subjects. Among them majority were males (50.8%),
the prevalence of self – medication with antibiotics came out to be 89.2%.Majority (61%) of the respondents
found self medication was “convenient”. Azithromycin was the most popular (27%) antibiotic for self-
medication, besides amoxicillin (23.4%) and fluoroquinolones (4.6%).
Conclusion: Self-medication with antibiotics is prevalent among medical undergraduates. There is a need
for an intervention to address this practice.
Keywords: Self medication, Antibiotics, Medical Students, questionnaire
INTRODUCTION medical services, especially when these are limited. For

those populations living in rural or remote areas where
Self-medication products are those not requiring a access to medical services may be difficult, patients
medical prescription and which are produced, distributed are able to control their own conditions to a greater
and sold to consumers for use on their own initiative. extent. Only if the condition fails to respond, persists,
Responsible self-medication can be used to prevent and or becomes more severe will the patient need to seek
treat symptoms and ailments that do not need medical professional medical care1.
consultation or oversight. This reduces pressure on
Antibiotics are one of the most prescribed drugs
Corresponding Author: worldwide2. Self-medication with antibiotics is a
Dr Ankur Shrivastava common practice in many countries in the world
Associate Professor, Department of Community Medicine, although the trend seems to be more in developing or
Mayo Institute of Medical Sciences, Barabanki resource-poor nations3.
Other factors have also contributed to prescription Aims and Objectives

drugs being deregulated to over-the-counter (OTC) sale
1. To estimate the prevalence of self-medication
and new drugs with specific pharmacological action have
with antibiotics among undergraduate medical
been successfully reclassified from prescription to non-
students.
prescription status in many countries. For example, in
the United States of America, products containing over 2. To know the factors associated with the practice
80 active ingredients of different therapeutic groups were of self-medication with antibiotics.
switched from prescription-only to OTC status between
1976 and 2000. In many cases, restrictions imposed on Material and Method
reimbursement of prescription drugs have provided the
The study was a cross-sectional study. A pre–designed
impetus for authorities to evaluate and deregulate self-
pre–tested questionnaire based study was carried out
medication products to OTC status1.
among 147 medical students of Mayo Institute of Medical
According to a consumer interview study carried out Sciences, Barabanki, Uttar Pradesh, in January 2018. The
in six Latin American countries, only 34% of dispensed approval of Institutional Ethics Committee was sought
medicines were classified as OTC. It was concluded before commencement of the study.
that a relatively high percentage of drugs were being
A questionnaire was used to assess knowledge,
dispensed without medical prescription or follow-up
attitude and practice of antibiotic usage among 1st year
and this was attributed to lack of access to medical care.
medical students. The students who were present on
Of equal concern is the fact that, in many countries,
the day of data collection, willing to participate were
although OTC medicines are provided with a patient
included in the study and those who were absent,
information leaflet the self-prescriber does not receive
not willing to participate or returned incomplete
any information whatsoever on how to use a prescription
questionnaire within the stipulated time were excluded.
medicine4.
After briefing about the study, the questionnaire was
A study conducted at All India Institute of Medical distributed to 1st year medical students during one of
Sciences, New Delhi observed that self-medication was their Community Medicine classes and was asked to
proportionately high among undergraduate medical and complete the questionnaire anonymously. Verbal consent
paramedical students in India, and it increased with was obtained from the participants, to utilize their data
medical knowledge of the student5. There are many for research purposes. Quality control was maintained
reasons for the increased likelihood of self-medication as per the standard protocol and Confidentiality was
among medical students. These students have easy maintained.
access to information from drug indices, literature, The results were analyzed by using percentage,
and other medical students to self – diagnose and self proportion, and chi-square test, when applicable, with
– medicate. Furthermore, they have easy access to the the help of Microsoft Excel 2007 and Statistical Package
medication itself through physician samples provided by for Social Sciences version 16.0 Statistical Software
pharmaceutical representatives, and “The White Coat” (IBM, Chicago, USA). A P < 0.05 was considered as
guarantees trouble-free access to drugs available in statistically significant for the purpose of this study.
pharmacies6.
The current study will provide suitable data to RESULTS

frame a new curriculum program to acquire and equip Out of 147 first year undergraduate medical students
our students to fight against Antibiotic Resistance. A of Mayo Institute of Medical Sciences, a total of 130
strong foundation is of utmost importance for a durable students participated in the study giving a response rate
construction hence we need to strengthen the base of the of 88.4%. Among them, 50.8% were males (n = 66)
health care system by nipping the problem of resistance and 49.2% were females (n = 64). The mean age of the
in the bud itself. Therefore, the present study was respondents was 19.89 ± 1.41 years. 50.8% (n = 66)
undertaken to assess the existing knowledge, attitude were in 17-19 years age group, 49.2% (n = 64) were in
and practices of first year MBBS students on antibiotics. 20-22 years age group.
The prevalence of Self–Medication with antibiotics

usage among medical students were found to be 89.2% (n =
116) in their lifetime, whereas in last one year 70% (n = 91)
medical students had indulged in self medication. Among
the study subjects 58 (50%) males and 50 (50%) females
were found indulging in self medication. (Table 1).
Table 1: Distribution of participants according to Age,
Sex and History of Self medication with antibiotics.
Self Non–self
Total
Medicated medicated
Figure 3 shows the reasons for self-medication
Age with antibiotics. Majority of the students self-medicated
17–19 years 60 (91%) 06 (09%) 66 (50.8%) because they found it convenient (60%), followed by
20–22 years 56 (87.5%) 08 (12.5%) 64 (49.2%) cost saving (18%), Some used old prescriptions for the
Total 116 (89.2%) 14 (10.8%) 130 same illness as a source for information about the drug
Gender (13%) and 4% students did not had trust in the doctor
Male 58 (88%) 08 (12%) 66 (50.8%)
Majority of respondents purchased the drugs from
Female 58 (90%) 06 (10%) 64 (49.2%) Medical store (86.2%). Other sources of the drugs
Total 116 (89.2%) 14 (10.8%) 130 included left-over drugs from previous prescriptions
(10.4%) followed by community pharmacies (1.7%).
Table 1 shows the distribution of certain characteristics

of undergraduate medical students according to the practice
of self-medication. The prevalence of self-medication
was found to be high among those aged between 17
and 19 years, but this association was not statistically
significant (P > 0.05). Self-medication practice was equal
among males and females, a statistically non-significant
association (P > 0.05).
Figure 1 shows the type of antibiotic that was most Discussion

frequently used for self-medication. Azithromycin was
the most popular (37%) antibiotic for self-medication Self-medication with antibiotics is becoming an
besides amoxicillin (27%) and Ofloxacin (14%). increasingly important area of healthcare, and this study
has shown that it is even more prevalent among medical
students. A major problem with self-medication with
antibiotics is the emergence of drug resistance. It is widely
believed that human malpractices, such as inadequate
dosing, incomplete courses, and indiscriminate drug
use, have contributed to the emergence and spread of
antimicrobial resistance7. An understanding of the level
of antibiotics selfmedication practice, the reasons for such
practices and the awareness about antibiotic resistance is
necessary to take steps for a more rational use of antibiotics.
Figure 2. Depicts the conditions prompting self- The total of 130 students participated in the study out
medication were common cold, cough, and sore throat of a total 147 undergraduate medical students giving a
(60%), fever (20%), and gastrointestinal tract infections response rate of 88.4%. The mean age of the respondents
(10%) followed by skin ailments (08%) and others (02%) was 19.89 ± 1.41 years. Similarly, the mean age of the
respondents was 20.3 ± 1.5 years in a study conducted In our study, the conditions prompting self-
by Kumar et al among medical students in coastal South medication were common cold, cough, and sore throat
India8. In a study on antibiotic self-medication among (60%), fever (20%), and gastrointestinal tract infections
university medical undergraduates in Northern Nigeria (10%) and skin ailments (8%) A similar observation was
by Fadare and Tamuno9, a response rate of 83.2% was found in studies by Kumar et al.8 (58.7%) and Fadare
found and the mean age of all respondents was 23.2 ± and Tamuno9 (34.8%). In contrast, gastrointestinal tract
2.5 years. infections (42.08%) was the most common condition
prompting antibiotic self-medication in the study by
In the present study the prevalence rate of
Olayemi et al.13
self‑medication with antibiotics among medical students
was 89.2%. The results were similar to those reported Majority (60%) of students in our study self-
by other Indian authors from Karnataka (88.18%)10, medicated with antibiotic because they found it to be
Uttar Pradesh (87%)11, and Mangalore (92.7%)8. The Convenient, followed by cost saving (18%), Some
result was also similar to those reported by Azad et students self-medicated because they found it easier to
al.12 in Islamabad (88%). And in Zaria by Olayemi et apply previous prescription (13%).
al13. (80.36%). While only 38.8% of undergraduate
medical students admitted to self-medication practice In other studies, the reasons cited for self-medication
with antibiotics in the study by Fadare and Tamuno9 were somewhat different. Badiger et al.6, Kumar et al8.,
conducted in Northern Nigeria. and Fadare and Tamuno9 in their studies found out the
illness being too trivial to be the most common reason
In our study, equal number of male and females
for self-medication.
students were involved in self-medication with
antibiotics, hence it was not statistically significant (P > Pharmacies were the major source of antibiotics
0.05). Where as in a study done by Kumar et al8, females (51.6%) for self-medication in our study which was
(81.2%) outnumbered males (75.3%) in antibiotics self- supported by other studies also.9, 13
medication.
The study was based on self-reported data about
In our study, the prevalence of self-medication self-medication with antibiotic hence recall bias cannot
was more among those aged between 17 and 19 be ruled out. All the students were encouraged to fill
years(52%), when compared to age group between 20 – the questionnaire independently, but mutual influence
22 years (48%), but this association was not statistically cannot be ruled out. Other limitations of this study
significant (P > 0.05). Where as in the study by Azad et included the absence of a comparative group, such as
al12.,13 self-medication was highest in the age group of students from another field; the small sample size; and
20-25 years as compared to those aged <20 years and the absence of interventions, like providing information
>25 years, but this association was also not statistically regarding hazards of self – medication.
significant (P > 0.05).
Concerning to type of antibiotics commonly used, Conclusion

Azithromycin (a macrolide) was the most popular (37%)
antibiotic for self-medication besides amoxicillin (a This study has shown that self-medication with
penicillin) (27%) and fluoroquinolones/ofloxacin (14%). antibiotics is common among medical undergraduates.
Similarly, Indu et al14,in their study on self-medication There is a need for a review of educational programs
of antibiotics among undergraduate medical students especially the teaching of clinical pharmacology to
of South India, found out that the most commonly used include modules on self- medication and rational use of
antibiotic for self-medication was macrolides (38%) medicines. The students should be educated and made
followed by beta-lactams (25%), fluoroquinolones aware of the dangers and implications of self-medication
(23%), and tinidazole (14%). Whereas in other studies, with antibiotics. Self-medication can facilitate access
by Kumar et al8. (59.6%), Fadare and Tamuno9 (44.10%), to medicines and reduce health care costs. High
Olayemi et al13. (43.11%), and Bala et al15. Penicillin ethical standards should be applied to the provision of
group were the most common class of antibiotics information, promotional practices and advertising.
frequently self-medicated. At the policymaking level, there is an urgent need to
legislate and enforce laws restricting access to antibiotic. 8. Kumar N, Kanchan T, Unnikrishnan B, Rekha
Most importantly, there is a need for a robust public T, Mithra P, Kulkarni V, et al. Perceptions and
enlightenment campaign to educate the populace of the practices of self-medication among medical
disadvantages and possible complications of antibiotic students in coastal South India. PLoS One
self-medication. 2013;8:e72247.
9. Fadare JO, Tamuno I. Antibiotic self-medication
Source of Funding: Self funded.
among university medical undergraduates in
Conflict of Interest: Nil Northern Nigeria. J Public Health Epidemiol
2011;3:217-20.
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J, Binjawadgi AS, Kanaki AR. Self‑medication
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in the community of Khartoum State, Sudan. J. be implemented. Asian J Pharmaceutical Clin Res
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Clinical Pharmacology and Therapeutics, Islamabad Med Dent Coll 2013;2:72-6.
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DOI Number: 10.5958/0976-5506.2018.00632.0
Utility of Dundee Ready Educational Environment Measure

for Evaluation of Nursing Educational Environment in Iraq

School of Nursing, University of Al-Qadysiah, Al- Diwaniyah city, Iraq
ABSTRACT
To appraise reliability of Dundee Ready Educational Environment Measure as a measure for nursing
educational environment and to evaluate students’ perception of educational environment at Al-Qadysia
Nursing School in Iraq. A descriptive cross-sectioinal questionnaire-based study conducted at Al-Qadysia
Nursing School in the 2015/2016 academic year. The Dundee Ready Educational Environment Measure
inventory was administered to 336 undergraduate nursing students. Data were collected from 283 completed
questionnaires and analysed using SPSS version 19.0. Participation rate was 95.3%. The study reporeted
good to high overall internal consistency of Dundee Ready Educational Environment Measure with an
overall mean score of 102.6 out of 200 (51.3%) which indicates unsupportive educational environment. Also,
mean Dundee Ready Educational Environment Measure subscales scores were 23.3 out of 48 (48.54%) for
Students’ Perception of Learning, 22.5 out of 44 (51.14%) for Students’ Perception of Teaching, 17.8 out of
32 (55.63%) for Students’ Academic Sefl-Perception, 23.3 out of 48 (48.54%) for Students’ Perception of
Atmosphere and 15.8 out of 28 (56.43%) for Students’ Social Self-Perception. Dundee Ready Educational
Environment Measure has adequate reliability as an instrument for measurement of nursing educational
environmnet. Also, students perceived educational environment at Al-Qadysia Nursing School seriously
negative and in need of extensive modifications. However, they were somewhat assured about their academic
ability and they have satisfactory social life.
Keywords: Dundee Ready Educational Environment Measure, nursing school, traditional curriculum,
undergraduate students.
INTRODUCTION of supportive, and the regular evaluation of, learning

environment should be a high priority for any health
Although it is considered as an “intangible” concept profession institute5, as it is a critical requirement for
that is beyond description, educational environment is as attaining quality assurance in medical education. For
important for the educational process as the heart is for this purpose, both quantitative and qualitative research
the living body1 and it expresses itself all the time students methods were used6, yet the latter must be valid, reliable
meet whether formally or informally2. In addition, it was and applicable. The most frequently used instrument for
proposed that it includes everything happens during the this purpose is Dundee Ready Educational Environment
course of study2. It covers the institute’s infrastructure, Measure (DREEM)7. It has been developed and validated
student-teacher relationship and availabilty of students at University of Dundee using Delphi technique15.
support system3. Also, it is concerned with psychosocial In addition, it has been translated to more than ten
and emotional well-being of students4. The provision languages and utilised for assessment and comparison of
educational environments at traditional and innovative
health profession institutes worldwide7,8,9. However,
few published studies had employed DREEM for
measurement of nursing educational environment10-14. Al-
School of Nursing, University of Al-Qadysiah,
Qadysia Nursing School (QNS) in Iraq was established
Al- Diwaniyah city, Iraq
in 2012. I have joined the school as pharmacology
Mobile: 009647705982654
lecturer since 2014. The curriculum, teaching methods
and assessment strategies are still conventional. To the direction. The paper-based Arabic version 15 of DREEM
best of my knowledge there is no previous study in the was administered by face-to-face contact with participants
literature that has investigated the qualities of learning near the end of the first semester of the 2015/2016
environmnet in the context of Iraqi nursing education. academic year on different occasions after a lecture
Therefore, current study was aimed at appraising class. Students were informed that their participation is
psychometric properties of DREEM inventory and its voluntary, anonymous and will not affect their academic
utility for evaluation of educational environmnet at an progress. Also, they were told that data they provide are
Iraqi nursing school. confidential and will only be used for research purposes.
In the event of return of filled questionnaire, consent was
MATERIALS AND METHOD implicit. After the negative items were reverse scored,
data from DREEM inventory were entered into Microsoft
A descriptive cross-sectional questionnaire-based Excel spreadsheets and processed using computer-based
study conducted at Al-Qadysia Nursing School (QNS) software, the Statistical Package for Social Sciences
in the 2015/2016 academic year. Agreement of the (SPSS) version 19.0. Descriptive statistics were applied
Institutional Ethical Review Committee was obtained to present percentages and socio demographic data. Data
prior to beginning the study. All male and female nursing from entire inventory, scores for categorized domains and
students (336) across years 2, 3 and 4 of the undergraduate each item were expressed as Mean ± Standard Deviation
programme were targeted in this study. Therefore, no (SD). Comparisons were accomplished using independent
particular sampling method was needed for subjects t-tests while one-way analyses of variance (ANOVA)
selection. Dundee Ready Educational Environment was used for comparisons across the three years of study.
Measure (DREEM) was used for collection of information Cronbach’s alpha coefficient 28 was used to evaluate
regarding educational environmnet. The 50 items within internal consistency of DREEM inventory. Chi-squared
the DREEM are sub-grouped into five subscales related to test was used to explore any possible association between
the concept of educational environment 7. Each individual students’ gender and their response to DREEM assuming
item is scored on a 5-point Likert scale with a score of that there is no such association. Probability values
0, 1, 2, 3, or 4 for strongly disagree, disagree, uncertain, less than 0.05 were considered statistically significant.
agree and strongly agree, respectively 15. However, nine Interpretation of DREEM was performed using the guide
negative items in the DREEM are scored in the opposite proposed by McAleer and co-workers29.
Table 1: Total numbers of students, respondents to DREEM and their gender distribution, in each year of
study at QNS for the 2015/2016 academic year
No. of No. of male No. of female Total No. of

Year of No. of No. of No. of
questionnaires respondents respondents respondents
study students females (%) males (%)
administered (%) (%) (%)
2nd 119 82 (69) 37 (31) 105 26 (24.76) 74 (70.47) 100 (95.2)
3rd
87 52 (60) 35 (40) 77 28 (36.36) 46 (59.74) 74 (96.1)
4 th
130 87 (67) 43 (33) 115 32 (27.84) 77 (66.96) 109 (94.8)
Total 336 221 115 297 86 (28.96) 197 (66.33) 283 (95.29)
Table 2: Cronbach’s alpha for overall DREEM and its five subscales at QNS for the 2015/2016 academic year
Domain Year 2 Year 3 Year 4 All years of study

SPL 0.66 0.53 0.65 0.63
SPT 0.73 0.74 0.73 0.74
SASP 0.65 0.70 0.60 0.64
SPA 0.77 0.75 0.60 0.72
SSSP 0.40 0.37 0.20 0.30
Overall DREEM 0.89 0.89 0.86 0.88
Table 3: Overall and subscales mean DREEM scores at QNSfor the 2015/2016 academic year
3rd year 4th year Overall

2nd year Mean Maximum
DREEM inventory Mean (%) Mean(%) Mean (%) P** value
(%) n = 100 score
n =74 n = 109 n = 283
Students’ perception of
23.05 (48.02) 23.9 (49.79) 23.1 (48.13) 23.3 (48.54) 48 >0.05
learning (SPL)
22.8 (51.82) 24.2 (55.0) 20.9 (47.5) 22.5 (51.14) 44 < 0.05#
teachers (SPT)
Students’ academic self
16.9 (52.81) 17.2 (53.75) 18.9 (59.06) 17.8 (55.63) 32 < 0.05##
perception (SASP)
22.4 (46.67) 22.9 (47.71) 24.4 (50.83) 23.3 (48.54) 48 >0.05
atmosphere (SPA)
Students’ social self
15.7 (56.07) 15.0 (53.57) 16.3 (58.21) 15.8 (56.43) 28 >0.05
perception (SSSP)
102.6
Total DREEM 100.9 (50.45) 103.2 (51.60) 103.6 (51.8) 200 >0.05
(51.30)
Table 4: Overall and subscale mean DREEM scores for male and female students at QNS for the 2015/2016
academic year
Male students Female students Overall Mean Maximum

DREEM inventory P* value
Mean (%) n = 86 Mean (%) n = 197 (%) n = 283 score
23.2 (48.33) 23.4 (48.75) 23.3 (48.54) 48 >0.05
learning (SPL)
21.4 (48.64) 22.9 (52.05) 22.5 (51.14) 44 >0.05
teachers (SPT)
Students’ academic self
17.2 (53.75) 17.9 (55.94) 17.8 (55.63) 32 >0.05
perception (SASP)
23.2 (48.33) 23.3 (48.54) 23.3 (48.54) 48 >0.05
atmosphere (SPA)
Students’ social self
14.9 (53.21) 16.1 (57.50) 15.8 (56.43) 28 <0.05
perception (SSSP)
Total DREEM 99.9 (49.95) 103.7 (51.85) 102.6 (51.3) 200 >0.05
Table 5: Comparison of DREEM overall and subscales scores at QNS and Nursing institutes running
traditional curricula
Overall
SPL/48 SPT/44 SASP/48 SPA/32 SSSP/28
Country DREEM/ 200 Reference
(%) (%) (%) (%) (%)
(%)
Iran 114.3 (57.15) 27.30 (56.88) 24.33 (55.30) 20.31 (63.47) 26.78 (55.79) 15.56 (55.57) 22
Current
Iraq 102.6 (51.3) 23.30 (48.54) 22.50 (51.14) 17.8 (55.63) 23.3 (48.54) 15.8 (56.43)
study
Malaysia 120.12 (60.06) 28.54 (59.46) 28.13 (63.93) 19.42 (60.69) 27.78 (57.88) 16.23 (57.96) 11
Pakistan 131.77 (65.89) 32.61 (67.94) 28.14 (63.95) 23.86 (74.56) 29.61 (61.69) 17.55 (62.68) 20
Philippine 123.41 (61.71) 28.80 (60.0) 27.56 (62.64) 20.88 (65.25) 29.15 (60.73) 17.03 (60.82) 21
RESULTS AND DISCUSSION (Table 5) reported positive students’ views about

teaching and they rated their teachers as being well-
trained. In addition, those students were more confident
Total numbers of students, respondents to DREEM
regarding their abilities to deal with coursework and
and their gender distribution in each year of study at
felt more prepared for the practice of nursing (Table 5).
QNS for the 2015/2016 academic year are shown in
Also, studies conducted in innovative medical institutes
table 1. The high participation rate (95.29%) reported
revealed comparable positive views23. In terms of the
in current strudy could be attributed to anonymous
school’s social climate, the latter was likewise perceived
study and voluntary participation (see Methods section).
by male and female students as being non-motivating
The results revealed good to high internal consistency
and stressful. Nursing students from international
for overall DREEM and acceptable for its subscales
traditional nursing schools (Table 5 ) were more
(Table 2). These results are similar to those reported
pleasant with social atmospheres of their institutes so
by previous studies conducted in different countries12,
as those studying at modern medical schools22, 23 except
18,19
. The lenghth of a questionnaire, misconception of
those from United Arab Emirates8 and Sri Lanka26 who
some items, translation factors and the negative items
expressed comparable views to those reported in current
a questionnaire contains are among the factors that
study. One reason behind the unhelpful educational
might influence its reliabilty20,21. In terms of quality of
environment at QNS maybe the traditional nursing
educational environmnet, participants at QNS had rated
curriculum where conventional teaching methods do
it as unhelpful. This perception was similar across three
not pave the way for building students’ capacity as
years of the nursing programme (Table 3). In addition,
self-directed life-long learners. Also, it (curriculum)
participants viewed teaching in the school as being
does not promote development of learners’ clinical,
seriously negative and teachers are in need of further
professional and generic skills that are necessary for the
training (Tables 3 & 4). Also, This study reported an
nursing profession24-26. Another reason could be lack of
average academic ability for students at QNS (Table 3),
staff development programmes in medical education.
yet 4th-year students gave the impression of more ability
When the number of females exceeds that of males in
to deal with coursework and to pass exams. Moreover,
an educational setting, the latter turns more suitable for
the school’s social climate was perceived as being
women 3. However, current study showed that both male
uncomfortable (Tables 3 & 4). Although participants
and female students expressed comparable perceptions
were somewhat satisfied about their social experience in
of a problematic educational environment at QNS (Table
the school (Table 3), females showed more satisfaction
4). Barcelo11 reported higher mean scores of female
than the males (Table 4). In contrast to data from
students for overall DREEM, perception of learning,
QNS, those from schools running similar traditional
perception of atmosphere and social perception. In
curricula showed positive students’ perception of
addition, Iranian female nursing students were more
learning environmnet (Table 5). On the other hand,
satisfied about teaching and they were socially more
studies conducted in innovative medical institutes8,22,23
pleasant than their male colleagues12. However, the
reported students’ perceptions of affirmative educational
latter had more positive perception of overall learning
environmnet. Maybe, the implementation of innovative
environment and they were more confident about their
educational strategies24 had accounted for such
academic ability. Moreover, a study conducted at an
perceptions. Nursing students’ perceptions of positive
“all female medical school” in Saudi Arabia27 reported
educational environment at traditional nursing schools
lower mean scores for overall and subscales of DREEM
worldwide (Table 5) maybe attributed to the modern
inventory than those reported in current study.
infrastructure of these schools. This conclusion is drawn
from my experience as a teacher at QNS, as the latter is
CONCLUSION
based in a building shared with medical and pharmacy
schools. Therefore, physical setting at QNS does not Current study showed that DREEM is suitable and
promote students’ communication, adversely affects applicable instrument for assessment of educational
their thinking and does not help them achieve their environment in Iraqi nursing education. In addition,
educational objectives. In contrast to the pessimistic nursing students at QNS expressed the perception of
views of teaching at QNS reported in current study, data unsupportive learning environment, rated their teachers
from studies conducted in traditional nursing schools in need of more training.
Financial Disclosure: There is no financial disclosure. 9. Miles S, Swift L, Leinster S. The Dundee Ready
Educational Environment Measure (DREEM): A
Conflict of Interest: None to declare.
review of its adoption and use. Med Teach. 2012;
Ethical Clearance: All experimental protocols were 34: e620–e634.
approved under the School of Nursing, University of Al- 10. Ahmed W, Tufail S, Nawaz H, Sana N, Shamim
Qadysiah, Al- Diwaniyah city, Iraq and all experiments
H. Evaluation of educational Environment of
were carried out in accordance with approved guidelines.
nursing undergraduates based on DREEM model
in institute of nursing, CMH Lahore medical
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DOI Number: 10.5958/0976-5506.2018.00633.2
Drivers’ Perception Towards Road Safety in Al Hilla City
Amean Ajeel Yasir

College of Nursing, University of Babylon, Hillah city, Iraq
ABSTRACT
Across sectional study design was adopted to assess the drivers perception toward road safety and to state
ways that will help to ensure road safety and reduction of road traffic accidents. The population under study
was (240) drivers who drive either their own car or rented or were driving the car as an occupation. The
study was conducted at two primary health care centers in Al Hilla city which covered Al Gameyah primary
health center and Al Kawthar primary health center. Structured questionnaire was developed for collecting
the data. It was divided into 3 parts, the first part included demographic data, second part consisted questions
pertaining to their perceptions by using Likert scale 3-point scale, and the third part included suggestions given
by drivers to ensure road safety. Community health nursing students interviewed the drivers and collected
the data during their clinical training in the above two mentioned primary health centers. Simple statistical
methods were used to assess the results of the study. Results showed that majority of drivers (81.7%) always
felt safe driving with seat belt on all the time, (43%) of them reported that loss of concentration & inability
to control the car was the major causes of accidents, followed by speeding (24,5%).
Keywords: Road safety, Drivers, Accidents, Community health
INTRODUCTION by drivers have also revolutionized one of our ways of

death too3, 4. The magnitude of the consequences of road
In recent years there is worldwide alarm due to traffic accidents far more believing as it leaves many
the rising incidence of motor traffic accidents, which homes fatherless, parentless, childless and the country’s
could probably contribute to the maximum percentage future economy would be affected with the higher
of the mortality and morbidity rate. It is evident from percentage of persons belong to those who contribute
the WHO’s initiative in dedicating the year 2004 as the to the economic growth and development of a nation.
year of “Road Safety”. Since then citizens in more than The survived are again left deficits looking forward to
100 countries are hosting hundreds of World Health help from the social welfare for their means and lose
Day events. Responsible countries have identified it as all hope in life, as they cannot be effective citizens. The
a major preventable cause of death and are developing emotional turmoil of the kith and kin, friends and the
newer strategies to combat road traffic accidents1, 2. Use neighborhood are unbearable and cannot be estimated in
of mobile phone could not be less credited for the cause figures5. The researcher had conducted the study aimed at
of road traffic accidents, as it has become part of human assessing the drivers perception toward road safety and
body, ready to respond to calls wherever they may to state ways that will help to ensure road safety. General
be. It is agreed by most people that cell phones have objectives of the study: To assess drivers’ perception
revolutionized our way of life by adding convenience, toward road safety. To identify the causes of road traffic
swift responses and an ability to continue working accidents as opined by the drivers. To obtain suggestions
uninterrupted by travel time. Cell phones when used by drivers to ensure road safety. To state ways that will
help to ensure road safety in Al Hillah city.
Amean Ajeel Yasir
College of Nursing, University of Babylon,
Hillah city, Iraq Across sectional study design was adopted. The
Phone number: 009647812267818 population under study was (240) drivers who drive
Email: [email protected] either their own car or rented or were driving the car as
an occupation. The study was conducted at two primary by using Likert scale 3-point scale, and the third part
health care centers in Alhilla city which covered Al included suggestions given by drivers to ensure road
Gameyah primary health care center and Al Kawthar safety. Community health nursing students interviewed
primary health care center. Structured questionnaire was the drivers and collected the data during their clinical
developed for collecting the data. It was divided into 3 training in the above two mentioned primary health
parts, the first part included demographic data, second centers. Simple statistical methods were used to assess
part consisted questions pertaining to their perceptions the results of the study.
Table 1: Drivers’ responses that reflect their personal experiences toward Road accidents
Always Sometimes Never

Statements
F % F % F %
1. I feel safer when driving with the seat belt on all the time. 197 81.7 39 16.6 4 1.7
2. Talking over the mobile phone (GSM) while Driving leads to loss of control. 180 75 53 22 7 3
3. Driving under the influence of alcohol leads to loss of control. 212 88.3 24 10 4 1.7
4. I listen to loud music while driving most of the time, which reduces my
186 77.5 38 16 16 6.5
concentration.
5. I drive my car when I am tired or exhausted. 144 60 67 28 29 12
6. I strictly follow road safety policies and regulations. 195 81.3 40 16.7 5 2
7. I take rest from time to time while driving long distance. 24 10 163 68 53 22
Table 2:Drivers’ perceptions toward the time they Table 4: Suggestions given by drivers to ensure road
fasten their seat belt. safety and reduce traffic accidents
Drivers’ perceptions F % Suggestion given by drivers F %

1. Before switching the car on. 45 19 1. Following the traffic rules strictly 67 23
2. Avoid speeding 41 14
2. After switching the car on. 34 14
3. Concentrate while driving 16 5.5
3. Immediately after moving the car. 24 10
4. Have mental relaxation 16 5.5
4. Never wear a seat belt. 137 57 5. Check the car before starting to drive 5 2
Total 240 100 6. Avoid drinking before driving 7 2.5
7. Install extra road traffic 10 3.5
Table 3: Main causes identified by drivers for the instructions
occurring of incidents 8. Do not give license for young people 9 3
9. Increase instructions board on the 9 3
Causes of accidents F % roads
1. Loss of concentration 78 29.0 10. Penalizing the careless drivers 29 10
11. Increase awareness through mass 23 8
2. Inability to control the car 73 27.0
media
3. Speeding and careless driving 63 24 12. Building safe roads and widening 9 3
the roads
4. Lack of sleeps and fatigue 27 10.0
13. Fasten seat belt and do not talk 44 15
5. Rains and weather disturbances 6 2.0 over the mobile phone (GSM)
6. Not enough street space 18 7.0 while driving
14. During long distance travel, driver 5 2
7. Lack of car services and trespass 3 1.0 should take period of rest in between
Total 268 * 100 Total 290 * 100
RESULTS AND DISCUSSION judgment and increases your risk of a crash 8-10. One of
the objectives of our study was to determine the extent to
The study has brought results significant for which the drivers followed the road safety policies and
affecting interventions to bring down the rate of traffic regulations, and it has been shown that there were nearly
accidents in Al Hillah city. The demographic data (16.7%) who only sometimes followed and nearly (2%)
shows that the majority of drivers are male (93.3%) in never followed at all the road safety policies. Therefore
the age group of (21-29) years old also in comparing the study has great concerns to create awareness of road
the drivers between the sexes, the males outstand the safety to this small percentage of driver who could bring
females (6.7%). This is evident as reported by khaleej down the accident rates massively as the results was
Time Online 2016, (80%) of fatalities are male between supported by Nofal,199, Ouimet and others 2014 8, 11.
(20-50) years of age (12). The results relative to identify Most of the drivers (68%) said that sometimes they take
the perceptions of the drivers towards road traffic rest from time to time while driving for long distance.
accidents show that maximum percentage of (81.7%) The National Transportation Safety Board (NTSB)
drivers always felt safe driving with seat belt on all the estimates (31%) of commercial driver deaths and (58%)
time, while (16.6%) of them felt important to use only of single-truck crashes are fatigue related 12. This is
sometimes. However it is interesting to note that only probably of high number of miles driven, truckers often
(1.7%) of them are never felt safe when driving with drive at night when the body is tired, working all day
seat belt on. This small percentage could be equated to before driving, driving long distances without stopping
the (59%) of people killed in reported traffic accidents in for breaks, taking medications, and driving alone on
2002 were not wearing seat Belt 6. The second important long rural roadways. We had other data related to safety
cause associated with traffic accidents in this study was measures were collected and analyzed in fulfill the
the use of mobile while driving. The use of mobile objectives of this study. The safety timing of fastening
phones while driving has sometimes leaded to loss their seat belt showed that (57%) of the drivers were never
control was admitted by a majority of drivers (75%). wear a seat belt, followed by (19%) of the drivers only
It has been aptly pointed in a research conducted by are wearing the seat belt before switching the car on,
Hassan 2013 as talking on a mobile phone while driving while (14%) of them are wearing it after switching the
is more dangerous than being over the legal alcohol car on and a small percentage of them (10%) are wearing
limit according to research as listening to someone on it immediately after moving the car. Though no study
the phone uses a lot more brainpower and uses the same supports this view, however it has been shown in report
areas to cope with sensory input and thus talking on the of WHO, 2004 that fastening of the seat belt can reduce
phone could result in a lapse of visual concentration risk of fatality by (45%) and can reduce moderate to
7
. Driving under influence of alcohol has not been critical injury by (50%) for passengers riding in the
accepted and clearly depicts the cultural practices of front seat 10, 11. The objectives of our study also included
muslim people that alcohol is not accepted norm, as obtaining suggestions to ensure road safety in Al Hillah
the majority of drivers (88.3%) agreed that it leads to city. There were many suggestions, however for easy
loss of control. Music is of course mentally relaxing inference the results have been grouped as administrative
and does take away the stresses of day-to-day chores suggestions and public health education and suggestions
of life. Yet it has been associated with traffic accidents to drivers. It was found that the suggestions to drivers
as in our study about (77.5%) felt their concentration is were with regard to following the traffic rules strictly,
reduced while listening to music during their drive. The avoid speeding, concentrate while driving, have mental
next cause frequently associated to traffic accidents was relaxation, fasten seat belt and not use mobile phones
identified in my study that nearly (60%) reported that while driving and check the car before starting to drive and
they drove their cars when they were tired or exhausted. avoid drinking before driving. Next various suggestions
Al Khalid 2006 has mentioned when you are behind the to administrative agencies such as install extra road
wheel of a car, being sleepy is dangerous. most people traffic instructions, do not give license for young people,
may not fully realize that drowsy driving can be just as increase instructions board on the roads, penalizing the
fatal as driving drunk. Like drugs or alcohol, sleepiness careless drivers, increase awareness through mass media
slows reaction time, decreases awareness, impairs and specialized awareness programs.
CONCLUSION 4. Central Department of Statistics & Information.

Highlights Demographic Survey 1428H) Riyadh
Accordingly, the researcher recommended that the
(KSA): National e-Government Portal; 2007.
drivers should follow traffic rules strictly, avoid speeding,
Available from: www.cdsi.gov.sa
concentrate while driving, fasten seat belt and not use
mobile phones while driving. Finally community health 5. Qayed MH. Epidemiology of road traffic accidents
nurses, health educators, nursing students, teachers and in Al Ahsaa Governorate, Saudi AraMediterrian
other skilled health personnel should continue taking a Health Journal. 1998;4:513–520.
vital role in reduction of road traffic accidents. 6. Bendak S. Seat belt utilization in Saudi Arabia
Financial Disclosure: There is no financial disclosure. and its impact on road accident injuries. Accid
Anal Prev. 2005;37:367–371.
7. Hassan HM, Al-Faleh H. Exploring the risk factors
Ethical Clearance: All experimental protocols were associated with the size and severity of roadway
approved under College of Nursing, University of crashes in Riyadh. J Safety Res. 2013;47:67–74.
Babylon, Hillah city, Iraq and all experiments were
8. Nofal FH, Saeed AA. Seasonal variation and
carried out in accordance with approved guidelines.
weather effects on road traffic accidents in Riyadh
city. Public Health. 1997;111:51–55.
REFERENCES
9. Al-Khaldi YM. Attitude and practice towards
1. World Health Organization. Global Health road traffic regulations among students of health
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2. Peden M, Scurfield R, Sleet D, Mohan
2011. Available from: www.who.int/country/sau/en.
Hyder AA, Jarawan A, editors. World
Report on Traffic Injury Prevention. Geneva 11. Ouimet MC, Brown TG, Guo F, Klauer SG, Simons-
(CH): World Health Organization; 2004. Morton BG, Fang Y, et al. Higher crash and near-
Available from: http: //whqlibdoc.who.int/ crash rates in teenaged drivers with lower cortisol
publications/2004/9241562609.pdf response: an 18-month longitudinal, naturalistic
study. JAMA Pediatr. 2014;168:517–522.
3. Ansari S, Akhdar F, Mandoorah M, Moutaery
K. Causes and effects of road traffic accidents in 12. “Accident Investigations - NTSB - National
Saudi Arabia. Public Health. 2000;114:37–39. Transportation Safety Board”. 2013
DOI Number: 10.5958/0976-5506.2018.00634.4
MF-GF Horizontal Distance as a Predictor of Sagittal Jaw

Dysplasia (A Cephalometric Cross Sectional Study)
Kasem Ahmed Abeas1; Issam Merza Abdullah1; Lamees Khudir Mohamed1; Arkan Muslim Abd Al-kareem1
1
Faculty of Dentistry, University of Babylon, Hillah city, Iraq
ABSTRACT
To overcome the deficiencies, at least geometric shortcoming, associated with the most commonly available
sagittal indicators (ANB, Wits), efforts were employed to develope another an accurate and valuable mean
for sagittal skeletal prediction. The study aimed to establish the mean values of a new sagittal approach
[MF-GF”] for the assessment of skeletal relationship in its different patterns and whether or not there is a
correlation with the other cephalometric indexes used in the study. The total study sample consist of ninety-
seven pretreatment lateral cephalometric radiograph of Iraqi subjects with a mean age (13.5± 2). Again it
has been subdivided into three skeletal relations (I, II, III) according to the combined criteria of (ANB angle,
W angle, Wits appraisal) for each relevant class. MF-GF” is a linear distance measured between two lines
perpendicular on the Frankfurt line from point M and G of the maxilla and mandible, respectively. Their mean
values were (6.83 ± 0.69; 10.29 ± 1.63; 1.52 ± 1.60) for class I; II; III, respectively. A statistical significant
mean difference was determined among all the classes. No significant gender differences were detected. A
high degree of association was found to be with ANB angle (r= 0.82, P value<0.001) followed by the wits
appraisal. It was concluded that the new MF-GF” distance can accurately be utilized in clinical assessment
of sagittal jaw relationship in conjunction with other well known methods of sagittal jaw indicators for
orthodontic diagnosis and treatment planning. Further studies are required to assess the reliability and
reproducibility of MF-GF” linear for different skeletal patterns using larger sample and different age groups.
Keywords: Sagittal jaw relation, MF-GF.
INTRODUCTION is the classical article of Steiner 4 who popularized the

ANB angle in clinical practice after it was introduced
Since 19471, Regardless the different well known by Riedel 5, as an anterio-posterior measure of jaw
modern methods; and more recently the cephalometrics disharmony. However, with age progression the
has a vital role in the interpretation of sagittal jaw relation reproducibility of ANB angle is questionable as the
for orthodontic patient. Various linear and angular nasion point is unstable in different directions as well
parameters have been incorporated by cephalometric as jaw rotation subsequent to growth and/or orthodontic
analyses to aid in diagnosing discrepancies within the treatment. The forementioned factors negatively would
apical jaw bases in the anterio-posterior direction2. The be affect the actual ANB angle reading 5-9. To overcome
reliability of the landmarks with jaw rotation, head the previous shortcomings, Jacoobson in 1975 10 was
posture, orthodontic treatment as well as growth is the developed the Wits horizontal distance depending on
common problem that was faced using these parameters the functional occlusal rather than the reference lines
whatever its type 3. “Cephalometrics for you and me”, of the cranial base whereby the severity of the skeletal
pattern can be measured. Unfortunately, an additional
problem had been arised as part from the difficulty
in identification of the occlusal plane especially in
Kasem Ahmed Abeas
patients with open bite, skeletal asymmetries, canted
Faculty of Dentistry, University of Babylon,
occlusion, and mixed dentition stage 11-13. Thereafter,
Hillah city, Iraq
recently different parameters Beta angle 14, Yen angle 15,
Mobile: 009647832435858
W angle 16 were developed to estimate the sagittal jaw
discrepancy. Although those angles have advantages MATERIALS AND METHOD

of being neither dependent on cranial reference plane Before sample assignment into the main skeletal
nor occlusal plane and so it gave a reliable picture of groups and to be included in the present study, all the
the sagittal jaw relation. Difficulties associated with lateral cephalograms which comprise our study sample
landmark identification, growth rotation, and unstability after their initial selection were traced by an Auto Cad
of the centre of the hypophysial fossa again are adversely 2010. According to certain predetermined criteria, ninety-
affect their actual values 17-20. seven standardized pretreatment lateral cephalometric
radiograph with high quality for Iraqi sample aged
The purpose of the present study was to test the ability between 11 and 16 years (57 females and 40 males) were
of a new anatomical cephalometric parameter [MF-GF” selected for a study. By using two angular (ANB and W
distance] in the interpretation of anteroposterior skeletal angles) and one linear ( Wits appraisal) parameters; the
relationship of the jaws for different skeletal classes for traced cephalographs again were subdivided into three
both genders independent on the rotation of the jaws as sagittal skeletal relations (29) class I; )33) class II; (35)
well as cranial and extracranial reference lines. class III. (Table 1; Figure 1)
Table 1: Showes sample classification using three skeletal anteroposterior measures into three skeletal types
(I,II,III).
Antero-posterior Measures
Skeletal Class No.
ANB angle W angle Wits
class I 2°- 4° 51°- 57° BO coincide or ahead of AO by 1mm 29
class II morethan 4° lessthan 51° AO ahead of BO 33
class III less than 2° morethan 57° BO ahead of AO 35
zz Porion (P) point: the most superior point on the
external auditary canal22.
zz Orbitale (O) point: The lowest point on the infra-
orbital margin22.
By connecting these points three reference lines
would be formed: (Figure 2)
Figure 1: Represent measurement of ANB angle (

red line); W angle (green line); Wits appraisal (syan
line) for sample classification. Figure 2: one of a study sample that represents
Cephalometric tracing of MF-GF" distance.
Cephalometric points and lines that are used for
MF-GF” distance construction: zz Line connecting P-O points forming Frankfurt plane.
zz Point M: Midpoint of the premaxilla. zz Line connecting M point perpendicular to Frankfurt
line at F point [M-F line].
zz Point G: Center of the largest circle that is tangent to
the internal inferior, anterior, and posterior surfaces zz Line connecting G point perpendicular to Frankfurt
of the mandibular symphysis 21. line at F” point [G-F” line].
Anatomical cephalometric angles and lines used for 27

. Several different studies have been reported on ANB
sample assignment: angle and wits appraisal 26-28 by different authors and
some on Beta angle; Yen angle; W angle 14-16 while not
1. ANB angle: formed by the connection of “A-N-B”
on MF-GF” distance. The horizontal linear measurement
points4, 5.
between the mandibular G point and the maxillary M
2. Wits [AO-BO]: Horizontal linear distance point on the frankfurt reference line has been proposed
between the perpendicular projection of A and B to be more reliable and simple cephalometric method in
on the functional occlusal plane10. estimating the sagittal skeletal disharmony of the jaws in
3. W angle: is measured between the M-G line and the their different relations as the latter two points are easily
perpendicular line on the S-G line from M point16. to be located and considered to be less susceptible, if
any, by remodeling process during orthodontic treatment
Data Analysis which is an advantage over the A and B cephalometric
points. Moreover, Projections on the true horizontal line
Statistical analysis was carried out using SPSS of the head can successfully be excluding the drawbacks
version 17. Student t-test was used to compare means enhanced during implementing the occlusal as well as
between genders. One way ANOVA test also was used anterior cranial base as reference lines.
for multicomparison of MF-GF” horizontal distance
Regarding our study results, the mean values of MF-
among the skeletal classes. In addition its correlations
GF” for skeletal class I; II; III were (6.83 ± 0.69; 10.29
with ANB and W angles and Wits appraisal index were
± 1.63; 1.52 ± 1.60), respectively. According to these
determined using Pearson correlation coefficient (r). A
values, each individual group had specific mean value
p-value of ≤ 0.05 was considered as significant.
differs significantly from the other. A statistical significant
mean difference was determined among all the classes.
The cephalometric M point is projected more forward
The balance and harmony of dentofacial complex on the Frankfurt plane than G point in the apical base
and its growth and development have been studied by relation is class II. In the same maner, the reverse is true
many investigators in four dimensions: namely height, for class III. No significant gender differences were found
depth, breath, and time, using lateral cephalometric among all the skeletal classes (Tables 2, 3). According
radiographs 23. Most orthodontic problems occur in to Pearson correlation coefficient (r); a varying degree of
the anteroposterior and vertical plane, so the lateral variability was found between the MF-GF” and the three
cephalographs provide the most useful information. anteroposterior skeletal measures of the jaws used in the
The anteroposterior disharmony has received maximum study. Nevertheless; there is a direct significant linear
attention in orthodontics as it is usually of utmost correlation between the MF-GF” distance and ANB angle
concern to patient and parents. Over the years, a number (r= 0.82; P<0.001) and Wits index (r= 0.70; P<0.001)
of analyses have been proposed with varying degrees while the former distance is indirectly proportional to W
of success and reliability in assessing the apical sagittal angle (r= -67; P< 0.001). A high degree of association
relation 24. The ANB angle has been remained the most was found to be with ANB angle followed by the wits
popular and useful principal method of establishing appraisal. So, as the ANB angle and Wits index increases,
sagittal jaw relation. However, there is some difference the MF-GF” value can be increased and indicating a class
between the cephalometric estimation of this angle and II tendency. When there is a class III tendency, the reverse
the absolute malrelationship between the apical jaw bases is true. Similarly, the MF-GF” distance shows gradual
7,25
. The Wits appraisal; similarly, uses a dental parameter, reduction as the W angle is increased. Anatomical as well
the functional occlusal plane, which is also subjected to as geometric variations among these sagittal jaw indices
variation with growth or orthodontic tooth movement 26, already was found.
Table 2: Reveals mean values for male and female, standard deviation, and gender defference of MF-GF”
Distance for different skeletal classes. There were no significant gender differences between means of MF-
GF” Distance for all classes
Skeletal class Gender N Mean ± SD t-test P value

Male 12 6.62 ± 0.76
Class 1 -0.712 0.483
Female 17 6.87 ± 0.69
Male 17 10.16 ± 1.52
Class 2 -0.447 0.658
Female 16 10.42 ± 1.78
Male 11 2.12 ± 1.85
Class 3 1.518 0.139
Female 24 1.25 ± 1.43
Table 3: Multiple comparison for MF-GF” Distance among the three skeletal classes. A significant difference
was found among the classes
95% CI
Study Variable Study group Mean ± SD Mean differences P value
Lower Upper
Class 1 6.83 ± 0.69
- 3.461 <0.001* -4.17 -2.74
Class 2 10.29 ± 1.63
Class 1 6.83 ± 0.69
MF-GF” Distance 5.302 <0.001* 4.59 6.005
Class 3 1.52 ± 1.60
Class 2 10.29 ± 1.63
8.764 <0.001* 8.08 9.44
Class 3 1.52 ± 1.60
*P value ≤ 0.05 was significant
CONCLUSION REFERENCES
The MF-GF” horizontal distance is a new 1. Wylie WL. The assessment of anteroposterior
anteroposterior measure of apical jaw bases disharmony dysplasia; Angle Ortod 1947;17: 97-109.
and simply can be used clinically in conjunction with
2. P. Aparna, Dilip Kumar N., Mandav Prasad,
other well-known methods of sagittal jaw indicators for
Naveen Shamnur. Comparative Assessment of
orthodontic diagnosis and treatment planning. Due to
the large variability in human population, an accurate Sagittal Skeletal Discrepancy: A Cephalometric
anteroposterior diagnosis cannot be achieved by merely Study. J Clin Diagn Res. 2015; 9(4): 38–41.
using a single cephalometric analysis. Hence, and as the 3. Moyers RE, Bookstein FL, Guire KE. The concept
need arises, it is imperative that a clinician be aware of a
of pattern in craniofacial growth. Am J Orthod
range of cephalometric analyses to be used appropriately.
1979; 76:136-48.
Further studies are requested to assess the reliability and
reproducibility of MF-GF” distance for different skeletal 4. Steiner CC. Cephalometrics for you and me. Am J
patterns using larger sample and different age groups. Orthod 1953; 39:729-55.
Financial Disclosure: There is no financial disclosure. 5. Riedel RA. The relation of maxillary structures
Conflict of Interest: None to declare. to cranium in malocclusion and in normal
occlusion. Angle Orthod. 1952;22: 140–45.
Ethical Clearance: All experimental protocols were
approved under the Faculty of Dentistry, University 6. Holdaway RA. Changes in relationship of points
of Babylon, Hillah city, Iraq and all experiments were A and B during orthodontic treatment. Am J
carried out in accordance with approved guidelines. Orthod 1956; 42:176-93.
7. Taylor CM. Changes in the relationship of nasion, 18. Bjork A. Facial growth in man, studied with the
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J Orthod 1969; 56:143-63. 13:9-34.
8. Jarvinen S. An analysis of the variation of the 19. Bjork A. Cranial base development: A follow- up
ANB angle: a statistical appraisal. Am J Orthod X-Ray study of the individual variation in growth
1985; 87:144-6. occurring between the ages of 12 and 20 years and
9. Freeman RS. Adjusting ANB angles to reflect its relation to cranial base and face development.
the effect of maxillary protrusion. Angle Orthod Am J Orthod 1955; 41:198-225.
1981; 51:162-71. 20. Melsen B. The cranial base: the postnatal
10. Jacobson A. The “Wits” appraisal of jaw development of the cranial base studied
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Odont Scan. 1974; 32: Suppl.64.
11. Haynes S, Chau M. The reproducibility and
repeatability of the Wits analysis. Am J Orthod 21. Braun S, Kittleson R, Kim K .The G-Axis: a
Dentofac Orthop. 1995; 107:640-7. growth vector for the mandible. Angle Orthod.
2004 ; 74: 328–331.
12. Demisch A, Gebauer U, Zila W. Comparison of
three cephalometric measurements of sagittal 22. Downs WH. Variations in facial relationship:
jaw relationship—angle ANB, ‘Wits’ appraisal their significance in treatment and prognosis. Am
and AB-occlusal angle. Trans Eur Orthod Soc J Orthod 1948; 34:812-40.
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23. Downs WH. Analysis of dentofacial profile. Angle
13. Rushton R, Cohen AM, Linney FD. The Orthod 1956; 26:191-212.
relationship and reproducibility of angle ANB and
24. Kumar V, Sandareswaran S. Cephalometric
the ‘Wits’ appraisal. Br J Orthod 1991; 18:225-31.
assessment of sagittal dysplasia. A review of
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assessing sagittal discrepancies: the Beta angle. Am 33-41
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25. Hussels W, Nanda RS. Analysis of factors affecting
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sagittal dysplasia indicator: the Yen angle. World
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DOI Number: 10.5958/0976-5506.2018.00635.6
The Anti-Fertility and Cytotoxicity Effects of Cyproterone

Acetate and Phenolic Extract of Hibiscusrosa Sinensis Linn
Flowers in Male Albino Rats
Al-Saily H. M.1, Al-Hady F. N.1, Al-Halbosiy M. M.2

Department of Biology, College of Science, University of Babylon, Hillah city;
1
2
Biotechnology Research Center, University of Al-Nahrin, Baghdad city, Iraq
ABSTRACT
The current study was designed to investigate the antifertility activity of Cyproterone acetate CPA and
phenolic extract of Hibiscus rosa sinensis L. flowers and their cytotoxicity on the splenic lymphocytes (In
vivo) and (In vitro) of male albino rats. The animals were divided into two groups, the first group was treated
with CPA at dose 5mg/kg/day for 50 days and the second group treated with phenolic extract of H..rosa
sinensis flowers in dose 300 mg/ kg/day for 60 days. The control group was also divided into two groups,
the first group treated with corn oil for 50 days and the second treated with tap water for 60 days. The results
showed a significant decrease (p<0.05) in the sperm parameters, and a significant increase (p<0.05) in
percent of sperms abnormalities and the decrease in the sexual efficiency of males treated with CPA, whereas
the sexual efficiency not affected in the group of rats treated with the phenolic extract. The pregnancy didn’t
occur in females mated with males treated with CPA until two weeks after the end of the treatment period.
While the pregnancy didn’t occur in females mated with phenolic extract of H. rosa sinensis flowers until
five weeks after the end of the treatment period, also the results showed a significant increase in proliferation
index (PIX) of splenic lymphocytes of albino rats (In vivo).
Keywords: antifertility, cytotoxicity, Cyproterone acetate, Hibiscus rosa sinensis L, male Rats
INTRODUCTION sperms in the testes and epididymis of treated animals.

Significant decrease in the percentage of live and motile
Cyproterone acetate used as a medicine for sperm and significant increase in the sperm abnormality
prostate cancer , it is steroidal antiandrogen inhibits the in caudal of the epididymis of treated male rats , the
testosterone and DHT action by competitive association treatment also caused a significant reduction in the level
with cellular receptors. Al-Hady (2000) 1 revealed that of hormones as FSH , LH and testosterone 5. Cytotoxicity
cyproterone acetate has an effect in reducing the fertility tests mainly aimed to detection the biological activity
of albino mice by decrease the sperm parameter in of tested substances, many cell types (e.g fibroblast,
treated rats , especially the dosage 5mg/kg /day for HeLa, splenocytes, lymphocytes and hepatoma cell)
50 days (Abd-Al-Ameer, 2008) 2 which prompted to can be used to carry out these tests 6. The aim of present
try to use it as a contraceptive for men 3. Al-Zubaide et study is to compare the cytotoxicity effect of CPA and
al., (2015) 4 also showed that the treatment of rats with crude phenolic extract of H. rosa sinensis flowers on the
phenolic extract of flower of H. rosa by dose 300 mg/ lymphocytes from splenocytes and the possibility to use
kg and duration of 60 days resulted in a significant the H. rosa extract as a male antifertility and compared
decrease in the sperm grade activity and concentration of with CPA.
Al- Saily, H. M.
Department of Biology, College of Science, The flowers of Hibiscus rosa sinensis L. were
University of Babylon, Hillah city, Iraq collected from nursery and agricultural areas in Babil
Email: [email protected] province in April and May 2017. The flowers were used
in the flowering stage after well cleaned and washed the purpose of sexual efficiency and fertility tests and
with water and left to dry in the air at room temperature monitored weekly for eight weeks to determine the time
for two weeks. After that, the dried flowers were grinded of conception.
with the grinder, until use.
Lymphocytes analysis (In vivo): The spleen was
Preparation of crud phenolic extract of Hibiscus rosa removed from euthanized rats and weighed it was teased
sinensis L. flowers: Ten gm of plant powder is taken between two frosted slides, and the tissue dispersion was
and put in the flask (500 ml) and add 400 ml of acetic separated by centrifugation at 260 g for 10 minutes at
acid 2%. The phenolic compounds of the plant were 4°C. The supernatant was discarded, and the pellet was
extracted by using reflex condenser in water path (70°c) suspended in 3ml red blood cell lysis buffer containing
for 8 hours. After extraction was completed leaving the 0.83% NH4Cl in 100 mM Tris buffer, PH=7.4 and
solution to cool down. Filtrated and the filtrate placed maintained at room temperature for 3 minutes. The cells
in a separator funnel and added to it an equal volume washed three times with media and suspended into 1ml
of n- propanol and amount of sodium chloride until of medium containing 10% FBS.
saturation. Two layers formed, the upper layer containing
the phenolic compounds and neglected the lower layer, The proliferation index (PIX) was calculated as
the upper has been concentrated in a rotary evaporator follows:
then deride in the oven (40°c), this product kept in the PIX =Absorbance of stimulated cells/ Absorbance
refrigerator until use7. of unstimulated cells.
General phenolic Reagent: This reagent was prepared Cell Culture Study
by mixing two equal quantities of aqueous solutions
of 1% ferric chloride and 1% of potassium ferric Lymphocytes analysis (In vitro): Splenic cell suspensions
cyanide. The extract was derided after it was obtained were prepared from eight untreated rats. Cells were
by dry calcium chloride (CaCl2) to get rid of any effect counted and assessed for viability on a Haemocytometer
of the moisture which could affect the identification. through trypan blue exclusion test. Viable cells (>95%)
Compounds of H. rosa sinensis extract was identified were adjusted to 2 × 106 cells ml-1 in complete culture
by infrared spectrum by using Ft. Infrared device8. media. The treatment with CPA and phenolic extract of
H. rosasinensis flowers (in different concentration) in
Animals: This study include 40 adult albino male rats vitro was performed in quadruplicates at the different
and 16 female albion rats. The groups of males were concentrations. CPA in concentrations 0.156, 0.312, 0.625
randomly divided into four groups each group contains and 1.25 mg/ml and phenolic extract in concentrations
10 animals: 18.75,37.5, 75 and 150 mg/ml were added to the cultures
First control group: (n = 10) treated with one ml of tap (2×105cells/well, or 2×106 cells/ml).
water. Statistical Analysis: Statistical Package for Social
Second control group: (n = 10) treated with one ml of Science (SPSS) system/version 23 was used to perform
corn oil. the analysis of data. Results expressed as mean ±
S.D. The Analysis of Variance (ANOVA), the Least
Third group: (n = 10) treated with phenolic extract of Significant Difference (LSD) test and Duncan was used
Hibiscus rosa sinensis flowers (300mg/kg) for 60 day 5. to compare between means.
Fourth group: (n = 10) treated with CPA (5mg/kg) for

50 days 2.
Identification of phenolic extract of Hibiscus rosa
Sexual efficiency tests and Fertility: The remaining 2
sinensis flowers by ft- Infrared: The infrared spectrum
animals from each group, each one placed with two of
for extract shows appearance absorption band at (3358)
the females who had previously consive and delivered in
cm-1 of (-OH) group and appearance absorption band at
a special breeding cage (40×30×15) where the existence
(1632)cm-1 of(C = C) aromatic bond which prove that
of a vaginal plug was examined after the coupling for
our phenolic extract of H. rosasinensis was produced
and that the –oH group that appeared back to the phenols male rats with phenolic extract of H. rosa flowers showed
found in the extract and if they were return to the water a significant decrease (p<0.05) in the concentration of
or moisture, the beam was appeared broad 8. sperms in the epididymis, grade activity of sperms and
percentage of sperm viability and a significant increase
Sperm Parameters Assays: Table (1) showed a (p<0.05) in the sperms abnormality percentage in the
significant decrease (p<0.05) in the sperm motility tail of epididymis as compared with tap water and corn
percent and epididymal sperm concentration, sperm oil controls. The results of the current study agreement
viability percent, while a significant increase (p<0.05) with many studies showed that some plant products have
in the abnormal morphology percent in the tail of the effectiveness of altering the sperm morphology or
epididymis in the male of rats treated with CPA and reduce its motility, such as the aqueous extract of the
phenolic extract of H. rosa as compared with tap water stem of Leptadenia hastate plant12.
and corn oil control groups. Also the treatment of adult
Table 1: Changes in sperm parameters in Experimental RatsTreated with CPA and Phenolic Extract of H.
rosa sinensis Flowers (Mean ± SD).
Sperm parameters Epididymis Sperms Sperms
sperm with with non- Immotile Viability Abnormality
Concentration progressive progressive sperm % % %
Groups Million/ml Motility % motility %
Control (DW) 75 ± 6.12 a 53 ± 4.18 a 16 ± 4.18 a 25 ± 7.90 a 87 ± 4.47 a 19 ± 4.18 a
Control (corn oil) 73 ± 7.58 a 59 ± 4.47 a 17 ± 5.70 a 30 ± 7.90 a 81 ± 7.92 a 15 ± 6.08 a
CPA 5mg/kg 24 ± 4.18 b 6 ± 2.23 b 13 ± 4.47 a 83 ± 2.73 c 33 ± 7.58 b 67 ± 7.58 c
Phenolic extract of H.
28 ± 4.83 9 ± 2.73 18 ± 2.73 74 ± 4.18 38 ± 5.70 52 ± 5.70
rosa Sinensis flowers
b b a b b b
300mg/kg
Changes in Sexual Efficiency: The males treated with CPA for 50 days could not mating with the females up to the
second week after the end of the duration of dosage where the sexual intercourse rats were 25% in the second day
and 25% in the fifth day and 50% in the first day of the third week compared to the control group treated with corn
oil, they were able to mate in percent 25% in the second day and 25% in the fourth day and 50% in the fifth day of
the first week, while ,The males which treated with the phenolic extract of H. rosa sinensis flowers for 60 days were
able to mate with the females in the first week after the end of the dosage period. The sexual intercourse ratio was
25%on the second day and 50% in the fourth day and 25% in the sixth day, where the ratio was close to the control
group treated with tap water which they can mate with females in percent 25% in the third day and 25% in the fourth
day and 50% in the sixth day of the first week Table (2).
Table 2: Changes In Percentages of Sexual Intercourse in Adult Males Treated with CPA and Phenolic
Extract of H. rosa–Sinensis flowers
Phenolic extract of H.
Control (Corn oil) Control (Tap water) CPA group rosa sinensis flowers
group
D 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6
W
1 25% 25% 50% 25% 25% 50% 25% 50% 25%
2 25% 25%
3 50%
Changes in Fertility Ratio: In Table (3).The pregnancy didn’t occur in females mated with males treated with CPA
in dose 5mg/kg of body weight for 50 days, until two weeks after the end of the treatment period, the pregnancy
percentage reached 25% in the third week and 25% in the fourth week and 25% in fifth week after the end of treatment
period compared to the controls males who were the pregnancy percentage was 50% in the first week and 50% in the
second week. While the pregnancy didn’t occur in females mated with phenolic extract of H. rosasinensis flowers
in dose 300mg/kg of body weight for 60 days, until five weeks after the end of the treatment period, the pregnancy
percentage 25% in the sixth week and 25% in the seventh week and 25% in the eighth week after the end of the
treatment period compared to the controls males who were the pregnancy percentage was 50% in the first week and
50% in the second week. The results of current study showed that the phenolic extract of H. rosa sinensis flowers
had a good effect for a longer period on fertility percentage compared with the effect of CPA if it was suggested as
anti-fertility for the male.
Table 3: Fertility Rates of Healthy Females Mated with CPA and Phenolic Extract of H. rosa sinensis Flowers
Groups Control Control (Tap CPA Phenolic extract of H. rosa

Weeks (Corn oil) water) 5mg/kg sinensis flowers 300 mg/kg
1st 50% 50%
2 nd 50% 50%
3 rd 25%
4 th 25%
5 th 50%
6 th 25%
7 th 25%
8 th 25%
Lymphocytes Analysis: Proliferation Index (PIX): Proliferation index (PIX) of lymphocytes Treated
The results presented in Table (4) showed that CPA with CPA: The results presented in Table( 5) indicated
group and phenolic extract of H. rosa sinensis flowers that the incubation of splenic lymphocytes with CPA
have a significant increase (P<0.05) in PIX compared to in concentrations (0.156,0.312. 0.625 and 1.25) mg/ml
for 24 hours showed a significant reduction in PIX of
both corn oil and Tap water controls, and non- significant
lymphocytes as compared to control in dose dependent
differences (P<0.05) in PIX between groups treated
pattern by which the PIX decrease by increasing the
with CPA and phenolic extract. Adenosine deaminase concentration of CPA. Our results consistent with other
ADA, an enzyme present in high concentration in studies reported cytotoxic effect of CPA in human
lymphocytes, it is responsible for purine metabolism, peripheral blood cell culture in vitro.
therefore it regulates the lymphocytes metabolism and
play important role in differentiation and growth of Table 5: Effect of CPA in different concentrations on
lymphocytes. the proliferation index PIX of lymphocytes (In vitro)
Treatment PIX
Table 4: Changes in the Proliferation Index (PIX) of mg/ml (mean ± SE)
splenic lymphocytes in Experimental Rats Treated Control 1.258 ± 0.069 a
with CPA and Phenolic Extract of H. rosa sinensis
0.156 1.167 ± 0.029 a
Flowers (In vivo) (Mean ± SD)
0.312 1.148 ± 0.085 a
Groups PIX 0.625 1.029 ± 0.054 b
Control (corn oil) 0.95 ± 0.04 a 1.25 0.856 ± 0.042 c
Control (Tab water) 0.92 ± 0.07 a Proliferation index (PIX) of lymphocytes treated
CPA 5mg/kg 1.26 ± 0.05 b with phenolic extract of H. rosa sinensis flowers: In
H. rosa sinensis extrsct the Table (6) the results revealed that the incubation
1.36 ± 0.12 b
phenolic extract 300 mg /kg of splenic lymphocytes with phenolic extract of H.
rosa sinensis flowers in concentrations( 18.75, 37.5,75 on the white Rats Rattus rattus (2008).Athesis of
and150) mg/ml for 24 hours showed a significant increase ph.d,college of science- University of Babylon.
in lymphocytes PIX in dose-dependent pattern by which 3. Zhang FP, Pakarainen T, Poutanen M, Toppari J,
the PIX increase by increasing the concentrations of Huhtaniemi L. The low gonadotropin- independent
phenolic extract of H.rosa sinensis flowers. constiutive production of testicular testosterone
is sufficient to maintain spermatogenesis. 2003;
Table 6: Effect of phenolic extract of H. rosa 100(23):13692-13697.
sinensis flowers in different concentrations on the 4. Al-Zubaide BA, Abood FN, Ali DJ. Effective
proliferation index PIX of lymphocytes (In vitro) anti – fertility of the phenolic extract of Hibiscus
rosa sinensis L. in male albino rats. J. of Babylon
Treatment PIX
mg/ml (mean ± SE) university. 2015; 1(23):46-54.
Control 0.884 ± 0.08 a 5. Al Zubaide BA. Effect of the phenolic extract
18.75 1.069 ± 0.03 a of Hibiscus rosa sinensis L. flowers in some
histilogical and physiological of reproduction
37.5 1.085 ± 0.02 a
male albino rats (2014). Athesis of ph.d , College
75 1.155 ± 0.01 b
of science- university of Babylon.
150 1.210 ± 0.06 b
6. Ekwall B. Screening of toxic compoud in
mammalian cell culture. Ann. N.Y. Acad. Sci.
CONCLUSION 1983; 407: 64-77.
The results showed that the incubation of splenic 7. Riberean-Gayon, P. (1972). Plant phenolics Oliver
lymphocytes with CPA for 24 hr. caused a significant and body. U.S.A. PP 254.
decrease (p<0.05) in PIX which decrease with increasing 8. Shriner RL, Hermann CKF, Morrill TC, Curtin,
concentration, whereas the incubation of splenic DY. The systematic identification of organic
lymphocytes with phenolic extract of H. rosa caused a compounds. 8th ed., John Wiley & Sons.Inc (2004).
significant increase (p<0.05) in PIX which increase with 9. Mosmann T. Rapid colorimetric assay for cellular
increasing concentrations as compared with control. growth and survival: application to proliferation
and cytotoxicity assays. J. Immunol. Methods.
Financial Disclosure: There is no financial disclosure.
(1983); 65: 55–63.
Conflict of Interest: None to declare. 10. Bayala B, Telefo PB, Bassole IH, Tamboura
HH. Anti-spermatogenic Activity of Leptadenia
Ethical Clearance: All experimental protocols were
hastata (Pers.) Decne Leaf Stems Aqueous Extracts
approved under the Department of Biology, College
in Male Wistar Rats. Journal of Pharmacology and
of Science, Hillah city, Iraq and all experiments were
Toxicology. (2011); 6: 391-399.
carried out in accordance with approved guidelines.
11. Nigam PK, Srivastava P, Patra PK. Serum
adenosine deaminase level in reactional and non-
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1. Al-Hady FN, Al-Giboory LF. Effect of Cy Leprol . 2005; 71: 20-2.
proterone acetate on the fertility of male mice. 12. Siddique YH, Afzal M. Induction of chromosomal
J. college of education of Baghdad University. aberration and sister chromatid exchanges by
2000; (3)11:9-18. chlomadinone acetate in human lymphocytes: a
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DOI Number: 10.5958/0976-5506.2018.00636.8
Self-concept in Relation to Inheritance Blood Diseases among

Adolescents in Babylon Governorate–Iraq
Sahar Hasan Issa1, Saja Hashim Mohammed1, Abdulmadhdi A. Hasan1

1
Department of Pediatric & Mental Health Nursing, College of Nursing, University of Babylon,
Hillah city, Iraq
ABSTRACT
Adolescence is considered a critical stage of life, thalassemic adolescents undergo changes in perception
due to frequent blood transfusions, severe complications, absenteeism from school and their psychosocial
problems. This study aimed to identify the level of self-concept and to find out the association between level
of Self-concept and related factors in adolescents with thalassemia major aged 10-18 in Babylon Governorate
Iraq. This is a descriptive cross sectional study which was conducted on non-probability purposive sample of
100 adolescents with thalassemia referring to therapeutic and blood transfusion center. The instrument used
to assess self-concept was Piers-Harris self –concept questionnaire ,the demographic data, clinical data and
school history were obtained after gaining their verbal consents . The analysis was performed by using SPSS
software version 21, Chi square test applied to assess the levels of associations between different variables.
The mean of self-concept was low (M.S=1.43±SD=0.36) and also a significant association between self-
concept domains except freedom from anxiety domain and absenteeism rate , and frequency of transfusion
(p<0.05). The results revealed that there was low self concept level among thalassemic adolescents. Urgent
psycho social intervention program is strongly requested to deal with this high priority public health problem.
Keywords: Self-concept, children, adolescent, thalassemia
INTRODUCTION chronic genetic disorders in 60 countries 4. It’s have

challenges on the individual at the physical, emotional,
Thalassemia is a hereditary issue that show up at cognitive levels and be more vulnerable to psychological
any age with most evident and major issues showing disorders 4-8. Where self-concept is a fundamental
in adolescence stage. It was calculated that 53/1,000 part of psychological functioning 9. Self-concept is a
child and youthful are liable to have illnesses with complex mental design that depicts subjective image
substantial genetic components 1. Thalassemia is one of their social credit, muscular, scholastic abilities ,
of the inherited hemoglobinopathies responsible for a conduct and body image , its framework from which
large number of chronic illness throughout the world 2. a person distinguish and interrelates with the self and
Thalassemia is considered as one of the serious health others 10, 11. Most psychosocial burden in adolescence
problems situated in the Mediterranean regions, about period when adolescents developed self-concept, it
300 million carrier of this disorder of hemoglobin is vital part for child mental health and progress. The
around the world 3. The world health organizations Psychosocial burden for thalassemia perceived even
have showed Thalassemia as one of the most popular more in adolescence stage 12, 13. So, this study was done
to measure the levels of self-concept among adolescents
Corresponding Author: with thalassemia referred to special diseases center in
Abdul Mahdi. A. Hasan Babylon, and to assess possible factors associated with
Department of Pediatric & Mental Health Nursing, low self-concept of Participants.
College of Nursing, University of Babylon,
Hillah city, Iraq
Phone: 009647716150716 The target population for this study was Adolescents
Email: [email protected] school patient who diagnosed with Inheritance blood
diseases and live in Babylon provenance Iraq and who Other approvals were taken from the ministry of
have attended the hereditary blood disease center in health , and official permission was obtained from
Babylon teaching hospital for maternity & pediatric. director of blood disease center at Babylon teaching
The parent and guardians who bring their child for blood Hospital for maternity and pediatric. To ensure their
transfusions were close from the study. agreement and facilitate to ensure the researcher’s task
to enter the center.
Sample and Sampling technique: Purposive sample
(non-probability) was used to recruit the Adolescents Instrument: For the present study, a questionnaire was
with thalassemia for this study . According to the developed based on study objectives, The Piers- Harris
following criteria: Child self-concepts scales sub-titled how do I feel about
Myself is a short means of self-assessments that were
zz Adolescents Ages between 10 and 18 years
made to evaluate the meanings of (I) in a child and an
according (WHO). Established diagnosis with
adolescent. The data on the scales are marked in true,
B-thalassemia major or sickle thalassemia child
somewhat true and very true in order to reveal the
was registered with thalassemia center attending
dimensions of these self-evaluations.
Blood diseases center for regular blood transfusion
at Babylon teaching hospitals in Babylon province. Data Collection Procedure: Data was collected on
zz Both gender. a self-administered questionnaire compromising 60
questions. that was self-developed to assess the self-
zz The participation agreement in this study is concept. The subjects personal data were collected and
achieved by having an informed consent from the their self-concept measured the collection of information
legal guardians and the children’s consent. was undertaken by only one researcher. in the present
zz Adolescents school patient able to read and write study the scale was given to 100 school thalassemia
Arabic language. adolescents attending blood diseases center at Babylon
teaching hospital for Maternity & Pediatric.
zz Adolescents school patients free from current
psychiatric disorders. Data analysis procedure: Data analysis is based on a
zz Babylon Governorate resident. sample of 100 valid questionnaires. For the data analysis
SPSS version 21 statistical package was used. Non-
Exclusion Criteria for this study: parametric test using the Chi χ2 test for differences
zz Orphan adolescents. and associations were applied. A P-value ≤0.05, ≤0.01
were considered as statistically significant at 5% (*) and
zz Patient with parents separated previously. highly significant at 1% (**) respectively, whereas P
zz Patient or Family refused to participant. value more than 0.05 considered as non-significant.
Table 1: Shows the Sociodemographic characteristics of the parents

Demographic Variables Rating Number Percentage
Mother Occupation house wife 94 94.0
Employed 6 6.0
Father Occupation Employed 40 40.0
free working 46 46.0
Unemployed 8 8.0
Retired 6 6.0
Mother Education does not read and write 7 7.0
Primary 20 20.8
Intermediate 31 31.0
Secondary 26 26.0
college or diploma 16 16.0
Conted…
Father Education does not read and write 5 5.0

Primary 12 12.0
Intermediate 24 24.0
Secondary 26 26.0
college or diploma 33 33.0
Table 2: Self-concept for Study Participants
Items Levels F % M.S ±SD

1. Happiness and Satisfaction Low 73 73.00 1.48 0.20
Moderate 23 23.00 1.97 0.13
High 4 4.00 2.43 0.11
Total 100 100 1.63 0.32
2. Popularity Low 74 74.00 1.51 0.21
Moderate 18 18.00 2.04 0.09
High 8 8.00 2.54 0.26
Total 100 100 1.69 0.38
3. Freedom form anxiety Low 32 32.00 1.45 0.27
Moderate 31 31.00 1.98 0.11
High 37 37.00 2.50 0.18
Total 100 100 2.00 0.48
4. Physical appearance and Low 75 75.00 1.41 0.24
attributes Moderate 22 22.00 1.99 0.11
High 3 3.00 2.38 0.22
Total 100 100 1.56 0.35
5. Intellectual and school status Low 68 68.00 1.50 0.23
Moderate 23 23.00 1.95 0.09
High 9 9.00 2.36 0.18
Total 100 100 1.68 0.35
6. Behavioral adjustment Low 83 83.00 1.31 0.21
Moderate 13 13.00 1.98 0.13
High 4 4.00 2.35 0.15
Total 100 100 1.43 0.36
Table 3: Association between self-concept of child and frequency of transfusion/month
low Moderate high

Variables Freq. transf. χ2 P value
No. % No. % No. %
Happiness Once 54 76.1 16 22.5 1 1.4 39.092 ** <0.001
and Twice 17 70.8 5 20.8 2 8.3
Satisfaction
Three 2 40 2 40 1 20
Variables Freq. transf. 73 23 4 100 χ2 P value
low Moderate high
No % No % No %
Conted…
Popularity Once 52 73.2 14 19.7 5 7. 78.178 ** <0.001

Twice 18 75 4 16.7 2 8.3
Three 4 80 0 0 1 20
low Moderate high
No % No % No %
Freedom Once 23 32.4 23 32.4 25 35.2 5.446 NS 0.243
form anxiety
Twice 7 29.2 7 29.2 10 41.6
Three 2 40 1 20 2 40
low Moderate high
No % No % No %
Physical Once 57 80.3 12 16.9 2 2.8 44.940 ** <0.001
appearance
Twice 16 66.7 7 29.2 1 4.2
and attributes
Three 2 40 3 60 0 0
low Moderate high
No % No % No %
68 23 9
Intellectual Once 52 73.2 14 19.7 5 7 22.693 ** <0.001
and school
Twice 14 58.3 7 29.2 3 12.5
status
Three 2 40 2 40 1 20
Table 4: Association between self-concept items and child’s absenteeism rate in school
low Moderate high

Variables Absenteeism rate χ2 P value
No % No % No %
Happiness Rarely 54 76.1 16 22.5 1 4.1 33.023 ** <0.001
and
Some time 17 70.8 5 20.8 2 8.3
Satisfaction
Frequently 2 40 2 40 1 20
Variables Absenteeism rate 73 23 4 100 χ2 P value
low Moderate high
No % No % No %
Popularity Rarely 52 73.2 14 19.7 5 7 78.178 **<0.001
Some time 18 75 4 16.7 2 8.3
low Moderate high
No % No % No %
Conted…
Freedom Rarely 23 32.4 23 32.4 25 35.2 5.466 NS 0.243
form
Some time 7 29.2 7 29.2 10 41.7
anxiety
low Moderate high
No % No % No %
Physical Rarely 57 80.3 12 16.9 2 2.8 44.940 ** <0.001
appearance
Some time 16 66.7 7 29.2 1 4.2
and
attributes Frequently 2 40 3 60 0 0
RESULTS AND DISCUSSION subareas and scores. Children with thalassemia major had
the mean of score of self-concept for all dimension was
The Demographic characteristics of the participants 1.43 in the low range , according the finding in table 2
show the children with thalassemia aged between (10-14) .The results of this study compatible with other studies
years highest percentage where present 69% of the study that examined self-concept in different region of the world
participants . Whereas, regarding Gender distribution , agree with study done by 14, 15,Also study done by 16, 17
the higher percentage from study participants was male was partially compatible with our study result where 58%
(58%), Only77% of children were in the primary school. of the thalassemic children had average level from self-
,While 52% reported that they had accounted not quite concept. The results for the “Popularity” subareas show
enough income . The majority Children were living with that children with thalassemia are unpopular where 74%
extended families constitute 62%. Table l clearly shows of them had low level from popularity and mean of score
the Sociodemographic data of children parents ,It shows 1.69 these results compatible with previous studies where
that the majority of the study subjects their father’s (46%) indicated negative impact of beta thalassemia major
had free work; whereas, the majority of mothers were on social relationship, involving common stigmas and
housewives (94%). Table 2 shows the overall score and discriminations in South Asian community 18. Results
each subarea obtained in the Piers-Harris Self –Concept regarding Table 4 revealed a highly important associations
Scale Based on the statistical cut off point, this table shows between self-concept domains and school absenteeism
that each subarea score obtained by participants was low (χ2=9.488; d.f.= 4; P=value=,<0.001) except freedom
in the Piers –Harries self-concept scales of Children. from anxiety, 19 congruent with our study results there
,about 75% of participants had an low or poor appearance were highly important associations between the effects
and attitude and 37% of participants had low or poor on psychosocial burden and recent schoolings 50% of the
anxiety . levels of happiness and satisfaction in 73% of patients who report severe levels of psychosocial burdens
the sample were low. According to the findings in Table 3 because of thalassemia on their educations.
,This table represents of the child clinical data , the present
study reported that regarding the frequency of transfusion
were highly significant association between all aspect
CONCLUSION
of self-concept domain except freedom from anxiety According to the findings of this study, it was
and frequency of transfusion at P value less than 0.001. indicated that self-concept of children with thalassemia
As shown in Table 4 This table represents of the child is low. This indicates the importance of psychological
school history , the present study reported that regarding consultations in educational fields. Considering the
the absenteeism rate were highly significant association psycho-social aspects of thalassemia, in their management
between self-concept domains except freedom from protocol and training, the adaptive strategies along with
anxiety and absenteeism rate at P value less than 0.001. providing new clinical and therapeutic services to the
In general , our study results indicated approximately patients and their families who directly engaged with
67.50% of thalassemic adolescents who participated in this these patients can increase self-concept of these patients
study had lower perceptions of self-concept in the overall in emotional, behavioral, social and school dimensions.
Financial Disclosure: There is no financial disclosure. major adolescents. International Journal of

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DOI Number: 10.5958/0976-5506.2018.00637.X
Cytotoxic and Apoptotic Effects of Phenolic Extract of Hibiscus

Rosa Sinensis Linn Flowers Against Cancer Cells And Normal Cells
Al-Saily H. M.1, Al-Halbosiy M. M.2, Al-Hady F. N.3

Department of Biology, College of Science, University of Babylon, Hillah city; 2Biotechnology Research
1
Center, University of Al-Nahrin, Baghdad city; 3Department of Biology, College of Science, University of
Babylon, Hillah city, Iraq
ABSTRACT
Phenolic extract of Hibiscus rosa sinensis Linn flowers was evaluated for their cytotoxicity and apoptosis
induction in human testicular cancer cell line Tera-1 and macrophage cancer cells from an adult BALB/c
strain mouse male RAW 264.7 as compared to normal human hepatic cells WRL-68. The results showed
that the phenolic extract of H. rosa sinensis flowers were effective on all cancer cell lines used in this study
and Tera-1 cells with IC50 value of 23.496 mg/ml were more sensitive toward phenolic extract of H. rosa
sinensis flowers than RAW264.7 cells with IC50 value 31.841 mg/ml, whereas the WRL-68 cells with
IC50 value 498.884 were not affected by phenolic extract. The Multi- Parameters Cytotoxicity Activity
of extract on Tera-1 cell line showed a significant decrease (P<0.05) in valid cell count, nuclear intensity
and mitochondrial membrane potential (MMP) and a significant increase in membrane permeability and
cytochrome C releasing, therefor the phenolic extract of H. Rose sinensis have anti-tumor activity, especially
on testicular cancer cells.
Keywords: cytotoxic, apoptotic, Hibiscus rosa sinensis cancer cells, normal cells
INTRODUCTION treat many diseases and its leaves and flowers are used
to stimulate hair growth7, and anti- diabetic effect, and
The H. rosa is native to tropical Asia, especially wounds healing, and cardiac protective effect. and
southeastern Asia (China), 8 or more different species reduce blood pressure8 have been found to be useful for
originating from the islands in the Indian and African treatment of hypercholesterolemia9. Alsoit is found that
East Coast and Pacific ocean1. The Hibiscus rosa sinensis the root extract act to reduce the lipids in blood and cause
plant is a perennial shrub with tap root and the flowers hypolipidaemic activity10. The Quercetin and Lutein are
take bright colors such as red, white, pink and yellow. a flavonoids content as glycosides, flavonoids have anti-
Red–colored flowers are used in medical applications2, oxidation and anti-cancer activity11. other studies which
the flowers of H. rosa contain flavonoids, phenolic suggested the anti-cancer activity of H.rosa sinensis
compounds, glucosides, phytosterols, terpenoids, tannins, plant12, 13.
saponins, flavones, alkaloids, carbohydrates amino acids
and proteins contributed to the medicinal utility of the
plant3-5. By using HPLC technique the phenolic extract
of H.rosa Sinensis flower showed contain: Acetylsalisalic Preparation of Hibiscus rosa extract: Crud phenolic
acid, Chlorogenic acid, Coumarin, Lutein, Cynidin, compounds were extracted according to Ribereau-
and Quercetin6. Hibiscus Rosa sinensis plant is used to Gayon, (1972) 14 method, 10 gm. of plant powder is
taken and put in flask (500 ml) and add 400 ml of acetic
acid 2%. The phenolic compounds of the plant were
Corresponding Author: extracted by using reflex condenser in water path(70°c)
Al-Saily, H. M. for 8 hours. After extraction was completed, leaving the
Department of Biology, College of Science, solution to cool down. Filtrated and the filtrate placed
University of Babylon, Hillah city, Iraq in a separatory funnel, and added to it an equal volume
Email: [email protected] of n- propanol and amount of sodium chloride until
saturation. Two layers formed, the upper layer containing 570nm with an ELISA reader. The mean absorbance for
the phenolic compounds and neglected the lower layer, each group of replicates was calculated. The percentage
the upper has been concentrated in a rotary evaporator of cell viability that exposed to various treatments is
then deride in oven (40°c), this mater kept in refrigerator obtained as follows:
until use.
cell viability percent =[(absorbance of treated cells/
Determined of Cytotoxicity: The cytotoxic effect Absorbance of non- treated cells)×100] 15.
of phenolic extract of H. rosa sinensis flowers was
investigated according to selected parameters including: The data of optical density was subjected to
MTT assay as assay of cell function to determined cell statistical analysis in order to calculate the concentration
viability, high content screening (HCS) technique for the of compounds required to cause a 50 % reduction in cell
apoptosis of cell. Only the most cytotoxic concentration viability for each cell line 16.
of the phenolic extract and the most sensitive cells as The High Content Screening (HCS) Assay (Diana et
assayed by MTT was selected to complete the other al., 2012): The multi- parameters cytotoxicity assay was
test:( HCS). performed by using the HCS kit to measurement of five
MTT assay: The cell viability was determined by independent parameters that monitor cell death, including
colorimetric assay using 3-[4,5-dimethylthiazoyl]-2,5- viability cell count, nuclear size and morphological
diphenyltetrazolium bromide (MTT dye), three kinds changes (nuclear intensity), changes in cell membrane
of cells were employed in this work: (Tera-1 cell line), integrity and cell permeability, mitochondrial membrane
(RAW 264.7) and the normal human hepatic cells potential and cytochrome C localization, release from
(WRL-68). Briefly, 100 µl of cell suspension was added mitochondria. Different concentrations of the phenolic
onto the 96 flat bottomed micro-titer plate wells, each extract of H. rosasinensis, 200, 400 and 800 µg/ml
line in a separated plate, for the three cell lines and two were used for treatment one cell line: the human testes
fold serial dilutions of H. rosa sinensis phenolic extract cancer cell lines (Tera-1) for interval time 24 hours.
(1.17, 2.34, 4.68, 9,37, 18.75, 37,5 and 75 mg/ml) were Tera-1 cell preparation: The protocol of Tera-1
added to wells, in a final volume of 200 µl complete cells was optimized according to instruction of ATCC
culture medium per each well. Triplicates were used per (American Type Culture Collection). EMEM medium
each concentration as well as the controls (cells treated containing 10% fetal bovine serum and 100 units/ml
with serum free medium), then the plates were incubated pencillium and 100 µlg/ml streptomycin were used for
in 5% CO2 incubator for 24 hours at 37°C. Ten µl of routine culture.
the MTT solution was added to each well. Plates were
further incubated in 5% CO2 at 37°C for 4 hours ,the Statistical Analysis: Statistical Package for Social
solution became yellow, then 200 µl of solubilization Science (SPSS) system/ version 23 was used to perform
solution of DMSO was added into each well and shaked the analysis of data. Results expressed as mean ±
for 5 min.(the DMSO solution became purpule). After S.D. The Analysis of Variance (ANOVA), the Least
complete solubilization of the dye, the absorbance of the Significant Difference (LSD) test and Duncan was used
colored solution obtained from living cells were read at to compare between means.
Table 1: Cytotoxicity effect of phenolic extract of H.rosa sinensis flowers on RAW264.7 cells, Tera-1 cells and
WRL-68 cells after 24 hours incubation at 37C°
Phenolic extract of H.rosa

Cell viability % (mean ± SD)
sinensis flowers
Conc. mg/ml RAW 264.7 Tera-1 WRL-68
1.17 92.15 ± 1.62 96.60 ± 1.51 96.56 ± 1.29
2.34 84.64 ± 2.83 95.40 ± 1.29 95.94 ± 1.22
4.68 75.05 ± 0.50 78.89 ± 3.32 96.25 ± 0.37
9.37 62.71 ± 0.57 62.07 ± 4.16 94.86 ± 1.54
Conted…
18.75 51.58 ± 0.49 56.32 ± 4.11 90.54 ± 2.08

37.5 47.96 ± 1.23 39.85 ± 4.04 74.61 ± 2.29
75 46.70 ± 1.53 32.40 ± 4.64 66.15 ± 2.79
Table 2: Cytotoxicity effect of phenolic extract of H. rosa sinensis flowers on multi cellular parameters of
Tera-1 cell line after 24 h. incubation at 37c° and evaluated on the Array Scan HCS Reader
HCS parameters (mean ± SD)

Concentrations Valid cell count Nuclear Membrane (MMP)* Cytochrome C
µg/ml intensity Permeability releasing
Control 2010 ± 31.82 297.2 ± 6.71 77.50 ± 5.79 310± 13.08 152 ± 9.89
(untreated) a a a a a
Doxorubicin 1205 ± 9.19 172.4 ± 4.52 172.6 ± 9.05 178.7 ± 10.82 258.6 ± 6.50
20µM c d c d d
200 1942 ± 31.11 289.5 ± 1.48 88.70± 3.96 290.5 ±6.36 159.9.3± 4.10
a a a a a
400 1783 ± 14.85 274 ± 7.49 98.40± 3.96 271.3 ±3.88 181.6± 6.50
b b a b b
800 1575± 19.80 226.7± 7.21 133.4± 8.55 237.1± 11.46 197.4± 4.10
c c b c c
Figure 1: IC50 of phenolic extract of H. rosa sinensis flowers–treated RAW264.7 cells after 24 hr of incubation
Figure 2: IC50 of phenolic extract of H. rosa sinensis flowers – treated Tera-1 cells after 24 hr of incubation.
Figure 3: IC50 of phenolic extract of H. rosa sinensis flowers–treated WRL-68 cells after 24 hr of incubation
RESULTS AND DISCUSSION and 498.884 mg/ml respectively. The results of this
study showed that the IC50 of Tera-1 cells was 23.496
Cytotoxic effect of phenolic extract of H. rosa sinensis mg/ml, whereas IC50 of RAW 264.7 cells was 31.841
flowers on cancer cell lines and normal cells in vitro mg/ml that’s mean the testicular cells more sensitive to
by using MTT assay: The cytotoxic effect of phenolic phenolic extract than macrophage cells, this may be due
extract of H.rosa sinensis flowers was determined to that phenolic compounds possess a reactive oxygen
by 3-(dimethylthiazol-2-yl)-2,5-diphenyltetrazolium species ROS production property especially hydrogen
bromid (MTT) assay on two different types of tumor cell peroxide (H2O2) radical 17, and because testicular cells
lines: tastis cancer cell lines Tera-1, macrophage cancer are more sensitive to H2O2 which induce apoptosis in
cell lines RAW264.7 and normal hepatic cells WRL-68. these cells 18. The hepatic normal cells WRL-68 were
This assay was performed to measure the cell viability not affected by the phenolic extract compared to cancer
by applying different concentrations of phenolic extract cells Tra-1 and RAW 264.7 cells.
on the tumor and normal cell lines Table(1). MTT
colorimetric assay was achieved to determine cell The Multi- parameters Cytotoxic Activity Phenolic
viability at each time- point, best values were chosen Extract of H. rosa sinensis flowers on Tera-1 cell
for the most significant IC50 values Figure(1), Figure(2) line: The multi- parameters cytotoxic activity of H.rosa
and Figure(3). The results indicated that the incubation sinensis phenolic extract was estimated by using Tera-
of RAW264.7 cells and Tera-1 cells with phenolic extract 1cells. Five of cell-health parameters were simultaneous
in concentrations 1.17, 2.34, 4.68, 9.37, 18.75,37.5 measurement by thermo scientific cellomics multi-
and 75 mg/ml for 24 hours showed a reduction in cells parameter cytotoxicity 3 kit. Three concentrations
viability in a dose dependent pattern by which cell (200,400,800 µg/ml) of phenolic extract were tested
viability decreased by increasing the concentrations of on Tera-1 cell line to detect the changes in five cellular
phenolic extract of H.rosa sinensis flowers. The lowest parameters (valid cell count, nuclear intensity, membrane
cell viability % was recorded in Tera-1 cells 32.40 % permeability, mitochondrial membrane potential MMP
in concentration 75mg/ml; however it was 46.70 % and cytochrome C) after 24hours of exposure. Table
and 66.15 % for RAW264.7 and WRL-68 respectively (2) showed that 800 µg/ml has the highest significant
at 75mg/ml. The results showed that the WRL-68 cells effect on all the five parameters when compared with
viability was not significantly affected by the application Doxorubicin 20 µM (substance used as anti-cancer)
of different phenolic extract of H. rosa sinensis flowers which consider the positive control. The concentration
concentrations as compared with the viability of Tera- 200 µg/ml showed a close results to those of the
1 and RAW246.7 cells. It was observed significant untreated cells which represent the negative control.
differences in the cell viability % between the different The incubation of Tera-1 cells with H.rosa sinensis
cell lines by calculating the IC50. The tera-1 significantly phenolic extract in concentrations ( 200,400 and 800 µg/
affected by cytotoxic activity of phenolic extract of H. ml) for 24hours showed a significant decrease (p<0.05)
rosa sinensis flowers with IC50 23.496 mg/ml, whereas in valid cell count, nuclear intensity and mitochondrial
IC50 values of RAW246.7 and WRL-68 were 31.841 membrane potential MMP, and a significant increase
(p<0.05) in membrane permeability and cytochrome 7. Janicke B, Hegardt C, Krogh M, Onning G,

C releasing as compared to untreated cells (negative Akesson B, Cirenajwis HM, Oredsson SM. The
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science- university of Babylon. 2014. line. Chinese Medicine. 2011; 6(39):2-8.
DOI Number: 10.5958/0976-5506.2018.00638.1
Prevalence, Control and Associated Factors of Hypertension in

Rural Middle Aged Women of Kerala
Sandhya GI1, Anitha Abraham2, Ramla Beegam3

1
Associate Professor, 2Assistant Professor, 3Professor &HOD, Community Medicine,
Dr SMCSI Medical College, Karakonam, Thiruvananthapuram
Abstract
Title: Prevalence, Control and associated factors with hypertension among rural women aged 30-60yrs in Kerala
Objective: To estimate the prevalence, control and factors associated with hypertension among middle
aged women of rural Kerala.
Background: Hypertension is a major public health problem in India. It is a leading cause for mortality and
morbidity in India
Result: The overall prevalence of hypertension was 32.1% and prehypertension was 8.4%. Among the
hypertensive 32.2% (10.2% of the total study population) were newly diagnosed. 55% the known hypertensive
were not taking treatment regularly and 57% of the known hypertensive have uncontrolled hypertension.
32.3% of the study population was overweight where as 12.8% was obese. Multi logistic regression revealed
that BMI>25kg/m2, perceived stress, family history of hypertension and diabetes were factors associated
with hypertension
Conclusion: This study has shown that hypertension is highly prevalent among rural women and the disease
is uncontrolled among the rural women.The fact that one tenth of the population has hypertension which
is undetected is alarming. Primary and secondary levels prevention of hypertension should be considered.
Keywords: Hypertension, Prevalence, prehypertension, control,rural women
Introduction reported that of a total of 9.4 million deaths in India in

1990, cardiovascular diseases caused 2.3 million deaths
Hypertension is an important disease and a risk (25%). A total of 1.2 million deaths were due to coronary
factor which directly and indirectly contribute to the heart disease and 0.5 million due to stroke.1 It has been
mortality and morbidity of the Indian population. predicted that by 2020, there would be a 111% increase
This disease can affect the population without causing in cardiovascular deaths in India.. Hypertension is a risk
symptoms and for this reason it can be undetected for factor for major cardiovascular diseases and there by a
a long period. Cardiovascular diseases account for a public health burden in India2,3,4 Moreover, most or all
large proportion of all deaths and disability worldwide. BP-related risk appears to be reversible within a few
Global Burden of Disease Study reported that in 1990, years with inexpensive interventions. Hypertension is
there were 5.2 million deaths from cardiovascular directly responsible for 57% of all stroke deaths and
diseases in economically developed countries and 9.1 24% of all coronary heart disease deaths in India.2 This
million deaths from the same causes in developing fact is important because hypertension is a controllable
countries.1The situation in India is more alarming. It was disease and a 2 mmHg population-wide decrease in BP
can prevent 151,000 stroke and 153,000 coronary heart
disease deaths in India.2,
Dr Sandhya GI
Associate Professor, Community Medicine A number of Prevalence studies about hypertension
Dr SMCSI Medical College has been conducted in urban areas of India5,6,7,8 but a few
Karakonam, Thiruvananthapuram, Kerala studies of hypertension in rural areas were published in
India9-13 . As per best of our knowledge women centered of the rural areas of India 9-13Based on this prevalence
studies regarding hypertension are limited14 . Although with 95% confidence interval (CI) and 20% relative
there is generally a lower prevalence of hypertension precision the sample size required is 324. Predicting
in the rural Indian population, there has been a steady a 5% non response rate the final sample size is 345.
increase over time in this rural population as well15. It has Considering a design effect of 2 final sample size was
also increased over the years—0.52% in Bombay (1959), 690.Sample size collected for this study was694.
1.99% in Delhi (1959), 3.57% in Haryana (1978), 5.41%
Selection of area: Area selected for the study is two
in Delhi (1983), 5.59% in Rajasthan (1984), 2.63% in
rural panchayath of Thiruvananthapuram district
Punjab (1985), 4.02% in Maharashtra (1993), 3.41%
namely Ottasekharamangalam and Amboori with a total
in Maharashtra (1993), 7.08% in Rajasthan (1994) and
population of 44000.
3.58% in Haryana15.In South Indian rural subjects, that
are almost urbanised, the prevalence has been reported to A multi stage random sampling technique was used
be as high as 17.8% (1993) and 12.46% (1994) in recent for the present study. In first stage five villages were
years15. A study conducted in Achudamenon centre selected randomly from a total of 24 villages. In second
for kerala has shown that incidence of hypertension is stage 694 eligible women were selected randomly from
23.6%9 and another study conducted in central Kerala these villages. We excluded migrant population and
reported prevalence of hypertension as 36%. women with chronic debilitating diseases. The selected
participants were interviewed with a questionnaire in
Most of the prevalence studies have reported that
local language which include parameters like physical
women have lesser prevalence compared to men11-14. One
activity, SES, existing morbidity, perceived stress and
of the study conducted in central India10 reported a high
their sleep pattern. Height, weight, abdominal obesity
prevalence of hypertension among women compared to
men in India. were examined .Height was measured through a
stadiometer, weight through weighing machine and
Diagnosis of hypertension is important. Chenni abdominal girth using a measuring tape at the level
urban study 8 reported that 32.8% of the people were of umbilicus. Blood pressure was measured using a
aware of their disease and among them 45.8% were under mercury column sphygmomanometer17 by a standared
control. A tribal study from Kerala state16 reported only technique. Study participants were instructed to refrain
10% diagnosed and 8% control of hypertension. Early from drinking coffee/ tea during the half-hour preceding
diagnosis and treatment of hyper tension is important as the interview. Three blood pressure measurements were
hypertension can be asymptomatic for a long period and taken at 5 minutes interval and mean were taken.. The
may lead to a number of complications. criteria for hypertension is based on WHO–International
Society of Hypertension (WHO–ISH) and the US Sixth
We performed population based cross sectional study
Joint National Committee on Detection, Evaluation and
in a rural panchayath of Kerala to study prevalence,
Treatment of Hypertension (JNC–VI)18 .Hypertension
treatment control of hypertension in women aged 30-60
years. is defined as as either an SBP≥140 mm Hg, and/or a
DBP≤ 90mmHg, and/or treatment with antihypertensive
medication . Socioeconomic assessment was based
Materials and Method
on modified Kuppuswamy scale19 Current use of
The study has started after getting ethical clearance prescription medication for lowering elevated blood
from the institution.The study purpose explained to all pressure among hypertensive subjects were considered
the participants and informed consent has taken from all as treatment.
the participants
Statistical analysis
Study design and period: It is a community based cross-
sectional study conducted in rural areas of Kerala State, The statistical package for social sciences (SPSS)
India. The study period was 2014 august to December. software version 16 was used for data entry and analysis.
Both mean and percentages were used for analysis. The
Sample size and sampling strategy: Sample size is Chi-square test were used to demonstrate relationships
calculated based the prevalence study conducted in one between categorical variables. Multivariate logistic
regression analysis were done using hypertension as Table 2: Age specific Prevalence of hypertension
the dependent variable and risk factors identified to be
Age group Prevalence in% P value
significant in the univariate analysis as independent
30-40 12.2
variables. The level of significance was set at P values ≤
0.05 for analysis of categorical variables. 41-50 27.8 <0.05
51-60 53.4
Result The associated factors of hypertension was identified
using multilogistic regression model. The factors which
Total population studied was 694. Mean age of
were significant in univariate analysis were used in
the study population was 45.44yrs with a standard
multivariate analysis. Inunivariate analysis factors like
deviation of 9.4yrs.The baseline characteristic of the
high BMI, family history of hypertension, diabetes
study population was given in table1. 32.3% of the rural
,decreased sleep, stress and agegroup were found to be
women were having overweight where as 12.8% were
significant Factors like SES, physical activity,educational
obese.61% belonged to lower socioeconomic status.
status were found to be non significant in univariate
Table 1: Baseline characteristic of study population analysis. In multilogistic regression age group, family
history of hypertension , perceived stress, diabetes and
Age group Number (%) BMI>25kg/m2 were found significant. Results of multi
30-40 213 (30.7) logistic regression were shown in table3
41-50 230 (33.1)
51-60 251 (36.2) Table 3 : Result of multi logistic regression
Education status
Primary 211 (30.4) Factor Odds ratio (95% CI) P value
High school 378 (54.5) Age group 2.18 (1.66-2.85) P < 0.05
Higher secondary & above 105 (15.1) Known diabetic 4.21 (2.52-7.01) P < 0.05
Occupation Family history
2.16 (1.41-3.32) P < 0.05
of hypertension
Household work 476 (68.6)
Perceived stress 5.28 (3.41-8.17) P < 0.05
Cooli 165 (23.8)
BMI>25kg/m 2
2.46 (1.64-3.69) P < 0.05
Others 53 (7.6)
Physical activity Among the total study population 151 were known
Mild 397 (57.2) hypertensives (21.8%).only 45% was taking regular
Moderate 243 (35) treatment and 57% of known hypertensives were having
severe 54 (7.8) uncontrolled hypertension
BMI (kg/m2)
18.5-23 246 (35.4) Table 4: Showed the treatment and control status of
23.1-2 135 (19.5) hypertension
25.1-29.99 224 (32.3)
Hypertension status Number (%)
30 or above 89 (12.8)
Known hypertensives 151(21.8)
Socioeconomic scale
Regular treatment 68(45%)
Low 423 (61)
Un Controlled hypertension 86(57%)
Medium 246 (35.4)
High 25 (3.6)
Discussion
Age specific prevalence of hypertension was given
intable2. It showed that as age increases prevalence This study has shown that rural women in south
of hypertension is increasing which is statistically Kerala are having high prevalence of hypertension.
significant. The pre hypertension prevalence detected This result is comparable with the result of previous
was 8.4% among the study group prevalence studies in rural area9-13. A meta analysis
conducted in rural area of India20 to determine prevalence detection and proper control of hypertension. Obesity
of hypertension showed prevalence of 27.6 with 95% reduction and stress reduction should be started in
confidence interval of 23.2 to 32.00 which is similar to school levels.
our result. As hypertension is a for runner of a number
of serious diseases like cardio vascular, renal and other Acknowledgements: We are Thankful to the paramedical
vascular diseases its control and early diagnosis is staff, field staff and the people of the community where
important. This study revealed kerala population has we have done the study
high prevalence and their awareness and control were Conflict of Interest: Nil
extremely poor.
The age specific prevalence has shown that
hypertension is also highly prevalent among young
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DOI Number: 10.5958/0976-5506.2018.00639.3
A Survey to Assess the Facility Access of People with Mobility

Disabilities in King Abdulaziz Medical City, Riyadh,
Saudi Arabia
Fayz Al shahry1, Jobby George2, Winnie Philip3, Amirah Ageil Al Shammari4, Hend Faisal Al Qudaimi4,
Sarah Saad Ghemlas4
1
Assistant Professor & Consultant of Rehabilitation, King Abdulaziz Medical City, National Guard Health
Affairs, Riyadh; 2Assistant Professor, 3Lecturer, 4Internship Student, Occupational Therapy, College of
Applied Medical Sciences King Saud bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia
Abstract
According to the World Health Organization, people living with disability accounted for 15% of world’s
population, and their numbers are expected to grow1. The Saudi national census estimated that 0.8% of
people have disability, yet no study in Saudi Arabia has examined the architectural barriers of healthcare
facilities and the difficulty it poses for person with disability (PwD). This study aimed at investigating
accessibility of the architectural facilities in King Abdulaziz Medical City (KAMC) for People with
Mobility Disabilities (PWMD). A quantitative cross-sectional study was conducted in KAMC in two phases,
in phase I, respondents (n=100) were surveyed on the accessibility of architectural facilities and in phases
II, an inspection was performed on the accessibility of architectural facilities using the Americans with
disability act (ADA) standardized checklist for building design. Phase I, survey results showed that people
ambulating by means of assistive devices needed additional help to access KAMC (p<0.05). In phase II,
the mean accessibility rates of the measured facilities of KAMC were found to be: parking (36%), exterior
access (32.5%), interior access (11.75%) toilets (34.75%), waiting area and registration counters (46.5%),
patient sleeping rooms (29.5%), and signage (45%). This study indicates that there is limited awareness
among (PWMD’s) and inadequate accessibility within the healthcare facilities in KAMC. Further education
to raise the awareness is needed so as to help the advocacy of the modifications needed to facilitate the
access of health care services for PWMD.
Keywords: Facility Access, People with Mobility Disabilities, Person with disability
Introduction national census, it was estimated that 0.8% of people

have disabilities in Saudi Arabia, which corresponds
Accessibility is the compatibility of an environment to 135,000 people3. Another Saudi survey on 60,630
to people’s functional capacities that allows them to children below age 16 with disabilities showed that
benefit from facilities and services. Among the People physical disabilities were the most common4. WHO
with Disability (PwD), the inadequacy of accessibility confirmed that road traffic accidents is the leading
limits their physical engagement with the outdoor world. cause of disability in Saudi Arabia2, WHO findings
The participation of (PwD) in society is considered were confirmed by yet another study in which traumatic
mandatory to promote equalization2. According to a accidents were identified as the major factor leading to
disability comparing to non-traumatic incidents5.
Fayz Al shahry A number of research evaluated accessibility barriers
to (PwD) revealed that they encounter difficulties seeking
Assistant Professor & Consultant of Rehabilitation,
health services, which substantiated that reasonable
King Abdulaziz Medical City,
physical accessibility is a minimum requirement to
National Guard Health Affairs, Riyadh, Saudi Arabia
guarantee fair access6. Physical accessibility studied in
primary health care settings in California identified that accessibility of architectural facilities whereas in phases
physical barriers have a negative impact on (PwD) when II, investigation was performed on the accessibility
they are looking for health care services7. Researchers of architectural facilities, the settings included King
explored primary care and specialty care clinics in United Fahad Hospital, King Abdulaziz Cardiac Center, King
States, and observed lack of accessibility in facilities Abdullah Specialized Children’s Hospital (KASCH),
for wheelchair users8. A survey on (PwD) accessibility and Health Care Specialty Center (HCSC) in King
of dental health facilities in Brazil concluded that Abdulaziz medical city (KAMC), Riyadh, Saudi Arabia.
37.3% of (PwD) reported physical barriers, and 43.8%
A quantitative cross-sectional study design was adopted.
of the dentists claimed that facilities are considered
inaccessible; the reason being the high level of education Phase I: Patient Survey: Applying the Saudi national
and awareness about (PwD’s) rights among the dentists senses values4 to obtain the sample size a sample of
in contrast to the (PwD’s) low education level9. 100 was calculated using a margin of error of 2% and
A rehabilitation center accessibility study in Iran 95% confidence interval. The respondents were selected
found that (PwD) encountered accessibility difficulties using convenient sampling technique. The inclusion
which made their health status wo rse10. Furthermore, criteria were People with Mobility Disabilities (PWMD)
other studies also confirmed the existence of poor of both genders in the age category 18 years and above.
accessibility for (PwD) in rehabilitation centers 6, A structured questionnaire was developed and circulated
11,12,13,14
. Evidence also was fou that there was inadequate among respondents in (KAMC); a pilot study was
accessibility for (PwD’s) in majority of the health clubs conducted to determine the reliability and validity of
and fitness facilities across United States15. It was also
the questionnaire. Data was collected by asking the
reported that (PwD) are struggling due to insufficient
respondents to mark their opinion. The questionnaire is
accessibility; importance of modifying the physical
depicted in table no.1
facilities for it is essential to make it barrier free.17
In Saudi Arabia researches have not examined the Phase II: Investigation on the Accessibility of
architectural barriers, leaving a wide gap in estimating
Architectural Facilities: The 2010 ADA standardized
accessibility, hence the current study was conducted
building design checklist18 was used to assess
with the specific objective to investigate the experience
of people with mobility disabilities regarding their architectural facilities such as parking, exterior routes,
facility access in KAMC. interior routes, toilet rooms, waiting room, registration
counters, examination rooms, medical equipment,
patient sleeping rooms, and signage. Among the facilities
Materials and method
that have similar dimensions in the same category, only
This study was conducted in two phases, phases one was assessed, for different facilities, assessment was
I, respondents were surveyed on the quality of taken individually.
Table 1: Queries and Responses with respect to facility access for people with mobility disabilities
S. Yes No
Questions
No. (%) (%)
1. No hesitation to visit KAMC because of facilities. 84 16
2. Caregiver not reducing the frequency of the visits because of the facilities. 88 12
3. Not needing help from others to access the facilities. 9 91
4. Not finding enough support from health care staff inside facilities. 12 88
5. Access to parking
Can you find an accessible parking? 48 52
Distance between the parking is problem 54 46
6. Access to entrance
Entrance door 80 20
Ramps 72 28
Conted…
7. Access to waiting area

Is the space in the waiting area enough to move for you? 82 18
8. Access to toilets
Do you easily find an accessible toilet? 76 24
Is the space in the toilet rooms enough for you move to you? 79 21
Can you reach the lavatory easily? 91 9
9. Access to doctor’s office/examination room
Can you enter the examination room/doctor’s office easily? 82 18
Is the space in the examination room/doctor’s office enough for you move to you? 80 20
10. Access to goods and services
Garden/Cafeteria 62 38
Mosque 37 63
11. Any other difficulties in other facilities 8 92
Table 2: Mean Score & Percentage of accessibility at KAMC
HCSC King
King Abdulaziz
KAMC (Khashem KASCH Fahad
Cardiac Center
Alaan) Hospital
7 10 10 9 Parking
36 28 40 40 36 %
7 8 13 12 Exterior Access
32.5 23 26 42 39 %
5 7 8 6 Interior Access
11.75 9 13 14 11 %
Mean Score & Percentage

10 20 8 12 Toilet
34.75 28 56 22 33 %
Waiting rooms & Registration
4 4 4 3
counter
53.5 57 57 57 43 %
Examination rooms & Medical
7 7 6 6
Equipment
46.5 50 50 43 43 %
0 32 24 21 Patient room
29.5 0 49 37 32 %
4 5 4 5 Signage
45 40 50 40 50 %
44 93 77 74 Total mean score
Findings 69% of the respondents were living within Riyadh. The

wheelchair 68% was the most used assistive device, 50%
The age of the respondents ranged from 19-106 years of the respondents did not receive formal education, and
with a mean age of 56.98 (SD ±19.71). The response 64% of the respondents had income less than 5,000 SAR.
rate was100%, majority 62% of the respondents was The purpose of their present visit to the facility 72% had
female. Most 69% of the respondents were married; and come for regular appointment 18% came for admission
3% emergency and 7% were periodically visiting the the accessibility the results of the site assessment of
KAMC for yearly check-ups. KAMC using the 2010 ADA standardized building
design checklist was found to be low. This inferred
Responses regarding facility access for (PWMD):
that receiving help might have prevented people from
The survey results suggest that 84% of the respondents
experiencing the difficulties of accessibility which
were willing to visit KAMC facility. 88% informed that
led them to report that the majority of facilities are
caregivers were not trying to reduce the regularity of
accessible. It could be concluded that awareness of
the visits because of the services. However 91% stated
accessibility is not fully acknowledged within the
that they needed help from others to access the facilities.
(PwD) population, education is needed to support this
With regards to the queries related to parking, 48%
population in recognizing their rights and advocacy
found reachable parking. 80% reported that exteriors
for them. Even though the accessibility barriers were
were accessible so was entrance doors and ramps 72%.
recognized, implementation of accessibility must be
82% reported that they had enough space and were
monitored to grantee the rights and access of (PwD) to
free to move around. Toilets were accessible and easily
obtain their needs and freedom of movement. Future
found by 76%. The toilet seat and lavatory height were
studies are recommended to investigate the knowledge of
handy for 91%. 80% reported that examination rooms
accessibility among healthcare providers and explore the
and doctor’s office were accessible. For access to goods
accessibility barriers for visual and hearing disabilities.
and services, (62%) respondents mentioned that access
to garden/cafeteria/coffee shop were easy. Mosques Conflict of Interest: The authors have no conflict of
were inaccessible by 63%. Chi square test indicated that interest to declare.
people with assistive devices need help to access KAMC
(χ2 =7.37; p<0.05). Also, it was statistically significant Source of Funding: “The author(s) received no specific
that married people do not find their caregivers trying to funding for this work.”
reduce their frequency of visits due to the facilities (χ2 Ethical Clearance: The Institutional review board
=4.76: p<0.05) of the King Abdullah International Medical Research
Phase II: Investigation on the Accessibility of Center (IRB-KAIMRC) approved the study with the
Architectural Facilities: Based on the 2010 ADA protocol number SP16/125. Phases I, an informed
standards for building design checklist, the measurement consent was obtained from the respondents, and for part
of the parking facility demonstrated a mean rate of II, an informed written consent was collected prior to
accessibility of 36% within KAMC. For exterior access site assessment.
32.5%, for interior access 11.75%, toilets 34.75%.
Waiting area showed a mean rate accessibility of 53.5%. References
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C; MEng, Williams S Rehabil for Accessibility of
mobility disabilities and visual impairments. Am.
outpatient healthcare providers wheelchair users:
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9. Rocha LL, de Lima Saintrain MV, Vieira-Meyer 16. Nary D, Froehlich AK, White G. Accessibility
AP. Access to dental public services by disabled of fitness facilities for persons with physical
persons. BMC oral health. 2015 Mar 15:35 disabilities using wheelchairs. Topics in Spinal
Cord Injury Rehabilitation. 2000 Jan 1;6(1):87-98.
10. Abdi K, Arab M, Rashidian A, Kamali M,
Khankeh HR, Farahani FK. Exploring barriers 17. Rimmer JH, Rubin SS, Braddock D. Barriers to
of the health system to rehabilitation services exercise in African American women with physical
for people with disabilities in Iran: A Qualitative disabilities. Archives of Physical Medicine and
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18. Northwest ADA Center University of Washington,
DC, Brooks CA, Charlifue SB, Gerhart KA.
Accessibility checklist for medical clinics and
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DOI Number: 10.5958/0976-5506.2018.00640.X
Evaluation of Prevalence of Exercise Induce Ecg Changes in

200 Patient with Diabetes Mellitus
Arul Murugan S1, Aravind C2, Vishnupriya. G3, E. Prabhakar Reddy4

1
Associate Professor of General Medicine, 2Professor of General Medicine, 3Junior Resident of General
Medicine, 4Professor of Biochemistry and Central Lab Head, Sri Lakshmi Naryana Institute of Medical
Sciences, Puducherry, Bharath University
Abstract
Introduction: Diabetes mellitus is a chronic metabolic disorder is one of the most common risk factor for
cardiovascular disease. Diabetic individuals exhibit 2 to 5 fold increased risk of developing MI and even
silent myocardial ischemic. Detection of CAD before its associated morbidity is reasonable and life saving.
One of the well known non – invasive relatively inexpensive rest in detected IHD is treadmill test.
Aim: To find out the asymptomatic exertional coronary ischemia in patient with diabetes mellitus of 10 yrs
duration.
Methodology: For those patients of 10 yrs duration of diabetes who are attending our diabetic and medicine
OPD conducted cross sectional observational study. After getting the consent, patients were made to run on
TMT.
Conclusion: 76.5% of the patients demonstrated positive TMT.
Keywords: Diabetes mellitus, cardiovascular disease,Tread Mill Test,
Introduction including myocardial infarction (MI), is the leading

cause of death in young diabetics. Cardiovascular
Diabetes mellitus is a chronic metabolic disorder diseases (CVD) are irrefutably responsible for 65% of
which can cause various micro and macro vascular deaths in diabetics, the majority of whom suffering from
complication. Diabetes mellitus is defined as presence of type 2 DM. In Framingham study it was demonstrated
FBS >126 mg/dl, PPBS >200mg/dl and HbA1C> 6.5[1]. that diabetic individuals exhibited a two to five fold
Patient may have myocardial ischemia without symptoms. increased risk of developing angina, MI, and congestive
Incidence of coronary artery disease (CAD) in heart failure. In individuals younger than 45 years, the
diabetics is four times higher compared to the age- risk of CVD surges to more than 11 fold compared to
adjusted general population. Early onset and rapid general population. Mortality statistics after myocardial
progression of atherosclerosis combined with early infarction or even after revascularization procedures
commencement of ischemic heart disease (IHD) in are regrettably increased in the setting of preexisting
association with diffuse involvement of the coronary diabetes. In most diabetic patients, diagnosis is delayed
arteries are common findings in diabetics. CAD, due to chiefly obscured and atypical symptoms meaning
that they don’t meet the usual clinical diagnostic criteria
for myocardial ischemia. Silent ischemia is defined as
Corresponding Author: transient ischemia without typical recognized associated
Dr. C. Aravind symptoms, especially chest discomfort. Patients with
Professor of General Medicine, DM experience silent myocardial ischemia more
Sri Lakshmi Narayana Institute of Medical Sciences, commonly than general population.
Puducherry
Mobile No. +919159186879 Diabetics are at high risk of developing extensive
Email: [email protected] CAD at younger age and silent ischemia which further
increases the chance of adverse outcome. Consequently, zz Electrolyte abnormalities

detection of CAD before its associated morbidity
zz Severe arterial hypertension–In the absence of
and mortality is reasonable and may be lifesaving.
definite evidence, the committee suggests an SBP
Screening and detection of high risk coronary lesion
with a non-invasive test is an attractive goal. One of higher than 200 mm Hg, a DBP higher than 110
the well-known non-invasive tests in detection of IHD mm Hg, or both
is Treadmill test or exercise tolerance test ( ETT).It is a zz Tachyarrhythmias or bradyarrhythmias
non-invasive, relatively inexpensive test, and commonly
performed in clinical practices. It provides substantial zz HOCM & other types of outflow tract obstruction
diagnostic and prognostic information. Exercise capacity zz Mental or physical impairment leading to an
is one of many important prognostic factors revealed inability to exercise adequately
during the test.
zz High-degree atrioventricular (AV) block
Tread Mill Test: ECG base test in which patient
made run on treadmill till he become fatigue and till In this article, the broader term “physical
he developed chest pain[5]. Treadmill stress testing is activity” (defined as “bodily movement produced by
indicated for diagnosis and prognosis of cardiovascular the contraction of skeletal muscle that substantially
disease, specifically CAD. This is the initial procedure of increases energy expenditure”) is used interchangeably
choice in patients with a normal or near-normal resting with “exercise,” which is defined as “a subset of PA done
electrocardiogram who are capable of adequate exercise. with the intention of developing physical fitness (i.e.,
[7, 8]
Contraindications have been outlined in guidelines cardiovascular [CV], strength, and flexibility training).”
from the American College of Cardiology (ACC) and The intent is to recognize that many types of physical
the American Heart Association (AHA). movement may have a positive effect on physical fitness,
morbidity, and mortality in individuals with type 2
Absolute contraindications include the following: diabetes [6].
zz Acute myocardial infarction (MI; within 2 days)
zz Unstable angina not previously stabilized by Aim and Objectives:
medical therapy–Appropriate timing of tests The study is to find out the asymptomatic exertional
depends on the level of risk of unstable angina as coronary ischemia in patient with diabetes mellitus of
defined by the Agency for Health Care Policy and >10 years duration.
Research Unstable Angina Guidelines
zz Uncontrolled cardiac arrhythmias causing Methodology
symptoms or hemodynamic compromise
This is a cross sectional observational study
zz Symptomatic severe aortic stenosis conducted in the diabetic patients who attended the
zz Uncontrolled symptomatic heart failure diabetic opd and medicine opd. Patient with >10 years
duration of diabetes who doesn’t have co-morbid
zz Acute pulmonary embolus or pulmonary infarction
condition like systemic hypertension/coronary heart
zz Acute myocarditis or pericarditis diseses/cerebro vascular accident/perpheral vascular
zz Acute aortic dissection diseses were included in the study. Patient with known
case of CAD, who are on antiplatelet drugs and smokers
Relative contraindications can be superseded if the were excluded from the study.
benefits of exercise outweigh the risks. They include
the following: After getting the consent, patient were made to run
on treadmill either Bruce or modified Bruce criteria.
zz Left main coronary stenosis
Patient who developed ST inversion >1 mm in >2 leads
zz Moderate stenotic valvular heart disease was taken as positive case[7].
Bruce Protocol (Maximal Table) Ethical Clearance: No. No.IEC/C-P/049/2016
Stage Minutes % grade MPH km/h METS

References
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Among total number of 200 diabetic patients who surgery with angioplasty in patients with
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Conclusion Type 2 Diabetes ; The American College of Sports
Medicine and the American Diabetes Association:
In the above conducted study the prevalence of
joint position statement
exercise induced ECG changes among 200 diabetic
patients is found to be 76.5%. 7. George D. Harris, MD, MS and Russell D. White,
MD, Exercise Stress Testing in Patients With Type
Conflict of Interest: The author’s declares no competing 2 Diabetes
interest
Source of Funding: Self/Diagnostic kits are provided

by institution as on complimentary basis for research.
DOI Number: 10.5958/0976-5506.2018.00641.1
Parasitic Tea Scurrula atropurpurea (Blume) Danser Active
Compound Potencies Towards Inhibition of DNA Methylation
in Cancer: An In Silico Study
Ni Luh Putu Eka Sudiwati1 , Tatit Nurseta2 , Mulyohadi Ali 3 , Aulani’am Aulani’am4 ,
Heru Santoso Wahito Nugroho5
1
Department of Nursing, State Health Polytechnic of Malang; Indonesia, 2 Department of Obstetri and Gynecology,
Saiful Anwar Hospital, Malang, Indonesia / Faculty of Medicine, Brawijaya University, Malang, Indonesia,
3
Department of Pharmacology, Faculty of Medicine, Brawijaya University, Malang, Indonesia, 4 Laboratory
of Organic Chemistry, Mathematic and Natural Sciences, Brawijaya University, Malang, Indonesia, 5 Health
Polytechnic of Ministry of Health at Surabaya, Indonesia
ABSTRACT
DNA methylation is metil group (CH3) adding towards DNA. This mechanism will affected cells function and
arise difference gene expression. Tumor suppresor gene hipermethylation, was silencing gene expression,
induced cancer progressivity, and interfere the therapy. Recent studies have been reported that some
compound from plants could act as an inhibitor on DNA methylation. Since methylation is inhibiting, the
silenced tumor suppressor gene caused by hipermethylation, will be re-active. Previous study was succesfully
identify flavonoid from Scurrula atropurpurea (Blume) Danser (SAD) that collected from Lawang city,
Jawa Timur. Fractionation of a compound have been carried out with a solvent n-heksan, chloroform, and
ethanol. Identification of a compound through investigating liquid chromatography mass specthrometry mass
(LCMS). The outcome showed that flavonoid compound in SAD were included flavanon, dihidroflavonol,
flavon, flavonol, katekin, and Epigallocathecin-3-O-gallate (EGCG). The study was an advanced study,
has an objectives to identify the SAD potency towards methylation inhibition, and it was insilico using
Autodock Vina on software PyRx 0.8. The result shown that an active compound isolated from SAD have
potency to inhibit DNA methylation, in which EGCG as the strongest candidate with binding affinity was
-10.4 Kcal./mol. Result of this study can be used to tested a potential active compound of SAD as anticancer
both in vitro and in vivo.
Keywords: DNA methylation, Scurrula atropurpurea (Blume) Danser
INTRODUCTION methylation towards some important tumor supressor

genes is due on cancer proression, and caused gene
Epigenetic modification have an important role silencing (4) . Some recent studies showed that EGCG
on cancer progresivity and therapy. DNA methylation could act as an DNA methyltransferase (DNMT) inhibitor
is one of epigenetic modification which have an effect via direct interaction, and induce demethylation and
towards cells funnction, via gen expression changing (1), reactivation of silenced tumor supressor genes caused by
(2), (3)
. In cancer, some epigenetic modification such as methylation (5), (6) . The research objective was to identify
the SAD potency as a DNA methylation inhibitor in
Corresponding author : silico experiment.
Heru Santoso Wahito Nugroho
Health Polytechnic of Ministry of Health at Surabaya, MATERIAL AND METHOD
Address: Midwifery Campus of Magetan, S. Parman
On the previous study, we already able to identify
Street No. 1, Magetan District, Jawa Timur Province,
Scurrula atropurpurea (Blume) Danser (SAD)
Indonesia, Email: [email protected]
Indian Journal of Public Health Research & Development, July 2018, Vol. 9, No. 7 207
flavonoids from Lawang Jawa Timur. Those flavonoids DNMT sample were collected from Protein Data
were : flavanon, dihidroflavonol, flavon, flavonol, Bank (rcsb.org) with ID 3SWR (Figure 1) (9) . The model
cathecin, dan EGCG (7) . The potency of those compound was DNMT protein from Human that linked to inhibitor.
was test using PASS method. The method was using DNMT activity was depend on it active functional
Structure Actvity Relation (SAR) approach, that be able site. DNMT active site was on amino acid 1226. The
to predict the compound activity based on the functional co-factor for this enzyme was zink (Zn) and zink finger
group similarity with drugs active group that been position (DNA binding domain) was the amino acid
known before (8) . 646-692. Natural flavonoid data (EGCG, catechin,
dihidroflavonol, flavone, flavonol, flavanon), were
collected from PUBCHEM NCBI. The potency of each
compound as DNMT inhibitor were analyze to find the
afinity of the coumpound with active site oof DNMT.
The Molecular Docking analysis was using Autodock
Vina from PyRx 0.8 program. The docking was done at
active site of DNMT.
We were inhibition mechanism to examine the

molecular interaction, and we can find which active
group function from the compound that will linked to
amno acid site. The molecular interaction analyze and its
visualization were use Ligand Scout V.2.0 (10), (11) .
FINDINGS
The SAD flavonoids potency towards DNA

Figure 1. The 3D Structure of Human DNMT 1 inhibiting methylation were presented on Table 1.
Table 1. Docking flavonoid on SAD with DNMT
Protein Binding Affinity (Kcal /

Active Compound Link Site
Target mol)
Glu1266A, Asn1578A dan Gly1223A

EGCG DNMT -10.4
Catechin DNMT -8.4 Asn1267A dan Glu1168A
Met1169A, Ile1167A, Phe1145A,

Dihidroflavonol DNMT -8.2 Leu1247A dan Glu1168A
Met 696A, Val1268A dan Asn1267A

Flavon DNMT -8.0
Trp1170A, Asn1578A, Ala699A dan

Flavanon DNMT -7.8 Val1268A
Met1169A, Ile1167A, Leu1247 dan

Flavonol DNMT -7.7
Phe1145A
Table 1 stated that on every SAD compound will link on DNMT active site, with different afinity. EGCG Afinity
towards DNMT was the highest, with smallest bindiing affinity value. When a compound and another were linking,
and have a small binding affinity, and this meanss the link will be strong. This mechanisme will give strong link and
higher inhibitor effect towards methylation. Contrary, highest binding affinity value gives weak inhbitor towards
DNA methylation. The docking of ECCG on SAD towards DNMT is shown on Figure 2.
208 Indian Journal of Public Health Research & Development, July 2018, Vol. 9, No. 7
Figure 2. Binding of EGCG on DNMT active site, with afinity -10.4 Kcal / mol via hidrogen bond with Glu1266A, Asn1578A and
Gly1223A residu on DNMT
Based on table 1 and figure 2 we known that ECCG clinially tested, but still give a toxic effect (4) .
have potency as a demethylation agent and flavonol ave
Previous study have shown that etanol fraction
the lowest demethylation potency among other SAD
of SAD Lawang content of EGCG, flavon and
flavonoid. EGCG predicted have strongest inhibitor
flavonol. Chloroform fraction, were content : cathecin,
DNMT potency, becaus its capable to bond the actove
dihidroflavonol and flavanon. From recent study, we
site of DNMT using 3 hidrogent bonds.
found that those comppound have potencies as an p53
DISCUSSION expression enhancer and strong proliferation inhibitor
agent compare to n-hexan fraction (7) . The anti-cancer
SAD Favonoid compound that isolated from Lawang
effect assumed from interaction from chloroform fraction
Jawa Timur can bond with active site of DNMT, and have
compound in the chlorodorm and n-hexan towards
a potency as an inhibotor DNA methylation. Insilico
DNMT inhibition activity, and inhibition apoptosis
study was shown that every SAD flavonoid compound,
and proliferation indirct and directly. The epigenetic
could form a bond with DNMT active site via certain
modification like methylation and demethylation will
and diferent amino acids. EGCG was a compound that
be able to influenc the tumor progresion, metastasis,
shown the highest afinity towards DNMT active site,
and resistency towards chemotherapy (1), (2), (12), (13), (14), (15) .
followed by : katekin, dihidroflavonol and flavon, with
Some studies have reported tha some genes were silenced
binding affinity value respectively were : -10.4 Kcal /
becaus og the methylation on its promotor (16), (17) . The
mol, -8.4 Kcal / mol, -8.2 Kcal / mol, dan -8.0 Kcal /
active compound of SAD Lawang in silico have been
mol. The smallest binding affinity value means that
proved inhibit DNA methyltion, and have opportunity
he compound have stronger inhibition effect potency
as a natural demethylation agent, that potencial as a drug
towards DNMT action.
for cancer in the future.
Previous studies have beeen shown that flavanol
CONCLUSION
compound, cathechin and EGCG were potencial
demethylation agent. EGCG will inhibit DNMT via This in silico study have been prove that flavonoid
blocking the cytosin to link in the DNMT active site. compound in the SAD Lawang owing a potency towards
EGCG eill form a hidrogen bond with DNMT active inhibition DNA methylation, with EGCG as the strongest
site, and methylation will be inhibit. This will reactivate candidate. Result of this study can be used to explore
the genes that silenced by methylation. The othet study potencies active compound from SAD as anticancer
also reported that cathechin and EGCG on green tea agent in future both in vitro and in vitro.
and apple give an demethylation effect 5-aza-2dC like.
5-aza-2dC is an synthetic DNMT 1 inhibitor, already
ADDITIONAL INFORMATIONS 8. Goel R K, Singh D, Lagunin A, Poroikov V. PASS-

assisted Exploration of New Therapeutic Potential
Conflict of Interest Statement
of Natural Products. Med. Chem. Res. 2011; 20:
All members of the team of research and article 1509e14
writing stated that there is no conflict of interest related 9. RSCB PDB. Biological Macromolecular Structures
to all research activities or publications of this research Enabling Breakthroughs in Research and Education
article. [Internet]. Protein Data Bank. 2011 [cited. 2017
January 1]. Available from: http://www.rcsb.org/
Source of Funding : All funds used to finance all
pdb/results/results.do?tabtoshow=Current&qrid=
research activities and publications of research articles
2748BE7D
come from the research team and the authors of the
article. 10. Pettersen E F, Goddard T D, Huang C C, Couch G
S, Greenblatt D M, Meng E C, Ferrin TE. UCSF
Ethical Clearance : To ensure that there is no Chimera Visualization System for Exploratory
ethical violation as a result of the implementation of this Research and Analysis. J Comput Chem. 2004; 25
research, before the research has been conducted ethical (13): 1605 - 1612.
feasibility testing. Ethical approval recommendation for 11. Trott O, Olson A J. AutoDock Vina: Improving
this study taken from Ethics Committee of State Health The Speed and Accuracy of Docking with A
Polytecnic of Malang, Indonesia with number “ Reg. New Scoring Function, Efficient Optimization
No. : 009 / KEPK – Polkesma / 2015 “. and Multithreading. Journal of Computational
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Research. 2011; 67: 1 - 6. Kedokteran Universitas Indonesia; 2011.
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DOI Number: 10.5958/0976-5506.2018.00642.3
Revitalization of Posyandu as an Effort to Improve the
Function and Performance of Posyandu
Antarini1, Heru Santoso Wahito Nugroho2

1
Health Polytechnic of Ministry of Health at Pangkalpinang, Indonesia,
2
Health Polytechnic of Ministry of Health at Surabaya, Indonesia
ABSTRACT
This research was conducted in 2017 at posyandu in the working area of Girimaya Health Center with
case study approach. The sample was chosen by purposive sampling technique. Data were collected by
checklist as a tool, referring to guidelines for the Nutrition Manager of the Ministry of Health. In addition,
triangulation was also done through in-depth interviews to key informants, namely the cadre leader and the
triangulation informant, the health center officer and the under-five mother. Although the quantity of health
cadres has been sufficient, but their quality has not been maximized. The limited facilities, infrastructure and
funds make the government need to pay special attention to improving it.
Keywords: Posyandu revitalization, Cadres
INTRODUCTION village. When the posyandu was proclaimed, there

were 25,000 posyandu, and in 2011 there were 268,439
Integrated Service Post (Posyandu) is managed posyandu. But in terms of quality, there are still many
and organized from, by, for, and with the community, problems such as lack of facilities and cadre skills, in
to empower and facilitate the community in accessing this case posyandu cadres are elected, willing, able and
basic health services, especially for mothers, infants and have time to manage Posyandu(4).
toddlers. Posyandu has 5 priority programs: maternal and
child health, family planning, immunization, nutrition, The ratio of posyandu to the number of villages is
and prevention and control of diarrhe(1). 3.42. Community empowerment in the health sector
requires the participation of cadres, community leaders
Since its inception in 1986, Posyandu has achieved and religious leaders, namely 569,477 trained cadres /
many results. Maternal mortality (MMR) and infant community leaders / religious leaders(5).
mortality (IMR) have been successfully lowered, while
life expectancy of Indonesian population has increased The implementation of revitalization of Posyandu in
significantly. The 2007 SDKI data shows that there has Pangkalpinang City began in 2006, with activities such
been a decrease in MMR to 228 / 100,000 live births and as fulfillment of Posyandu facilities such as scales, Card
IMR to 34 / 1,000 live births. However, data from the to Healthy, Posyandu Information System, incentives for
SDKI 2012 shows an increase in MMR of 359 / 100,000 cadres, Supplementary Feeding, cadre training, cadre
live births and IMR of 4000 / 100,000 live births. By fulfillment for each posyandu and coaching posyandu;
2015 the MMR declines to 305 / 100,000 live births but to date these activities have not been evaluated.
of the Intercensal Population Survey Data.(2). MMR
Evaluation of activities can be done at the following
in Indonesia is higher compared to Myanmar (200 per
stages: 1) input (to find out whether the resources used
100,000 live births), Philippines (100 per 100,000 live
are in accordance with the standards and needs), 2) the
births), while in Thailand, Vietnam and Malaysia MMR
process (to know the effectiveness of methods, staff
is below 100 per 100,000 live births.(3)
motivation and communication among staff), 3) output
In quantity, the development of posyandu is very (to determine whether output can reach target)(6).
encouraging because there are 3 to 4 posyandu in each
MATERIAL AND METHOD
This research was conducted in 2017 at posyandu in Girimaya Health Center, Pangkalpinang, with case study
approach. The sample was chosen by purposive sampling. Data from posyandu cadres were collected by checklist
as a tool, referring to guidelines for the Nutrition Manager of the Ministry of Health. In addition, triangulation was
also done through in-depth interviews to key informants, namely the cadre leader and the triangulation informant, the
health center officer and the under-five mother.
FINDINGS
Table 1. The Results of Evaluation
Posyandu
No. Activity
Ceria Kelapa
Registration
1. Record toddler in register book, ask for card to healthy / MCH book. Yes Yes
Record the pregnant mother in register book, measure weight and upper arm
2. Yes Yes
circumference.
Record Couples Age of Fertile in register book, go to the counseling and health
3. Yes Yes
services.
Measurement of weight and upper arm circumference
Weighing a toddler Yes Yes

a. Insert a toddler into a weigh case, barefoot and diapers, then slide the
pendulum up the needle perpendicularly.
1. b. Read the weight by looking at the numbers at the end of the shear pendulum. Yes Yes
c. Record the weighing result on a MCH book Yes Yes
d. Return the pendulum to zero, then issue a toddler. Yes Yes

Measuring the upper arm circumference of pregnant women and women of
2.
childbearing age to determine the nutritional status. Yes Yes
Recording
Toddler
a. Recording and plotting the weights, creating child growth line. Yes Yes
1. b. Record every incident in the child. Yes Yes

c. Filling data on breast milk, immunization and vitamin A Yes Yes
d. Copying the weight to a posyandu information system. No No
Weight and upper arm circumference are recorded in MCH books and pregnant
2.
women register books in posyandu information systems. Yes Yes
The upper arm circumference is recorded on the register register of fertile-age
3. No No
couples / women of child-bearing age in the posyandu information system.
Counseling
1. Explain the growth of toddlers based on the results of weight measurement. Yes Yes
2. Delivering information about food for toddlers. Yes Yes
Conveying information and counseling to pregnant women and postpartum
3. Yes Yes
about examination results including high risk
4. Convey information to couples of childbearing age about family planning Yes Yes
5. Provide other necessary health counseling. Yes Yes
6. Referring to toddlers or pregnant women at risk. Yes Yes
Cont... Table 1. The Results of Evaluation
Posyandu
No. Activity
Ceria Kelapa
Provision of Health Services
1. Giving Immunization. No No
2. Provision of vitamin A capsules to infants, toddlers, and postpartum mothers. Yes Yes
3. Provision of blood booster tablets Yes Yes
4. Family planning services No No
5. Supplementary feeding Yes Yes
6. Antenatal care No No
7. Provision of mild treatment. No No
DISCUSSION it is not easy to get a new cadre who is willing to spend

time providing services at posyandu because many
Knowledge and Skills of Cadres
housewives who still help the head of the family to earn
The number of active cadres in both posyandu are a living.
5 people with high school education (80%) and all are
Posyandu cadres operate posyandu activities with
housewives. The number of active cadres is sufficient
preferred criteria from local community members, can
and varies from 4-5 people, but at the time of posyandu
read and write Latin letters, have pioneer and reformer
implementation, sometimes not all active cadres can
souls, community mobilizers, volunteer willingness to
attend. The lack of cadres and the number of workloads
work, have the ability and free time.(8)
leads to a shortage of jobs. Kader is active if participated
in posyandu activities at least 8 times a year. The Training of cadres aims to improve the capability
smoothness of posyandu services is supported by the and quality of cadres. This activity greatly supports
activeness of the cadres. Kader is said to be active if in the improvement of posyandu. Since 2007, cadres
posyandu there are at least 5 cadres(7). training has been carried out by Health Office or other
organizations in turn. Performance-related training
All cadres have not been exact in determining
provides space for the development and upgrading of
the age of children. Determining the age of toddlers
skills and competencies that can have a direct impact on
should be written in years and months, but the cadres
individual or team performance.(9)
write the age in years. This is not appropriate because
it is associated with complementary feeding (age 6-24 Incentives for Cadres
months) which requires the cadres to calculate the age in
months. In addition, the program of Early Stimulation, Incentives for cadres are provided directly by the
Detection, and Intervention for Growth and Development health center every three months regularly. The active
implemented with age in month. and attendance of the cadres can be monitored through
the attendance list, so that it can be easily seen the
All cadres are able to measure weight and suitability between incentives and attendance.
meticulously in reading and recording the weight. Not
all cadres are able to fill MCH book/ card to healthy, Ridwan et al reported that one of the impacts of
because there are new and uninformed cadres on how posyandu revitalization is an increase in the number of
to fill them. active cadres due to the transportation costs provided
by the government(10). One indicator of posyandu
Cadre skills are lacking as some of them are new revitalization progress from the input aspect is the
cadres. Older cadres who have been in posyandu number of cadres who have access to improve their
training have dropped out. Therefore, the training that economic condition(11).
has been implemented so far less effective. In addition
Other rewards are free service for cadres and their
families at health centers. The result of Syafei’s research are used to finance posyandu activities(1).
shows that free service is given to the cadres and their
Posyandu Activities
families. However, not all free service policies for
cadres are made by health center. There are health center 1. Registration
that provide free service policy only to the cadres only,
there are even health center that do not make free service Registration has been carried out according to the
policy for cadres(12). standard that is: fill the register register book and ask
card to healthy / MCH Book. For pregnant women, fill
Facilities and Infrastructure the register register of pregnant women and invite to the
place of measurement of weight and measurement of
The results showed that posyandu had good scales,
upper arm circumference.
weighing pants, upper arm circle ribbons, MCH book
/ card to healthy, extension aids, Vitamin A and Fe 2. Weighing and measuring the upper arm
capsules, cadre manual and recording and reporting circumference
books. However the SKDN diagram data board is only
owned by the Posyandu Ceria. The making of SKDN There are 4 cadre posyandu Ceria able to measure the
diagram can be done outside of Posyandu activity. weight, while 1 cadre can not do it because he is a new
Posyandu Kelapa has a very complete counseling tool cadre. There are 2 posyandu Kelapa cadres who have
that poster 5 posyandu program, diarrhea prevention, not been able to measure the upper arm circumference
environmental health, maternal health, balanced because they have not been trained on the subject(14).
nutrition, ARI prevention, and immunization.
Weight measurement aims to monitor the growth of
Facilities and infrastructure such as buildings, toddlers every month. On the basis of this month’s data
tables, chairs etc. most still use community property. can be determined follow-up(8).
Scales, stationery, and register books are available at
3. Recording
all posyandu. Extension poster can only be installed
in posyandu which already have their own building, Not all cadres are able to perform recording of
meanwhile for posyandu that do not have building, toddlers and pregnant women because each cadre
poster still kept at home of cadre chairman. Stock card performs tasks in accordance with their respective tables,
to healthy is already available at both posyandu. so that inexperienced perform tasks at other tables. They
also do not copy the contents of the card to health into
Cards to healthy and MCH books are an important
the book of information system posyandu. In this case,
tool for monitoring infant growth, so malnutrition cases
the cadres need to be trained on filling in the format of
can be detected and addressed as early as possible.
the posyandu information system first. The benefits of
Achieving a policy objective must be supported by posyandu information system are: 1) as a reference for
the availability of facilities and infrastructure. Without posyandu cadres to understand the problems, so as to
facilities and infrastructure, tasks can not be executed develop appropriate activities and in accordance with
so that the objectives can not be achieved properly. the needs of the target, 2) to provide information on the
The availability of facilities and infrastructure is a management of posyandu, to build posyandu for the
determinant of the performance of a policy(13). benefit of the community(15).
Operational Fund 4. Counseling
Besides the 5 posyandu activities, there are other Counseling is not carried out by cadres, but is
activities in Posyandu Ceria namely the Toddler still widely assisted by health workers. Counseling is
Family Development and Healthy Fund. Community rarely done by the cadres due to the lack of tools and
contributions are mainly used for the cost of extension materials, and the low ability of cadres in
supplementary feeding. Fund management is done by doing counseling.
Posyandu management. Each income and expenditure
Activities related to maternal and child health,
are managed responsibly. Funds obtained by posyandu
family planning, nutrition, immunization and diarrhea
prevention have been implemented. Posyandu activities activities to run properly, it takes coaching from
that are always implemented are weight measurement health workers and related institutions. The purpose of
of children under five, supplementary feeding and coaching is to provide guidance, to guide the coverage
immunization. At Posyandu Ceria, family planning of posyandu increases, to help solve problems and to
programs, maternal and child health, and diarrhea motivate the cadres to be more energized and achievers.
prevention are not done, as health workers recommend
that they be served in village maternity huts, considering Basically the cadre’s guidance function is to increase
that the facilities at posyandu are incomplete. the cadre’s insight, so their skills and confidence are
higher. This will be seen in his stance and accompanied
Individual counseling is conducted on table IV. by a sense of responsibility(1).
The given material is aligned with the condition of the
toddler. The first step of the cadre before carrying out the Monitoring activities are carried out by the health
counseling is to pay attention to the card to be healthy, office through monthly reports from community health
then tell the mother about the state of the child based centers. Supervision is not done specifically, but is done
on changes in the child’s weight listed on the card to in conjunction with coaching. Supervision is a very
healthy and cadre carry out counseling based on the important activity in order to achieve organizational
results of weight measurement of children under five(8). goals. The purpose of supervision is to improve
management functions and have a forward-looking
5. Health Services orientation(6).
At Posyandu Ceria, immunizations, family planning CONCLUSION

services and pregnancy checkups were not performed
because the posyandu activities were conducted in the Although the quantity of health cadres has been
homes of residents and there were no midwives in the sufficient, but their quality has not been maximized.
posyandu. However, the Posyandu Ceria has healthy The limited facilities, infrastructure and funds make the
funds used for supplementary feeding. government need to pay special attention to improving
it.
Posyandu Kelapa activities are carried out at village
health posts so that health services such as immunization, INFORMATION
family planning and pregnancy tests can be carried out, There is no conflict of interest related to this study.
because there are midwives in charge at the venue. There All funds of this study taken from researchers. this study
is no additional feeding at Posyandu Kelapa Karenan no already has ethical clearance.
funds available.
REFERENCES
The two posyandu have implemented the service
with a five table system but most of the posyandu in 1. Kemenkes RI. General Guidelines for Posyandu
the implementation of registration and weighing are Management (Pedoman Umum Pengelolaan
incompatible with the 5 table system. This is done by the Posyandu). Jakarta: Kemenkes RI; 2011.
cadres to maintain the effectiveness of work and time 2. Kemenkes RI. Indonesia Health Profile 2015puskes.
efficiency. Jakarta: Kemenkes RI; 2016.
To see the commitment of health workers, it can be 3. Unicef Indonesia. Maternal & Child Health.
seen from the presence of health workers in posyandu Jakarta: Unicef Indonesia; 2012.
activities. health personnel present at the two posyandu 4. Kemenkes RI. Curriculum and Module of
are village midwife, midwife, nurse and doctor of Training of Posyandu Cadres (Kurikulum dan
community health center. The attendance of health Modul Pelatihan Fasilitator Pemberdayaan Kader
worker of community health center in Posyandu is Posyandu). Jakarta: Kemenkes RI: 2012.
obligated once a month(1). 5. Kemenkes RI. Indonesia Health Profile 2014.
Guidance and Supervision Jakarta: Kemenkes RI; 2015.
6. Muninjaya GA. Health Management (Manajemen
In order for the implementation of posyandu Kesehatan). 2nd ed. Jakarta: EGC; 2014.
7. Ferizal Y, Mubasysyir H. Implementation Process 11. Depdagri RI. General Guidelines for Posyandu
of Posyandu Service Management on Intensity Revitalization (Pedoman Umum Revitalisasi
Posyandu [Data Analysis of Sakerti 2000] (Proses Posyandu). Depdagri RI; 2001.
Pelaksanaan Manajemen Pelayanan Posyandu 12. Syafey, Luthfan, Mubasysyir. Empowerment of
Terhadap Intensitas Posyandu [Analisis Data Cadres in Posyandu Revitalization in Batang Hari
Sakerti 2000]). Manajemen Pelayanan Kesehat. Regency (Pemberdayaan Kader dalam Revitalisasi
2007. Posyandu di Kabupaten Batang Hari). J Manaj
8. Depkes RI. Posyandu Cadres in Family Nutrition Pelayanan Kesehat. 2008.
Improvement Efforts (Kader Posyandu dalam 13. Winarno B. Public Policy, Theory and Process
Usaha Perbaikan Gizi Keluarga). Jakarta: Depkes (Kebijakan Publik Teori dan Proses). Yogyakarta:
RI; 2006. Media Pressindo; 2008.
9. Dharma S. Performance Management [Philosophy, 14. Ditjen Bina Gizi dan KIA Kemenkes RI. Guidance
Theory and Its Implementation] (Manajemen for Health Center Nutrition Executor in Coaching
Kinerja [Falsafah, Teori dan Penerapannya]). Posyandu Cadre (Panduan Tenaga Pelaksana Gizi
Yogyakarta: Pustaka Pelajar; 2005. Puskesmas Dalam Pembinaan Kader Posyandu).
10. Ridwan M, Dewi M, Mubasysyir H. Revitalization 2012.
of Posyandu, Its Influence on Posyandu 15. Kraft Food Foundation. Handbook of Posyandu
Performance in Tanggamus District (Revitalisasi Cadre (Buku Pegangan Kader Posyandu).
Posyandu, Pengaruhnya Terhadap Kinerja
Posyandu di Kabupaten Tenggamus. J Manaj
Pelayanan Kesehat. 2007.
DOI Number: 10.5958/0976-5506.2018.00643.5
Global Comparison of Ambulance Services in Select Countries
and Feasibility to Have Standardized Ambulance
Services for India
Parag Rishipathak1, Rajiv Yeravdekar2, Prasad Rajhans3

1
Deputy Director, 2Director, 3Consultant - EMS, Symbiosis Institute of Health Sciences,
Symbiosis International (Deemed University), Pune, India
ABSTRACT
Introduction: Emergency Medical Service (EMS) is provided by a variety of individuals, using a variety
of methods. The levels of service available will fall into one of three categories: Basic Life Support (BLS),
Advanced Life Support (ALS) and Intermediate Life Support (ILS)
Objective: The objective of the study was to compare the ambulance services in various parts of the world
and to study the feasibility of having standardized ambulance services for India.
Methodology: The present study focuses on Ambulance services in select countries of the world based on
questionnaire circulated and responses obtained. This study is based on the responses obtained from EMS
stakeholders working in EMS field in India and various parts of the World. Their responses were corroborated
for authenticity through additional sources e.g. website, official publications of their Institutions and in some
cases through personal interaction with the authorities.
Results: There is no standardization of ambulance design across various procurements in the country and the
industry is forced to re-integrate their vehicles every now and then. Most of the ambulance specifications are
written by medical specialists who are unable to translate the user requirements in automobile terminology
there by resulting in a huge gap between the user expectations and industry deliverability. Developed
and developing countries have both Basic Life Support (BLS) & Advanced Life Support (ALS) type of
Ambulances.
Conclusion: The real concept of an ambulance is missing in India. EMS is responsible for delivery of
Emergency care in pre-hospital or out of hospital environment and to develop relatively good EMS model.
India should have both BLS as well as ALS type of ambulance services which should include Ambulance
Vehicles, Ambulance drivers and Emergency Medical Technicians (EMT’s). There is also need to issue
necessary instructions to the buyer of the incompletely built vehicle about the constructional and functional
aspects of the ambulance.
Keywords: Advanced Life Support (ALS), Ambulance, Basic Life Support (BLS), Emergency Medical
Service, Intermediate Life Support (ILS).
Introduction to provide immediate aid to the victims in order to save

their lives. The World Health Organization (WHO) in its
In India, every 4 minutes, one person dies on the landmark 2005 treatise on EMS and pre hospital trauma
road1. While 7 to 10 percent are critically injured, 20 care systems also, has established the importance of
to 30 per cent are seriously hurt, of these about 30 per EMS and pre hospital trauma care systems in reducing
cent are disabled for life, either partially or totally2. morbidity and mortality from injury and violence and
Considering the rate of road accidents and following therefore the need and priority for development of EMS
critical injuries, there is a need for Emergency services
system worldwide3. the service. The objective of this paper were to study
ambulance services in the selected developed and
As per a WHO draft outlining the key concepts for
developing countries and study the feasibility of having
developing pre hospital trauma care systems minimally,
standardized ambulance services for India.
an effective pre hospital care system should contain
the following elements: “Prompt communication and Methodology
activation of the system, the prompt response of the
The present study focuses on Ambulance services
system and the assessment, treatment and transport of
in select developed & developing countries of the
injured patients, regardless of country or terrain in which
world based on questionnaire circulated and responses
their injuries occur and regardless of the economic
obtained. This study is based on the responses obtained
status of the country or municipality rendering care and
from EMS stakeholders working in EMS field in
treatment”4.
these countries (developed & developing countries).
The first one hour after the road accident is critical The primary data was obtained from an interview and
for saving lives. In this “golden hour”, as coined by Dr. an analysis of the responses obtained from various
R Adams Cowley5, prompt medical aid can be critical EMS stakeholders to the questionnaire administered
to the patient’s survival6,7. Death rate can be reduced by personally. Their responses were corroborated for
30% if better medical aid is provided in the first hour authenticity through additional sources e.g. website,
after accident. Proper wound care, immobilization of official publications of their Institutions and in some
fractures, availability of Oxygen, intravenous fluids, cases through personal interaction with the authorities.
prompt recognition of life - threatening conditions and Similar questionnaire was also administered to EMS
transport to definitive care can all reduce morbidity authorities in various parts of India via e mail. In order
and mortality. This should be the chief function of a to obtain a global perspective and understanding of EMS
well-equipped ambulance. Unfortunately, in much of system prevalent in various parts of the World, similar
the developing world such services are unavailable questionnaire was administered to EMS authorities in
and care and transport of the sick and injured patient various parts of the world via e mail. Unfortunately,
are carried out by lay people. EMS essentially aims at despite repeated reminders researchers managed to obtain
either providing treatment to those in need of urgent limited responses, both nationally & internationally.
medical care, with the goal of satisfactory treatment, To supplement the interview responses, information
or arranging for timely removal of the patient to the of countries included in the study from secondary data
next point of definitive care. This role must be played were collected.
by an efficient ambulance service and subsequently the
As regards secondary data, published literature
Casualty department at a hospital or another place where
relevant to Ambulance services in various parts of
physicians are available.”8
the world to include select countries and India was
EMS is provided by a variety of individuals, identified. This was to identify various Ambulance
using a variety of methods9. To some extent, these are services existing in various parts of the World and study
determined by country and locale, with each individual various Ambulance services existing. Literature was
country having its own ‘approach’ to how EMS should identified through electronic literature searches & data
be provided, and by whom. Generally speaking, the bases. Websites of various EMS organizations were
levels of service available will fall into one of three also accessed. This was to identify various Ambulance
categories: Basic Life Support (BLS) Ambulance is services existing in India and various parts of the World.
used to transport relatively stable patients; Advanced The Basis of selection of Countries and the Inclusion
Life Support (ALS) Ambulance that contains all criteria and Exclusion criteria are detailed further.
emergency equipment and drugs necessary to manage
any kind of patient emergency; and, Intermediate Life
Results and Discussion
Support (ILS), which is essentially a BLS provider For purpose of this study, three strata with countries
with a moderately expanded skill set, may be present, having Emergency Medical Services were considered
but this level rarely functions independently, and where for study.
it is present, may replace BLS in the emergency part of
Countries that do not have existing EMS were countries having existing EMS) of size n= 147 which is
omitted from the study. Countries were grouped in divided into three strata as under.
three categories, High, Medium and Low Human
For strata n1=79 we have Pi=79/147 and hence,
Development Index. The Human Development Index
(HDI) is a comparative measure of life expectancy, n1 = n.Pi = 15 x 79/147 = 8.0612 rounded off to 8
literacy, education, standards of living and quality of life
for countries worldwide4. n2 = n.P2 =15 x 23/147 = 2.234 rounded off to 2
It was noticed that the group / population is not n3 = n.P3 =15 x 45/147 = 5.591 rounded off to 6
homogenous, hence stratified sampling techniques were
Thus using proportional allocation the sample sizes
applied. Each strata was formed on basis of common
for different strata are eight, two and six respectively
characteristics thus,
which is in proportion to the size of the strata seventy
Strata I included. nine: twenty three:” forty five (79:23:45) (i.e. stratified
sample was obtained). Thus after performing stratified
79 Countries with High Human Development Index. Random Sampling following countries were selected
from each strata for the study.
Countries having existing Emergency Medical
Services. Eight Countries with High human Development
Index with existing EMS:
Strata II included
United States of America, New Zealand, Canada,
23 Countries with Medium Human Development
Germany, Hong Kong, Singapore, United Kingdom,
Index.
France
Countries having existing Emergency Medical
Two Countries with Medium human Development
Services
Index with existing EMS
Strata III included.
Sri Lanka & South Africa
45 Countries with Low Human Development Index.
Six Countries with Low human Development Index
Countries having existing Emergency Medical with existing EMS
Services.
Kenya, Pakistan, Bangladesh, Sudan, Afghanistan,
It was ensured that all elements are most homogenous Nepal
within each stratum and heterogeneous between different
India is in Medium human development index
strata. For selection of countries to constitute sample
category with existing Emergency Medical Services.
from each stratum, simple random sampling technique
was used. Name of each element was written on a slip of The sample size consisted of all EMS stakeholders
paper and all slips were put in a box, mixed thoroughly working with various EMS setups across the world.
and blindly drawn the required number of slips and put A total of Seven hundred and fifty filled forms were
back for all participants to have equal chance of being collected. Incompletely filled ambiguous responses,
in the sample. Repeat slip was not included on second ineligible forms etc. were discarded. Finally, six hundred
time. (i.e. once an item is drawn selected for sample, and seventy two forms were analyzed. The forms filled
it cannot appear again in the sample.) It was ensured were collected, collated and analyzed by using statistical
that in successive drawing each of remaining elements package for social sciences (SPSS) Software version16.0
of population has same chance of being selected. for the purpose of the study. It can be seen (fig. 1) that
That is if Pi represents proportion of population (High 60.5% of respondents say that India has only Basic
Human Development Index) included in stratum i and Life Support (BLS) type of Ambulances and 26.3%
n represents total sample size, the number of elements replied India has Advanced Life Support (ALS) type of
selected from stratum i is n.Pi. For e.g., when we want a Ambulances, whereas 13.2% of respondents replied that
sample size of n=15 to be drawn from a population (all India has both or other type of Ambulance Services.
points were highlighted during these discussion10:
There is no standardization of ambulance design

across various procurements in the country and the
industry is forced to re-integrate their vehicles every
now and then.
Most of the ambulance specifications are written

by medical specialists who are unable to translate the
user requirements in automobile terminology there by
Fig. 1: Type of Ambulances available in respondents’ part of resulting in a huge gap between the user expectations
India
and industry deliverability.
This analysis shows that developed and developing
countries have both Basic Life Support (BLS) & There are certain inherent limitations in the existing
Advanced Life Support (ALS) type of Ambulances. laws which allow goods vehicles to be converted
as ambulances for passenger application without
The Ministry of Road Transport and Highways, incorporating essential safety features in patient
Govt. of India has set up five Working Groups on compartment like side door, forward backward seating,
4Es of Road Safety i.e. Education, Engineering occupant restraints, certified electrical systems, etc.
(Vehicles), Enforcement and Emergency Care on the
recommendation of the National Road Safety Council Thus Ambulance was broadly categorized as:
(NRSC).9 The Working Group on Emergency Care in its
Basic Life Support Ambulance – A vehicle
report observed that the real concept of an ambulance
ergonomically designed, suitably equipped and
is missing in India. Existing ambulances are more like
appropriately staffed for the transport and treatment of
transport vehicles and any vehicle suitable to lay a
patients requiring non - invasive airway management/
patient is called an ambulance without consideration to
basic monitoring.
the overall ambulance design. Unrestrained occupants,
particularly those riding in the patient-care compartment, Advanced Life Support Ambulance - A vehicle
are particularly vulnerable. It is, therefore, all the more ergonomically designed, suitably equipped and
necessary in an ambulance to take care of occupant safety, appropriately staffed for the transport and treatment
patient care ergonomics, medical equipment selection of patients requiring invasive airway management/
and placement, vehicle engineering and integration, etc. intensive monitoring
The working group recommended that there is a Information analyzed from Secondary Data of
need to formulate the various countries from study shows that in selected
countries ambulance vehicles attempt to meet either
“National Ambulance Code” 10 with necessary
European standard for ambulances CEN 1789, published
amendments in Central Motor Vehicle Rules (CMVR)
by European Committee for standards or United States
that defines the Constructional and Functional
federal KKK-1822 standards. They are either Basic Life
Requirements for Road Ambulances. In view of this,
Support (BLS), or Advanced Life Support (ALS) or
an Expert Committee was constituted with approval
both.
of the Hon’ble Union Minster for Road Transport and
Highways to formulate the “National Ambulance They are used for transportation depending upon
Code”. The Committee took stock of the existing trends severity of illness.
vis-a-vis ambulance construction, design and integration
to understand the current scenario, limitations of the Emergency Calls.
existing framework, available technology, manufacturer Doctor’s urgent admission request.
maturity, local conditions, past trends, etc. The
committee members shared their experiences as regards High dependency and urgent inter – hospital transfer.
the Indian reality and deliberated on the reasons behind
Major incidents.
the condition of ambulances. The following important
Conclusion November 5, 2017 from: http://hdr.undp.org.
The real concept of an ambulance is missing in India. 4. United Nations Development Programme. The
Existing ambulances are more like transport vehicles Human Development concept. Retrieved on
and any vehicle suitable to lay a patient is called an November 5, 2017 from: http://hdr.undp.org/en/
ambulance without considering the overall ambulance humandev.
design. As EMS is responsible for delivery of Emergency 5. Hudak III, Joseph J. (2015). The Origins of the
care in pre-hospital or out of hospital environment and to Golden Hour of Medical Care and Its Applicability
develop relatively good EMS model, India should have to Combat Medicine [Master’s thesis]. Army
both BLS as well as ALS type of ambulance services Command and General Staff College’ Defense
which should include Ambulance Vehicles, Ambulance Technical Information Center, Fort Belvoir, VA.
drivers and Emergency Medical Technicians (EMT’s). Retrieved on November 25, 2017 from: http://www.
There is also need to issue necessary instructions to dtic.mil/docs/citations/ADA624140.
the buyer of the incompletely built vehicle about the 6. Eisele, C. (2008). The Golden Hour. Journal
constructional and functional aspects of the ambulance. of Emergency Medical Services. Aug 31, 2008
Any body builder who is engaged in the activity of Retrieved on September 25, 2017 from: http://www.
building ambulances needs to follow the prescriptions jems.com/articles/2008/08/golden-hour.html?c=1.
of National Ambulance code for necessary compliance,
7. British Red Cross. (2001, May). Road Accidents and
verification & certification.
First Aid. Retrieved December 27, 2017, from https://
Ethical Clearance- IEC, SIU clicktosave.com.au/wp-content/uploads/2013/06/
British_Red_Cross_Road_ Accidents_First_Aid1.
Source of Funding- Nil pdf.
Conflict of Interest - Nil 8. Nhsrcindia.org. (2018). Retrieved January 8,
2018 from http://nhsrcindia.org/sites/default/files/
References Emergency%20Medical%20Service%20in%20
India%20Concept%20Paper.pdf.
1. India Sees One Road Accident-Related Death Every
Four Minutes. (2016, June 10). Retrieved December 9. The Ministry of Road Transport & Highways
12, 2017 from: https://www.thequint.com/news/ (2016). Retrieved December 26, 2017 from http://
india/india-road-safety-2015-recorded-highest- pib.nic.in/newsite/PrintRelease.aspx?relid=155892.
number-of-fatalities-tamil-nadu-maharashtra-save- 10. Constructional and Functional Requirements for
life-foundation. Road Ambulances (National Ambulance Code)
2. A case study in French Emergency Medicine. The Printed by-The Automotive Research Association
Internet Journal of Rescue and Disaster Medicine 1 of India Set-Up by- Ministry of Road Transport and
(2). Highways Government of India. http://www.nisc.
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3. United Nations Development Programme. History
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DOI Number: 10.5958/0976-5506.2018.00644.7
A Low Cost Wireless Patient-health Tracking System
Mandeep Singh1 , Deepak Jain2

1
Assistant Professor, 2Research Scholar, EIED, Thapar University, Patiala, INDIA,
ABSTRACT
Remote health monitoring systems have started to become one of the main building blocks of modern
healthcare systems. It offers innovative and better ways to monitor chronic diseases or detect early
deterioration, especially in case of patients, old people and infants. It acquires physiological signals using
sensors and wirelessly transmits them to a remote healthcare station where they are monitored. This paper
presents the design and development of a health monitoring system using a 16 bit microcontroller that
monitors vital parameters namely heart rate, respiration rate, body temperature and body orientation.
MSP430 based microcontroller acts as the data acquisition unit interfaced with orientation sensor and the
Bluetooth chip, tied around the upper arm of the patient. An elastic chest belt houses the sensors for body
temperature and respiration rate. The pulse sensor is worn either on the index finger or the ear. The data is
then transferred from the board to a nearby laptop or mobile phone via Bluetooth where the data is stored
and displayed graphically.
Keywords: Wireless monitoring, orientation, physiology parameters, healthcare system, wearable embedded
system.
Introduction belt for calculating the respiration rate, a LM35 sensor

to measure the body temperature and the MPU9150
Affordability of healthcare has started to become body orientation sensor worn on the upper arm by the
a bigger issue. Generally automation is the key to patient. All the sensors are connected to MSP430 based
reduce costs. This automation is provided by the microcontroller board where these signals are processed
wireless medical embedded systems through ubiquitous and then sent wirelessly through Bluetooth module to a
patient monitoring and automated data analysis1. The laptop/smart phone, from where the data can stored and
population of people aged 65 and above was around displayed and send to the physician for consultation.
500 million in 2006. The number will be doubled by
2030 to around 1 billion. The conventional healthcare Body sensors: 1.
systems, used in hospitals which focus on diagnosis and Pulse sensor
2.Temperature,
Data aquisition
and signal
Wireless Receiver for
transmission: display, tracking
3.Respiration processing by a
treatment, are shifting their focus towards an individual- rate, Micro-controller
Bluetooth/ WiFi and record
4.Orientation
oriented healthcare system with the main purpose of
early detection of risk factors, early diagnosis, and early Figure 1. Block diagram of the proposed system
treatment2-4. Materials anad method
A basic block diagram of the wearable vital signs Heart rate
monitoring system is depicted in Figure 1. It shows the
location of pulse sensor on the index finger which is used Continuous monitoring of vital signs can help
to monitor heart rate, a force sensitive resistor on the chest identify a patient’s risk for stroke, heart attack, heart
failure etc.5 . In this system heart rate is measured using
photo-plethysmograph (PPG) technique. It is a low cost,
Corresponding author: non-invasive technique to measure heart rate at skin
Mandeep Singh surface6. It uses a an LED which illuminates the skin
Assistant Professor, EIED, Thapar University, Patiala, surface and a photo detector which detects the intensity
INDIA, E-mail: [email protected] of light reflected back which changes periodically with
the heart rate. With each heartbeat, a surge of blood key aspects to detect early changes in the health status
is forced through the vascular system, expanding the of critically ill patients8. In this design it is monitored
capillaries in the finger, and changing the amount of using a force sensitive resistor (FSR). It is a square
light returning to the photo detector7. resistor with sensing area of 1.75”x1.5”. It is placed
on the chest belt. It is one of the cheapest methods to
PPG signal has been used to detect heart rate at
monitor respiration rate. When a person inhales the
different positions of the human body to select the best
chest expands and the resistor experiences force and
location having highest accuracy and minimum artefacts.
consequently its resistance increases. When the person
Three different locations were chosen which were the
exhales the chest contracts and the pressure/force on the
ear, index finger and the palm. Figure 2a) represents the
resistor reduces and the resistance decreases. A voltage
output waveform of PPG taken from the index finger,
divider is made with this resistor and a 22kΩ resistor
2b) is from the palm and 2c) is from the ear. The peak
with a voltage supply of 3.3V. The output voltage across
values for the 3 output waveforms were 3V, 2.5V and 2V
the resistor changes periodically with the respiration
respectively. As evident from the figure 2a also, the most
rate. The peak voltage is about 1.7V.. Figure 3 depicts
prominent peak came from the output of the index finger,
the waveform corresponding to the output voltage of the
where a significant pulse wave is visible. Therefore the
FSR. It is very easy to calculate the respiration rate from
index finger has been selected to acquire the pulse rate.
this waveform using a voltage level detector algorithm
in microcontroller. The sensor was calibrated with the
help of a spirometer which also helps in finding the
respiration rate. In spirometer with one hand you have to
hold the sensor close towards a nostril and with the other
hand you have to close the other nostril and breathe into
the sensor.
Figure 3. Output waveform of voltage across resistor

connected in a voltage divider circuit
Body Temperature
Body Temperature is a vital sign as it can be used

Figure 2. PPG output waveforms from a) index finger, b) palm to detect infection, viral or an inflammation etc. So it is
and c) ear. very important to monitor it. As the system has to made
Later on, the pulse sensor has been calibrated using wearable, temperature was monitored at 4 different
with a standard Medical grade pulse oximeter. The locations namely wrist, chest, anterior calf and auxiliary.
output from the pulse sensor and oximeter was taken The normal temperature is approximately within the
simultaneously. The index finger was considered the range of 95.9-98.6° F (35.5-37.0 °C) 9. The sensor used
best position due to its best output. Positioning of the for these locations was LM35 by Texas Instruments. It is
sensor at the palm was found to be quite uncomfortable highly accurate at room temperature with an accuracy of
and the output at ear was quite low, though it could be ±0.25°C. It has a wide range from -55°C to 150 °C. The
used as a probable position. output voltage is directly proportional to temperature in
°C with a scale factor of 10mV/° C. For example if the
Respiration Rate output voltage is 320mV then the temperature is 32 °C.
The monitoring of the respiration rate is one of the
Body Orientation Results
In some cases, it is important to note down the The heart rate is taken from the index finger as the
sleeping pattern of the patient. Body orientation in this output of the pulse sensor is most significant from there.
system tells whether the person is lying down or standing, Table 1 shows the comparison of heart rate calculated
sitting or rolled-over. Orientation is monitored using using the pulse sensor on index finger and a standard
MPU9150 sensor. This sensor keeps the track of body medical grade pulse oximeter.
movements that may be useful in clinical correlation. It
is one of the finest 9-axis motion tracking device which Table 1 Heart rate using pulse sensor and
has an inbuilt 3axis accelerometer, 3-axis gyroscope and comparision with pulse oximeter
a 3-axis magnetometer. It has an inbuilt digital motion
Subject Pulse Oximeter Pulse Sensor (Heart
processor; 16-bit ADC’s (Analog to Digital Converter) Number (Heart Rate bpm) Rate bpm)
Error
and can measure up to ±16g of force, ±2000 degrees/
1 85 82 3.5%
sec rotation and ±1200μT magnetic field. It uses I2C
2 86 89 3.4%
(inter-IC communication) communication with the
3 97 99 2%
microcontroller.
4 78 75 3.8%
Microcontroller 5 66 64 3%
The microcontroller used is Texas Instruments 6 68 70 2.9%
MSP430G2553. Its launch pad kit with the circuit on 7 95 95 0%
board can be seen in Figure 7 with the whole circuit. The 8 69 70 1.4%
microcontroller has 8 analog channels, supports UART 9 83 82 1.2%
(Universal Asynchronous Receiver/Transmitter), I2C 10 88 90 2.2%
communication and has an inbuilt 10-bit ADC. It also Average Error 2.3%
acts as the data acquisition unit of the system.
It has been observed from table 1 that the maximum
Wireless Communication
error was found to be ±3.8% and the average error is
There are a number of wireless technologies available ±2.3 % of true value, which is acceptable.
in the market. Mainly two of them are frequently used
namely Bluetooth10 and Zigbee11. Bluetooth is used in Table 2 shows the respiration rate calculated using
this system as it is more popular, low cost and easy to the sensor and a spirometer. It was observed from table
use. When Bluetooth is connected with the laptop it 2 that the maximum error was found to be ±1 unit and
assigns a COM port to the Bluetooth and it can be used average error is also ±1 unit which is acceptable.
as UART. Basically it acts as a cabled serial port. Table 2 Respiration rate using FSR and
Software Used spirometer
Code composer studio 5.5.0 12
Subject Spiro meter Force Sensitive Error
Code composer studio is an integrated development Number Resistor (units)
environment which is used to program Texas Instruments 1 14 14 0
Microcontroller. 2 23 22 -1
NI LabVIEW 3 28 29 1
National instruments Laboratory Virtual Instrument 4 16 15 -1
Engineering Workbench (LabVIEW) software is used 5 15 15 0
for making a Graphical User Interface (GUI). VISA 6 17 18 1
resource is used for connecting with the Bluetooth via 7 25 26 1
COM port. It tells about the Heart Rate, Body 8 13 12 -1
Temperature, Respiration Rate and Orientation. It 9 17 18 1
also has a visual alarm which turns bright green if any 10 21 20 -1
parameter is abnormal. Average Error ±1
Table 3 shows the readings of the temperature of the Table 4 Mean and standard deviation at different
participants at different locations with LM35 sensor and locations
a standard clinical digital thermometer.
Standard
Location Mean Avg. Error
Table 3 Temperature measurement at Deviation
different locations with LM35 sensor and a Wrist 30.077 0.496 0.77%
digital thermometer Chest 33.011 0.116 0.5%
Axillary 32.133 0.35 1.2%
Digital Thermometer
LM35 Error Interior thigh 32.644 0.415 1.03%
(calibrated)
Subject 1 Conclusion
Wrist 30 30.3 1% In this paper, design of a low cost Bluetooth

based wireless patient monitoring system is presented,
Chest 33 33.2 0.6%
which can monitor 4 vital parameters like heart rate,
Axillary 32 32.4 1.2% respiration rate, body temperature and orientation. All
the sensors are connected to the analog channels of the
Anterior Calf 32.6 32.8 0.6%
microcontroller. Using UART the microcontroller is
Subject 2 connected to Bluetooth which sends the data wirelessly
Wrist 31.2 31.5 1% to LabVIEW on the laptop where the status of the person
can be monitored. As the data is being stored in real time
Chest 33.2 33.4 0.6% on the laptop or smart phone, further, the data can be
Axillary 31.6 31.4 0.6% shared through internet with a medical specialist in case
of emergency. An alarm button is also given which goes
Anterior Calf 32 32.1 0.3%
high if any parameter goes out of its normal range, which
Subject 3 can trigger an SMS or email to the ward of the patient.
The proposed system is of very low cost (around Rs.
Wrist 31.4 31.5 0.3%
600 or USD 10) and the novelty is that it can remove so
Chest 32.9 33 0.3% much junk of wires around the patient on hospital bed.
It can be used to monitor the health of elderly people,
Axillary 31.7 31.1 1.8%
patients at home, working personnel etc. It is also useful
Anterior Calf 31 30.3 2.2% in rural areas where health centres are not in abundance
or lack of facilities.
The temperature was monitored throughout the day
Ethical Clearance - The study is related to an
at the 4 locations. One such reading is shown in table
electronic circuit which operates on 3.7 V and does not
3 and the mean and standard deviation was found out
involve any intervention method or intrusive device to
which is shown in table 4. Temperature was taken from
the patient. Hence, ethical issue does not arise.
the chest as the deviation was the least, it was least
effected by external environment and won’t affect the Source of Funding - The present study is self
person during daily work. Hence the LM35 sensor was sponsored.
pasted on the chest belt itself. The error in the reading
was found to be quite small and hence temperature was Conflict of Interest – There is no conflict of interest.
successfully monitored. Moreover, this at this location,
References
error due to artifacts is also minimum. 10 participants
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MPU9150 sensor was able to identify with an accuracy A. Pantelopoulos, “Wireless MedicalEmbedded
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future challenges”, IEEE Engineering in Medicine Analysis of the Pulse Oximeter Waveform to
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Medical Informatics: Ubiquitous Health Care 8. M.A. Cretikos, R. Bellomo, K. Hillman, J. Chen,
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World Psychiatry, vol. 6, pp. 65–67, 2007. 9. M. Sund-Levander, C. Forsberg, L.K. Wahren,
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6. J. Allen, “Photoplethysmography and its 11. ZigBee (August 2017). [Online] Available at: http://
application in clinical physiological measurement”, www.zigbee.org.
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Available at: http://www.ti.com/tool/ccstudio
DOI Number: 10.5958/0976-5506.2018.00645.9
The Association of Risk Factors with Dental Caries in
Primary School Children in Banjar Disrtict
Rasuna Ulfah1, Erida Wydiamala2, Lenie Marlinae3
Student of Public Health Magister Program Medical Faculty LambungMangkurat University, 2Department of
1
Parasitology Medical Faculty LambungMangkurat University, 3Enviroment Health Department Public Health
Program Medical Faculty LambungMangkurat University
Abstract
Dental caries experienced by almost 70-95% in school children throughout Southeast Asia.1 The dental and
oral disease is the highest disease in primary school age children in Indonesia with a prevalence of 74.4%.2
This study aims to determine the relationship of risk factors with the incidence of dental caries in primary
school children. This research is quantitative with cross-sectional design conducted on elementary school
children in Banjar District. Sampling is based on multistage cluster sampling that has been established based
on inclusion and exclusion criteria with a sample size of 136 primary school children. Data were analyzed
using logistic regression test. The results showed that 82.4% of primary school children had high dental
caries. The logistic regression test showed that three variables had significant relationship and were the risk
factor of dental caries incidence was sweet food consumption (p = 0,000; OR = 16,980), oral and mouth
hygiene (p = 0,000; OR = 62,126), knowledge of the mother = 0,009; OR = 9,927) and the most influential
factor on dental caries incidence is the habit of maintaining oral hygiene (OR = 62,126). The conclusions
of this study are factors related to the risk of dental caries in primary school children is the consumption of
sweet foods, the habit of maintaining oral hygiene and knowledge of the mother, with the most influential
factor is the habit of maintaining oral hygiene.
Keywords: Dental caries, risk factor, elementary school age children.
Introduction (2013) shows South Kalimantan is the second highest

province with people with dental and oral problems by
Dental caries is a disease of the hard tissue of the 36.1% compared to the national average of 25.9%. The
tooth begins with continuous enamel and cementum, caries experience rate (DMF-T) depicting caries severity
which is caused by the activity of a microbial organ in South Kalimantan is 7.2 and is second highest in
in a fermentable carbohydrate. The sign is the Indonesia. Far above the national average DMF-T figure
demineralization of hard tooth tissue followed by of 4.6.5
damage to organic matter. As a result, bacterial invasion
and pulp death and the spread of infection periapical can The high incidence of dental caries and mouth
cause pain.3 can be caused by many factors, such as diet, oral
hygiene, socioeconomic, educational, knowledge and
The prevalence of dental caries and mouth in environmental practices.6,7 Primary school-aged children
Indonesia reaches 72.6% far above the target to be are susceptible to dental and oral diseases. Because at
achieved in 2020 of 54.6% .4 Basic Health Research Data that age children are very fond of sweet foods and oral
hygiene is less awake.8 Teeth damage left in children
can cause infection in the mouth and cause pain. These
Correspondence:
conditions affect the appetite and nutritional intake of
Rasuna Ulfah
children, so it can lead to growth disorders and affect
E-mail: [email protected]
[email protected] the nutritional status of children who ultimately have a
negative impact on the quality of life of children. 1 was 136 schoolchildren.12 The sampling technique used
multistage random sampling. The sample used was
Mulu et al. (2014) stated that consumption of sweet
elementary school children in the district of Banjar by
foods and low oral hygiene habits was significantly
randomly taking 3 primary schools representing urban
associated with dental caries in children.9 Improved
and 3 primary schools representing rural areas. The
oral hygiene resulted in plaque accumulation on tooth
data obtained were analyzed by Logistic Regression
surfaces that would increase the risk of dental caries.10
test at 95% significance level. The instrument used to
According to Tyath et al., (2015), the high caries rate is
measure the consumption of sugary foods is the Food
also influenced by socioeconomic level.11
Frequency Questionary (FFQ), to measure the habits
Materials and Methods of maintaining oral hygiene, maternal knowledge and
location of residence is a questionnaire. Drinking water
The design of this study was analytic observational is checked by pH and flour content in the laboratory.
with the cross-sectional design. The population in this Dental examination is performed by health workers for
study is all elementary school children in the region of dental caries data in school children.
Banjar Regency. The sample size using the two-way
hypothesis formula according to the Lemeshow formula
Results and Discussions
Findings
Table 1 Results of univariate analysis
Variable Category Frequency %

Sweet Food Consumption High 99 72,8%
Low 27 27,2%
Habits Maintain Oral Hygiene High 28 20,6%
Low 108 79,4%
Mother’s Knowledge Height 84 61,8%
Less 52 38,2%
Social Economics High 48 35,3%
Low 88 64,7%
Drinking water Eligible (pH≥6,5 dan Flour ≥1ppm) 0 0%
Not Fulfilling the Requirements (pH <6,5 dan
136 100%
Fluor <1ppm)
Location of Residence Urban 68 50%
Villages 68 50%
Dental caries Height 112 82,4%
Low 24 17,6%
Based on table 1 above can be seen that the oral hygiene and only 28 respondents (20,6%) had a
consumption of sweet foods high in elementary habit of maintaining high oral hygiene.
school children in the region of Banjar Regency is 99
Table 1 shows that 52 respondents (38,2%) have
respondents (72,8%) and low consumption of sweet
inadequate mother’s knowledge about dental health, and
foods is 27 respondents (27,2%).
84 respondents (61,8%) have high maternal knowledge
According to table 1, it was found that 108 about dental health.
respondents (79,4%) had a habit of maintaining poor
Table 1 shows the respondents with low the correlation between mother’s knowledge with a risk
socioeconomic level as many as 88 respondents (64,7%) of dental caries is obtained p-value = 0,009 which means
and 48 respondents (35,3%) at high socioeconomic level. there is the correlation between mother knowledge with
dental caries incident in elementary school children.
Respondents with drinking water sources fulfilling
the chemical requirements (pH ≥6,5 and Flour ≥1ppm) The result of logistic regression test with
were 0 respondents (0%), while respondents with 95% confidence level to see a correlation between
drinking water sources did not meet the requirements socioeconomic level with risk of dental caries was
of 136 respondents (100%). In table 1 can be seen obtained p-value = 0,947 (p> 0,05). This means there
respondents who live in urban areas as much as 50 is no relationship between the socioeconomic level with
respondents (50%) and residing in rural areas as many risk of dental caries.
as 50 respondents (50%).
Table 2 shows the results of logistic regression test
Based on the findings in the field, elementary school with 95% confidence level to see a correlation between
children in Banjar Regency experienced high dental and location of residence with dental caries incidence in
caries 112 children (82,4%) and low dental caries only elementary school children obtained p-value = 0,745 (p>
24 children (17,6%). 0,05), so there is no relation between and location place
to live with dental caries events.
Table 2: Analysis Multivariat
Table 2 shows the most influential variables on
95%
Odds dental caries in primary school children in the habit
P Confidence
Variable Rasio of maintaining oral hygiene with a value of odds ratio
Value Interval
(OR)
(CI) of 62.126, meaning that children who have a habit of
3.602-
maintaining low oral hygiene are at risk 62,126 times
Sweet Food Consumption 0.000 16.980 have high dental caries.
80.049
The Habit of Maintain Oral 12.810- Discussion

0.000 62.126
Hygiene 301.294
High consumption of sweet foods in the form of
1.784- snacks is very liked by children, besides tastes good,
Mother Knowledge 0.009 9.927
55.246 the price is relatively cheap, easy to get with various
shapes and colors of food vary.13 Sweet foods, especially
Socio-Economic 0.947 1.052 0.235-4.737
containing sucrose, will be metabolized by bacteria in
Residence Locations 0.745 0.787 0.187-3.321 plaque as a source of energy for bacteria. This metabolism
will produce an acid which results in a decrease in
Table 2 shows the results of logistic regression test plaque pH to the extent that it may cause tooth surface
with 95% confidence level to see the relationship of demineralization. The more frequent the consumption
consumption of sweet foods with dental caries obtained of sweet foods will cause the pH below normal and a
p-value = 0,000 (p <0.05) which means there is a certain time will cause the demineralization of the tooth
relationship between the consumption of sweet foods surface so that the process of dental caries begins.3 The
with the risk of dental caries in school children basic. results of this study supported by Chen et al. (2017) with
p-value = 0.002, where the child children who consume
The result of logistic regression test with 95% sweet foods and drinks have a higher risk of dental caries
confidence level to see the relationship of habit to than children who rarely eat sweet foods.14
maintain oral hygiene with a risk of dental caries in
elementary school children obtained p-value = 0.000, Caries is a disease caused by the interaction of
which means there is a relationship between the habit of germ plaque with diet and teeth. There is no doubt that
maintaining oral hygiene with the risk of dental caries. without the plaque there will be no caries. One way that
plaque formation on the tooth surface can be limited,
According to table 2, it is known that the result of either by preventing its formation or by clearing plaque
logistic regression test with 95% confidence level to see over a period of time by cleaning the teeth correctly
and regularly.15 This study is in line with the research respondents with habits maintain low oral hygiene has
of Cheng et al. (2014) obtained p-value = 0.001, where a risk 62 times the occurrence of caries compared to
the children who have a habit of maintaining high oral respondents with the habit of maintaining oral hygiene
hygiene have a low caries level.16 high. The results of this study are supported by the
research of Aurora et al. (2015) in his study of dental
The role of mother plays an important role in
caries risk factors in Ferozepur India, suggesting that
educating and nurturing children in maintaining healthy
low oral hygiene measures in children are a risk factor
teeth. The role of the mother in the family is as a health
for the high rate of dental caries in children.22
leader and caregiver. Based on this role a mother must
know various things about oral health. in dental care. Conclusion
Increased maternal knowledge of health behaviors will
Based on the result of the research, it can be
improve their ability to monitor the health behaviors of
concluded that risk factors related to dental caries in
their children.17 Similar results were also found in Sari
school children are sweet food consumption (p-value =
(2016) p-value = 0,029 where the higher the mother’s
0,000), the habit of maintaining oral hygiene (p-value =
knowledge the lower the child’s caries index. 18
0,000) and maternal knowledge (p-value = 0,009). The
The high socioeconomic level in society, on the most influential variable on the occurrence of dental
one hand, societies with high socioeconomic levels caries in elementary school children in the habit of
have a greater interest in healthy living thus allowing maintaining oral hygiene (OR = 62,126).
financing and higher dental care.19 On the other hand, it
Ethical Clearance: This study approved and
gives greater opportunities to choose different types of
received ethical clearance from the Committee of Public
food based on health needs and considerations, but leads
Health Research Ethics of Medical Faculty, Lambung
to consideration of the desire to buy good food thus
Mangkurat University, Indonesia. In this study we
increasing the risk of dental caries.20 This study is in line
followed the guidelines from the Committee of Public
with the research of Ngantung et al., (2015) where there
Health Committee of Public Health Research Ethics
is no socioeconomic effect with dental caries in children
of Medical Faculty, Lambung Mangkurat University,
with p-value = 0.164.20
Indonesia for etchical clearance and informed consent.
Logistic regression test cannot be done at drinking The informed consent included the research title, purpose,
water source in this research, because data obtained from participant’s right, confidentiality and signature.
136 respondents (100%) have drinking water source
Source Funding: This study done by self funding
that does not meet the requirements chemically so that
from the authors.
drinking water variable is issued in the test.
Conflict of Interest: The authors declare that they
The result showed no correlation between residence
have no conflict interest.
location with dental caries incidence where p-value
= 0,745, this is indicated from high dental caries data References
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di Rural dan Urban Kota Cimahi. Jurnal Ilmiah
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Caries In 12 Year Old School Going Children in
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Health. 17; 1-8.
DOI Number: 10.5958/0976-5506.2018.00646.0
Indonesian Rural Medical Internship: The Impact on Health
Service and the Future Workforce
Hardisman Dasman1, Lillian Mwanri2, Angelita Martini2

1
Department of Public Health and Community Medicine, Andalas University, 2Department of Public Health,
College of Medicine and Public Health, Flinders University of Australia
Abstract
Background: Studies have shown a shortage of medical practitioners in rural areas, and that graduate
doctors are reluctant to practice in the rural areas. To address this shortage and reluctance, the Government
of Indonesia implemented a rural medical internship program with the aims of preparing medical graduates
for primary medical practice, and attracting them to rural areas. The purpose of this study was to understand
the experience of medical interns in the rural medical internship program, and to identify the barriers and
enablers to achieving the program aims.
Method: A purposive sample of 38 medical interns (70.4%) from five districts of West Sumatera Province,
participated in focus group interviews. The interviews were recorded and transcribed verbatim. Data was
coded and categorized before thematic analysis for experiences in rural setting specifically to identify factors
important for retention of the doctors.
Results: The medical interns indicated that their exposure to rural practice did not influence their decision to
practice in rural area in the future, with most interns reporting that they did not intend to undertake clinical
practice as rural doctors. The main reasons expressed were due to interpersonal issues with senior clinicians,
nurses and hospital staff, which resulted in their autonomy and decision making processes being undermined;
and a perceived lack of professional and financial reward for practicing as rural doctors. Overall, the study
found that the program improved access to medical services in the five districts, but may not improve the
shortage of medical practitioners in rural areas on a long term basis
Conclusion: A rural medical internship program improves rural medical services. However, the program
alone will not address the long term goal of improving rural workforce shortage. Providing incentives for
rural doctors and structural change are needed in order to make rural practice more attractive.
Keywords: medical internship, rural, primary care, Indonesia
Introduction The program aimed to increase the number of

doctors in rural areas, and to improve the quality of new
A lack of medical practitioners in rural areas is a
medical graduates by preparing them for practice in
significant issue affecting health care systems in low
primary medical services. The new model of internship
and middle income countries. To address this workforce
mandated new graduates undertake their internship in
shortage in 2010 the Indonesian government enacted
Community Health Centers and District Hospitalsfor a
new government regulations and implemented a rural
period of one year. This rural medical internship training
medical internship program. The government cited
aimed to a) improve competencies for the new medical
evidence that the introduction of new medical graduates
graduates; b) expand the rural medical workforce; and
to rural practice results in serving rural and remote
c) improve the health care access of the communities.1,8
communities after their internship,1 and this has been
This study examined medical interns’ experience during
supported in studies showing that placement in rural
internship program whether the program improve the
medical training promotes rural career retention.2-7
health care workforce shortage and rural health service

Hierarchical relationship
delivery. Power exertion
Interpersonal Lack of role understanding and respect by
Method
relationships nursing staff
To understand medical interns’ experience in the Support by nursing staff
Dissatisfaction with work culture
Indonesian Rural medical internship program, we
conducted focus group interviews. Focus groups are used Incentives Inadequate salary
in qualitative research to enable discussion that produces
Career
rich data quickly, is undertaken within a social context.9 Better understanding of rural practice
intentions
Additionally, direct observation for the internship work
was also conducted. Improved medical services
The study was conducted in from 2011 to 2013 in The medical interns perceived that the rural
five districts of West Sumatera Province, Indonesia. internship provided improvement to health services.
All medical interns in the five districts were invited via They expressed the view that many districts suffered
email to participate in the focus groups. Thirty eight of from a shortage of doctors and that the interns filled this
the 54 medical interns (70.4%) agreed to participate in workforce gap. In district hospitals, the interns were
focus group interviews (table 1). involved in provided treatment or further advanced
examination. In the Community Health Centers, the
Table 1. Location and Number of Focus Group
interns were involved in a variety of programs such as
Interview Participants
epidemic infectious diseases surveillance, household
sanitation surveys and public health promotion and
Focus Geographical Number of
Group
District
Area Participants
education.
1 Agam North 5 Interpersonal Relationship

Pesisir
2
Selatan
South 8 A hierarchal relationship between interns and
3 Solok Middle 10 senior clinicians was found. The clinical practices of
4 Tanah Datar East and Hilly 5 medical interns were mandated to be under the control
West and of the clinicians who were on duty at that time. The
5 Pariaman 10 strict hierarchical approach to procedures in medical
Coastal
Total 38 services led to disharmonious professional relationships
between interns and senior clinicians. Within the
Results work environment, medical interns showed disrespect
to senior clinicians, they felt that the senior clinicians
This study found that issues around workforce,
exerted their power over interns.
interpersonal relationships, and career choices (table 2).
“…maybe in other hospitals, the medical interns are
Table 2. Main themes and related sub-themes
respected similar to other doctors, but our condition in
found during interviews
this hospital is totally different. So what is our position?
We are doing medical practice, take care patients. Maybe
Theme Sub-theme
some of them also do not have much clinical experience
either. They just show off their seniority” (IA4).
Improved Rural medical shortage
medical Filling workforce gap Some participants perceived that many nursing staff
services Public health programs undervalued and did not respect the medical interns’
work. It was considered that nursing staff did not
understand the role of the medical interns and thought
that they were similar to medical students who are doing
clerkships.
“Here, the nursing staff …….. do not respect and influenced their decision. One was the uncomfortable
underestimate what the interns do…” (ITD1). relationship between doctors and nurses and other health
professionals that they encountered during internship.
“…If there is any fatal condition of a patient after Additionally, some interns indicated that living as rural
obtaining treatment, they (nurses) always blame it as doctors was far from the ideal standard of living as a
our fault” (ITD3). doctor in Indonesia.
Unpleasant relationships with the senior clinicians “Personally I do not want choose my career as a
and lack of respect from nursing staff made medical rural practitioner as long as there is a chance to pursue
interns feel uncomfortable and caused dissatisfaction medical specialist qualifications. We know and we see
with the work culture of the hospitals. The interns that living as a rural or general practitioner just like
expressed their dissatisfaction with this situation as that... there is not sufficient support from the government.
physical and mental burdens. Of course, also we cannot obtain more income by doing
Incentives private practice because of the social and economic
condition of people in rural regions” (IS3).
Generally, the interns only received a monthly
stipend from the Ministry of Health, which was lower Discussion
than local average professional monthly salary. Even Overwhelmingly, the medical interns considered
though the medical interns in the District Hospitals that the program met its strategy to improve access to
became an important part of the medical workforce, and enhance health services in rural settings, and they
there was no additional reward for them by hospital felt an important part of health service delivery. The
management. This was considered a major disincentive general perception among medical interns was that rural
to the rural medical internship program. medical practitioners are not well remunerated.
“We do almost every task in emergency department The most significant result of this study was that
and even minor surgical procedures. We do not get any the medical interns’ exposure to rural practice did not
financial incentive from the hospital, and you know… all influence their decisions to include practicing as rural
the incentive for the procedure that we have done goes to doctors in their future careers. These findings are in
senior clinician” (IA3). contrast to many studies that found that training in
Career Intentions rural settings can influence future career choice of the
trainee.2,3,5,7,11,12 The differences in findings in this study
The rural medical internship program did not were due to factors including negative perceptions and
change the career intentions of interns to become rural unpleasant experiences that medical interns encountered
medical practitioners. This study revealed that the and the different work culture of rural practitioners
internship placement in rural areas provided real clinical in Indonesia. Therefore the rural medical internship
experience for the interns and made them aware of the program may not help to improve the medical workforce
different career choices. However, no one had a clear for rural areas over the long term.
view that doing the internship encouraged him/ her to
become a rural medical practitioner. The medical interns perceived that there was
improvement in access to health services resulting from
“Maybe, the influence of this internship on our the additional medical workforce provided through
career choice is we know what it looks like to be a doctor. the program, addressing the lack of availability of
We get the pictures: what a hospital medical officer looks medical practitioners.13 While the implementation of the
like, what a rural doctor in a heathcentre is and what a internship program improved access to medical services
medical specialist looks like. So, we can make decisions in rural areas, the quality of service was also maintained
based on those pictures. Before, we only imagined how or improved. The interns reported that their supervision
to be a doctor but now we see it, and we can make our by senior clinicians, and their high level of competency
future career based on that” (IA1). that enabled them to practice with minimal supervision,
helped to improve services to the rural areas. This is
The medical interns expressed several reasons that
consistent with a recent study in South Africa, where
medical interns were found to improve health services It was also observed in earlier studies that unpleasant
in the community while prepare them to be able practice experiences for medical interns are not uncommon. For
independently14. example, medical interns may face significant challenges
that cause distress or psychological problems during the
Despite becoming an important part of the medical
internship due to mistreatment and work overload.18-20
workforce in the rural District Hospitals, the medical
Our study also shows that some both medical and
interns faced financial hardship and did not see financial
nursing staff treated medical interns as medical students
reward in the long term. Financial incentives including
who were always under his/ her control and instruction
increasing salaries, supplements, allowances, pensions,
without independence, findings that are consistent with
benefits and loans, introduced in various countries,
the literature.21,22
have demonstrated success in increasing workforce
retention.3,4,15-17 There is also evidence that non-financial In some hospitals, the hierarchy between the interns
incentives can be applied to increase retention of rural and senior clinicians was strictly applied, with senior
doctors, such as more opportunity to obtain additional clinicians imposing strict control over what medical
training and further medical qualifications.4 As recent interns could or could not do. These strict hierarchical
literature suggests, without addressing these problems procedures can lead to disharmony in the professional
and challenges will undervalue both medical internship relationship. Mutual respect and collaborative efforts
program and community medical service.18 between interns and nursing staff need to be promoted,21,22
with the appropriate professional behavior to their staff
and colleagues.
Figure 1. Current Practice of Medical Internship in Indonesia

Importantly, rural doctors in Indonesia do not Republik Indonesia Nomor 299/Menkes/Per/

receive adequate rewards from the National or District II/2010 tentang Penyelengaraan Program
Governments.23 Rural doctors receive only the basic Intersnhip dan Penempatan Dokter Pasca
salary with minimal additional support, which is Internship. In. Jakarta: Departement Kesehatan
considerably insufficient compares to other government Republik Indonesia; 2010.
employees who work in the same geographic area. This 2. Hancock C, Steinbach A, Nesbitt TS, Adler SR,
condition engendered negative attitudes in the medical Auerswal CL. Why doctors choose small towns:
interns which led them to decide not to practice as rural A developmental moddel of rural physician
doctors for their long term career. The current study recruitment and retention. Social Science and
demonstrated that the medical interns’ perceptions about Medicine 2009;69:1368–76.
rural practice were negative and this was influenced by a
3. Matsumoto M, Inoue K, Kajii E. Policy
number factor as seen in Figure 1.
implications of a financial incentive programme
Conclusion to retain a physician workforce in underserved
Japanese rural areas. Social Science and Medicine
The rural medical internship program provided 2010;71:667-71.
valuable, wide-ranging experience to medical interns
4. Peña S, Ramirez J, Becerra C, Carabantesc
practicing in rural district hospitals and community
J, Arteaga O. The Chilean Rural Practitioner
health practices. The findings revealed that there was
Programme: a multidimensional strategy to attract
an improvement in health service delivery as a result
and retain doctors in rural areas. Bulletin of World
of the internship program. However, the internship
Health Organization 2010;88:371–8.
program may not improve the medical workforce for
rural areas in the long term because the exposure to rural 5. Rogers ME, Searle J, Creed P. Why do junior
practice did not influence their decisions about their doctors not want to work in rural location, and
future careers to consider practicing as rural doctors. what would induce them to do so? Australian
The interns face interpersonal issues, which resulted in Journal of Rural Health 2010;18:181-6.
their autonomy and decision making processes being 6. Straume K, Shaw DMP. Internship at the end of
undermined. There was also a lack of professional earth- a way to recruite physicians? In: Rural and
and financial rewards which is a general disincentive Remote Health; 2010.
for rural doctors in Indonesia. These challenges should 7. Stagg P, Greenhill J, Worley PS. A new model to
be addressed to improve long term benefit of health understand the career choice and practice location
care services and medical workforce development in decisions of medical graduates. In: Rural and
Indonesian districts regions through structural changes Remote Health; 2009.
in rural health services.
8. DIKTI-Depdiknas. Intersnhip menuju Indonesia
Ethical Clearance: Formal permission was Sehat. In: DIKTI; 2010.
obtained from the Department of Health and the Nation 9. Bowling A, Ebrahim S. Handbook of Health
and Public Protection Board of West Sumatera Province Research Methods: Investigation, Measurement
of Indonesia No.B070/WAS-BKPL/2011. Participation and Analysis. Maidenhead, UK: Open University
of the medical interns were voluntary and they were Press; 2005.
advised that their participation would remain anonymous
10. Liamputtong P. Qualitative Research Methods.
as they would not be personally identifiable.
Melbourne: Oxford University Press; 2009.
Source of Funding: The research is funded by 11. Matsumoto M, Kajii E. Medical education
Ministry of Research and Higher Education of Indonesia. program with obligatory rural service: Analysis
of factors associated with obligation compliance.
Competing Interests: The authors declare that
Health Policy 2009;90:125-32.
there is no competing interests.
12. Straume K, Shaw DMP. Effective physician
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DOI Number: 10.5958/0976-5506.2018.00647.2
Effectiveness of an Educational Program Concerning
Nurse- Midwives Knowledge Concerning SBAR (Situation,
Background, Assessment, Recommendation) Tool
Communication on Maternal Health Documentation
Sunduss B Dawod1, Rabea M Ali2, Ezedeen F Bahaaldeen3

1
Assistant Teacher, Fundamental Nursing, College of Nursing, University of BASRA, Iraq, 2Professors,
3
Assistant Professor, Maternal & Neonate Nursing, College of Nursing, University of Baghdad
Abstract
Background: Poor communication is responsible for up to two-thirds of sentinel events, and of those events,
over half were related specifically to poor transition of patient care between providers(1).
Objective: To assess the effect of SBAR (Situation, Background, Assessment, Recommendation) educational
program on nurse –midwives knowledge in maternal health report documentation accuracy.
Method: A quasi- experimental design was carried with the application of pre- post test for nurses-midwives’
knowledge regarding SBAR communication tool. The study was held in Al-Elwia maternity teaching
hospital, Al –Karckh maternity hospital and Al-Yarmouk teaching Hospital. Non-probability sample
consisted of (84) nurse- midwives. The questionnaire comprised of demographic data, nurses- midwives
knowledge of SBAR using (3) level Likert scale for assessment, with Cut –off point (2). Content validity
was determined through (21) expert. Pilot study was conducted on (10) nurses-midwives during 15th to 22nd,
may, 2017. Reliability of the questionnaire (pre (0.89), post (0.89), evaluation (0.936)). Descriptive ,and
Inferential statistical data analysis were used.
Results: The result shows low, moderate, and high mean scores and relative sufficiency in pre test SBAR
periods. While in posttest period there is moderate and high mean scores and relative sufficiency in all items
except items (12,13,17,18,19,& 20), presented low mean scores and relative sufficiency in both periods ( pre
and posttest period). No significant differences between pre , and posttest periods with the socio-demographic
characteristics, except for work place shows significant differences in pre, and posttest periods at (P-value
: 0.001-.040) respectively. The results also presents that participants were extremely confident in applying
scenario for Placenta praevia, and Abortion.
Conclusion: The study concluded that there is improvement in nurses – midwives knowledge concerning
SBAR communication tool application after implementation of the program.
Keywords: SBAR, communication, tool, nurse-midwives, knowledge, maternal health, documentation.
Introduction recently been adopted in some health care settings is the

Situation, Background, Assessment, Recommendation
Communication errors in the health care setting often (SBAR) protocol (4). The SBAR protocol was positioned
have severe consequences(2). Communication errors as a solution to these problems. When SBAR is used,
also lead to other negative outcomes, such as increased the sender communicates the patient’s condition in a
length of stay and decreased patient satisfaction (3). concise manner by delivering each of the components of
Accordingly, to implement practices that aid in the the protocol In this way, SBAR ‘‘allows for an easy and
reduction of communication errors. One practice that has focused way.
to set expectations for what will be communicated strategies. Intervention classes offered in 90 minutes
and how between members of the team safety.’’ (5). sessions at various times throughout a 2-week timeframe.
Methodology A questionnaire was constructed through the review

of literatures and previous study, and use of information
A quasi- experimental design was carried throughout
which had emerged prior to need assessment. The
the present study with the application of pre-test and
questionnaire comprised of demographic data and
post-test for nurses-midwives’ knowledge regarding
nurses- midwives knowledge of SBAR using (3) level
SBAR communication tool. The study was held in (3)
Likert scale for assessment, with Cut off point (2), they
maternity hospitals. Non-probability sample consisted
were given a scenario that required an urgent response
of (84) nurse- midwives who are working in the morning
and contact of a provider, the SBAR Observed for
shift, different educational levels, who are working in
seven scenarios. (Post-partum hemorrhage, Premature-
critical care wards and who agree to participate in the
early rupture membranes, Placenta praevia, Teenage
study.
pregnancy, Preeclampsia, Abortion, & Postdate
Implementation of the Program: pregnancy). Content validity determined through (21)
expert. A pilot study was conducted on (10) nurses-
At the SBAR- introduction, primarily the researcher midwives during 15th to 22nd ,may, 2017. Reliability of
provided staff with information about the study, asked the questionnaire showed very high level of stability and
them to participate, and obtain informed consent. The internal consistency of study domains (pre (0.89), post
SBAR- intervention, based on the evidence for best (0.89), evaluation (0.936)). Descriptive ,and Inferential
practice, included teambuilding and collaboration statistical data analysis were used.
strategies, positive communication techniques,
communication styles, empathy, and problem-solving
Results
Table (1): Nurse –Midwives Knowledge in Pre-Posttest for SBAR Tool.
Pretest no. (84)

Statistic Posttest no. (84)
NO
Items
MS SD RS% Ass. MS SD RS Ass
The nursing documentation is important to
1 2.8452 .45241 94.84 High 2.9762 .21822 99.21 High
improve nursing practice.
2 SBAR is easy to use 2.0357 .36227 67.86 Mod. 2.7976 .57623 93.25 High
3 SBAR summarize the time and effort 2.0595 .39120 68.65 Mod. 2.8214 .54132 94.05 High
SBAR communication reduces maternal
4 2.0595 .35909 68.65 Mod. 2.8214 .51859 94.05 High
mortality
The patient situation information
5 preferable to be comprehensive and more 2.0476 .40790 68.25 Mod. 2.8095 .52587 93.65 High
detailed regarding social status
SPAR contains all the necessary
6 2.0238 .41000 67.46 Mod 2.8571 .46937 95.24 High
information
The information transferred to doctor or
7 duty team without mentioning the name 1.9881 .52627 66.27 low 2.8690 .40419 95.63 High
of nurse.
8 SBAR recognize malpractice easily. 2.1548 .52627 71.83 Mod 2.8810 .45003 96.03 High
Serious conversation is faster to describe
9 2.4405 .81183 81.35 High 2.8929 .41122 96.43 High
the case health.
10 The SBAR less time consumer 2.7500 .59869 91.66 High 2.9167 .35426 97.23 High
The patient is more comfortable in the
11 2.309 .57899 76.98 Mod. 2.464 .81184 82.14 high
conversation
12 The SBAR guarantees rights of nurse 1.52 .7589 50.79 low 1.46 .6899 48.209 low
Cont... Table (1): Nurse –Midwives Knowledge in Pre-Posttest for SBAR Tool.
The verbal conversation ensures patient

13
privacy
1.654 .7001 55.158 low 1.523 .7073 50.79 low
Shortness of evening shift lead to a difficulty

14 2.64 .8966 88.9 High 2.13 .50622 71.03 Mod
record
When in waiting room I observe only the cases
15 2.702 .90728 90.07 High 2.464 .81184 82.14 High
and will wait doctor’s instructions
case sheet field of nursing notes space is
16 2.452 .9766 81.73 High 2.166 .95480 72.2 Mod
Enough
17 The document ensure my presence 1.821 .5467 60.2 Low 1.547 .70766 51.569 Low
We receive the case ready without need for
18
observations
1.988 .60677 66.26 Low 1.345 .63622 44.83 Low
Regular documentation ensures continuity of

19
patient care.
2.047 .96823 68.23 Mod 1.654 .82481 55.13 Low
Equipment document have priority more than

20 1.5 .81403 50 Low 0.940 .71407 31.33 Low
Nursing documentation
MS.: Mean Scores; SD: Standard Deviation, RS.: Relative Sufficiency, Ass.: Low: (0-66.66) ,Mod.= Moderate :
(66.67 -77.77), High (77.78– 100)
Table indicates low mean scores and relative sufficiency in items (7, 12,13,17,18,20) , moderate mean scores and
relative sufficiency in items (2,3,4,5,6,8,11,16,19) , and high mean scores and relative sufficiency in items (1,9,10,14,15)
in pretest periods. While there is high mean scores and relative sufficiency in items (1,2,3,4,5,6,7,8,9,10,11,15),
moderate mean scores and relative sufficiency in items ( 14,15), and low mean scores and relative sufficiency in
items (12, 13, 17, 18, 19, 20) in posttest period. for work place shows significant differences in pre, and posttest
periods at (P-value : 0.001-.040) respectively.
Table (2): Comparison between Pre-Posttest Periods (SBAR program) on Overall Domains.
Paired Samples Statistics
NO Mean SD Std. Error Mean Correlation Sig
pretest 84 41.7619 4.47650 .416

Pair 1 .416 .000
posttest 84 50.5595 5.39824 .58900
Paired Samples Test
Paired Differences
Sig.
Domain S. Error 95% Confidence Interval t Df.
Mean SD (2-tailed)
Mean
Lower Upper
pretest
-8.79762- 5.39250 .58837 -9.96786- -7.62738- -14.953- 83 .000
posttest
There are significant different correlations between pretest and posttest because the value of the correlation is
equal to 0.416 therefore
There is significant different means between pre-post SBAR program.

Table (3): SBAR Training Feedback.
SBAR Training Feedback

Statistic Mean for
Somewhat Extremely SD for all
Cases No. Not Confident all
Confident Confident
Premature-early rupture
14 3 (21.4%) 8 (57.2%) 3 (21.4%) 5.814 0.415
membranes
Placenta praevia 14 1 (7.1%) 5 (35.8%) 8 (57.1%) 6.564 0.468
Teenage pregnancy 14 2 (14.2%) 5(35.8%) 7 (50%) 6.533 0.466
Preeclampsia 14 1 (7.1%) 8 (57.1%) 5 (35.8%) 6.15 0.439
Abortion 14 1 (7.1%) 5 (35.8%) 8 (57.1%) 6.564 0.468
Postdate pregnancy 14 2 (14.2%) 6 (42.9%) 6(42.9%) 6.128 0.437
Table( 3) shows that participants were extremely The verbal conversation ensures the patient
confident in applying scenario no. (2 & 5) for Placenta privacy (item 13) (pre: 1.654, post: 1.523). The
praevia, and Abortion (Mean± SD= 6.564± 0.468) communication is more useful than writing, but does
respectively, then followed by scenario no. (3) for not guarantee the continued health care discussed.
Teenage pregnancy (Mean± SD = 6.533± 0.466), while It was stated that SBAR provides a framework for
other less confident. On a scale of 1 to 10 (with 1 not communication between members of the health care
confident at all and 10 extremely confident). team about a patient’s condition, and has been found to
facilitate both the collection, organization, and exchange
Discussion of information as well as be an effective strategy to
Nurses-Midwives Knowledge in Pre-Post SBAR: develop teamwork (7) .
The study result show in table (1) indicates that The document ensure my presence (item 17),
there is low mean scores and relative sufficiency in (pre:1.821, post :1.547). In our health institution,
pre test SBAR period in items (7, 12, 13, 17, 18, 20). confirmation of attendance or the presence for the nurse
Moderate mean scores and relative sufficiency in items - midwife in their work areas is not on the patient’s
(2, 3, 4, 5, 6, 8, 11, 16, 19). High mean scores and report or documentation, but on the fingerprint for the
relative sufficiency in items (1, 9, 10, 14, 15). While in credibility of the daily attendance. It was discussed
posttest period there is moderate and high mean scores the need to utilize a tool that concentrated on patients’
and relative sufficiency in all items except (12, 13, 17, needs while prioritizing the information shared between
18, 19, 20) items. caregivers(8).
The SBAR guarantees the rights of the nurse for We receive the case ready without the need for
her work (item 12) shows low mean of scores in both my observations (item 18) (pre-1.988, post -1.345). In
periods (1.52, 1.46) , and this because it is new program the system of our hospitals nursing role is very limited
that needs more than a session and more than Scenario and the specific process of reception and diagnosis is
and more time to gain the confidence of the nurses - the first duties of the doctor only, but in some cases,
midwives and health organizations. They did not have especially in the delivery room, the nurse intervenes
previous experience with the SBAR communication. to provide primary care, especially the expertise in
both felt that prior to the initiation of the SBAR tool, the dealing with urgent cases in obstetrics. It was stated
collaboration and teamwork was not so strong in terms that SBAR-based checklist allows for the nurse, as the
of making effective treatment plan, they both felt that frontline caregiver in the best position to assess patient
they received adequate and organized information about condition, to organize and present the situation while
referred patient from the primary care providers who recommending to doctor a course of action in succinct,
used SBAR format (6) . clear and concise terms (9).
Regular documentation ensures continuity of scenario no. (2 & 5) for Placenta praevia, and Abortion
health care for patient item 19) (pre-1.988, post -1.345). (Mean± SD= 6.564±
As a result of the weakness in nurses- midwives work is
the deficit in documentation,. A nursing audit can focus 0.468) respectively, table no.(4) , On a scale of
on implementation of the nursing process, on client 1 to 10 (with 1 not confident at all and 10 extremely
outcomes, or on both in order to evaluate the quality of confident) (14). A study conducted to investigate the impact
care provided, not only evaluates the quality of care of of using a standardized method called SBAR on work
an individual client but also provides an evaluation of shift report in ICUs to take an effective step in solving
overall care given in that health care facility (10) . existing problems, as well as follow-ups to be made by
the nurse of the next shift. Checklists recorded by two
Equipment and tools document takes priority observers. The results show that nurses’ performance
more than nursing documentation (item 20) (pre:1.5, improved after work shift delivery report training using
post: 0.940). A handoff,” or “patient care transfer,” is SBAR tool. results indicate that the performance score
an interactive process of transferring patient-specific showed significant statistical difference before and after
information from one caregiver to another or from one the intervention and the score has increased after the
team of caregivers to another for the purpose of ensuring intervention in general performance and all areas (15).
the continuity and safety of the patient’s care (11) .
Conclusion
Relationship between Pre - Posttest SBAR and
Demographic Characteristics: The study concluded that there is improvement
in nurses – midwives knowledge concerning SBAR
No significant statistical differences were found communication tool application after implementation of
between pre , and posttest periods with demographic the program.
characteristics, except for work place shows significant
differences in pre, and posttest periods at (P-value : Conflict of Interest: None declared.
0.001-.040) respectively. Emergency care is a broad Ethical approval: for two health directorate
specialty. Emergency nurses require a depth and (Al-Karkh sector &Al-Russafa sector. and all
breadth of knowledge and skill to care for patients with participating hospitals
undifferentiated and undiagnosed problems. SBAR
use is a relatively new phenomenon and this may have Source of Funding- Self
played a role in the low usage because nurses may not
References
know the positive aspects of a structured handoff. A
study found that SBAR can be used in any setting but [1] Pillow, M. (Ed.). (2007). Improving hand-off
can be particularly effective in reducing the barrier to communication. Oakbrook, Ill.: Joint Commission
effective communication across different disciplines and Resources.
between different levels of staff (12) . [2] Suteliffe K, Lewton E, Rosenthal. M.
Comparison between the Two Pre-Posttest Periods Communication failures an insidious contributor
(SBAR) on Overall Domains: to medical mishaps. Acad Med .2004, 79(2).186-
194.
There are significant different correlations between
[3] Pronovost P., et al.: A practical tool to reduce
pretest and posttest because the value of the correlation
medication errors during patient transfer from an
is equal to 0.416 therefore there is significant different
intensive care unit. Journal of Clinical Outcomes
means between pre-post in SBAR program. It was
Management 11:26–33, 2004.
expected that the SBAR report tool would keep nurses
more focused and would lead to shorter reports , whereas [4] Doucette J. View from the cockpit: What the
their time on task improved (54% to 66.4% ) the overall aviation industry can teach us about patient safety.
duration was unchanged (13) . Nursing. 2006;36(11): 50-53.
[5] Kaiser Permanente. (2010). SBAR technique for
SBAR Training Feedback communication: A situational briefing model,
Participants were extremely confident in applying 2010.
[6] Phung Kim Nguyen, The use of SBAR [11] Kurt.A. Patton .Ms. Handoff communication safe
communication tool - A DNP Project Submitted transition in patient care 2007.
to the Faculty of college of nursing, In Partial [12] Karen S. Kesten, DNP, Role-Play Using SBAR
Fulfillment of Requirements for Degree of doctor Technique to Improve Observed Communication
in nursing practice, university of ARIZONA, 2 0 1 Skills in Senior Nursing Students, Journal of
6. Nursing Education, 2010 , Vol. 50(2), 2011.
[7] Leonard M, Graham S, Bonacum D. The human [13] Paul Cornell , Townsend M. et al.: Improving shift
factor: Thecritical importance of effective Report Focus & Consistency with the Situation,
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care. Qual Saf Health Care. 2004(13) ;pp85-90. Protocol ,Taiwanese journal of Oestetrics &
[8] Vardaman J, Cornell P, Gondo M, et al.,: Beyond Gynecology 56(2017) 171-174.
communication: the role of SBAR in changing [14] Adrian Hayes, Poppy Roberts, Sarah Watson, et
health care environment. Health Care Manag al.: Clinical hazards in patient safety. Chips 2011.
Rev.2012;37(1):88-97.
[15] Azade Inanloo1, Nooredin Mohammadi, Hamid
[9] Anne Claiborne Ray Streeter 2010,: Haghani.: The Effect of Shift Reporting Training
Communication behaviors associated with the Using the SBAR Tool on the Performance
competent nursing hand-off , A dissertation of Nurses Working in Intensive Care Units,
submitted in partial fulfillment in degree of Doctor Client-Centered Nursing Care2017 . Volume 3.
of Philosophy in College of Communications and Number 1.
Information Studies at University of Kentucky.
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DOI Number: 10.5958/0976-5506.2018.00648.4
Assessment of Nutritional Status of Alcoholic
Liver Disease (ALD) Patients
Tripti1, Neeru2, Karuna Singh3

1
Research scholar, Department of Amity Institute of Food Technology, Amity University, Noida,UP. ,
2
Lecturer (Home Science), HES(II), Department of Secondary Education, Haryana,
3
Assistant Professor-III, Department of Amity Institute of Food Technology, Amity University, Noida, UP.
ABSTRACT
Introduction- Malnutrition is an increasingly recognized as complication in both alcoholic liver disease and
non- alcoholic liver diseases. It has been considered as an important predictive factor, which greatly affect
the short and long-term outcomes of the disease. Malnutrition is very profound and more severe in patients
having chronic liver diseases due to alcoholism. Patients with alcoholic liver diseases exhibited a wide range
of nutritional deficiencies.
Objective: To assess the nutritional status of alcoholic liver disease patients.
Material and Method: 120 subjects suffering from liver disease attended OPD were taken for study purpose
and were divided into two groups. Group-A: 60 patients having ALD and Group-B: patients having NALD.
Assessment of nutritional status was done by Child-Pugh classification (scores) to assess severity of the
diseases, anthropometric and dietary methods to evaluate nutritional status.
Results: The mean age of ALD patients was 48.8 and non-alcoholic liver disease was 52.1 years. 73.33%
of the total patients were suffering from deficiency of both energy and proteins to some extent alongwith
41.67% of them presented with both moderate and severe PCM. There was insignificant difference between
both groups in daily food intake in terms of energy, proteins, carbohydrates and fats. All patients were taking
less calories and more protein than RDA. According to MAMC, observed that ALD sufferers showed more
signs of malnutrition in terms of frequency rather than non-alcoholic liver disease sufferers. But when both
groups were compared according to reasons behind the diseases, there was no significant difference was
observed between alcoholic and non-alcoholic disease patients.
Conclusion: The analyzed data highlights the protein calorie malnutrition in both groups of ALD and NALD
patients. The more suitable measures should be taken to address the problem.
Keywords: Nutritional status, alcoholics, protein calorie malnutrition (PCM), outpatients, alcoholic liver
disease (ALD). Non-alcoholic liver disease (NALD), Mid arm muscle circumference (MAMC), Child-Pugh
scores, Malnutrition, Recommend Dietary Allowances (RDA).
INTRODUCTION absorption and metabolism of food, thus playing a

central role in the maintenance of a healthy nutritional
At the start of the medical history, all the medical
status. There is a strong association between alcoholic
practitioners noticed that the people who have weak
disease and nutritional abnormalities, as liver is the main
liver function/activity have poor recovery rate due
site for the metabolism of alcohol and thus malnutrition.
to acute and chronic disease. The reason behind was
It is also a well-known fact that all the nutrients, whether
the poor digestion and absorption of nutrients due to
macro or micro, are metabolized by the help of liver. In
insufficiency of digestive organ i.e. liver. Liver plays
fact, metabolic activity of liver accounts for 20-30% of
an essential physiological function in the digestion,
the oxygen consumption and energy expenditure of the
body (Lieber,2004)9. Compromised liver functioning in by means of 24-hr recall method and food frequency
alcoholic liver disease patients result in the development questionnaire and administered by researcher.
of protein energy malnutrition (PEM) (Mezey,1978)20.
Anthropometric Method: The anthropometric
The term malnutrition can be defined as a condition measurements were performed on the subjects while
when body is deprived of or not receiving enough coming to OPD for their checkups. Various measurements
nutrition to maintain health. It may also be defined of height, weight, BMI, MUAC and triceps skin fold and
as a loss of muscle tissue or fat mass. It also leads to MAMC.
impaired immune function along with poor oral intake of
Biochemical Method: In biochemical methods,
nutrients (Merli,1987)18. Multiple factors are responsible
total bilirubin, serum albumin, prothrombin time or INR
which contribute to malnutrition including controlled
and haemoglobin levels were also checked.
diet recommendations used to restrict the symptoms
and associated complications like ascites and hepatic Child-Pugh Classification for Severity of Liver
encephalopathy, which enhances the poor nutritional Disease
profile, predisposing the sufferers to more infections
and leading to worsen the functional hepatic state Encephalopathy
(McCullough et. al.,1989; Riggio et. al.,2003; Runyon
None (1 point)
et. al.,1998)13,23,26. Sarcopenia is very common in both
liver injury and alcohol related liver diseases and it is the Grade 1: Altered mood/confusion (2 points)
major component of malnutrition. Partly, it was thought
that the patients having alcoholic liver diseases have Grade 2: Inappropriate behavior, impending stupor,
more severe malnutrition and it can be assessed by using somnolence (2 points)
anthropometry and subjective global assessment criteria. Grade 3: Markedly confused, stuporous but
The anthropometry includes their height, weight, MUAC, arousable (3 points)
MAMC, which clearly indicates presence or absence of
malnutrition. For the assessment of nutritional status Grade 4: Comatose/unresponsive (3 points)
even in cirrhotic patients the anthropometric parameters
Ascites
measurements proved as a reliable and safe tool.
Absent (1 point)
Material and Method
Slight (2 points)
Study population
Moderate (3 points)
Total 120 males were used for this study. Subjects
were divided into two groups. 60 subjects were included Bilirubin
in Group-A who were suffering from alcoholic liver
disease (ALD) and another 60 were kept in Group-B, <2 mg/dL (1 point)
also suffering from liver disease with no history of
2-3 mg/dL (2 points)
alcoholism (Non-alcoholic liver disease).
>3 mg/dL (3 points)
Inclusion criteria: Only willing male patients
having liver disease (Both ALD & NALD). Albumin
Exclusion criteria: patients having no signs of any >3.5 g/dL (1 point)

kind of liver disease
2.8-3.5 g/dL (2 points)
Assessment of Nutritional status
<2.8 g/dL (3 points)
Nutritional assessment was carried out by following
methods: Prothrombin time prolongation
Dietary Method: Dietary intake was assessed Less than 4 seconds above control/INR <1.7 (1
point)
4-6 seconds above control/INR 1.7-2.3 (2 points) >10 mg/dL -->3 points
More than 6 seconds above control/INR >2.3 (3 RESULTS

points)
Total120 patients, all males, having age mean of
CTP Score Interpretation 49.8 years, were taken for the study. Equal number of
patients was taken having etiology of liver disease (with
5 to 6 points: Child class A and without history of alcoholism). The patients were
7 to 9 points: Child class B functionally classified on the basis of the Child-Pugh
classification of scores.
10 to 15 points: Child class C
Table 1 represents that the groups were compared
Notes according to age and functioning of liver. Maximum
numbers of subjects from both groups fall under the
In cases of Primary Biliary Cirrhosis, Bilirubin point
category of Child- Pugh B score which indicates the
values are sometimes considered differently:
severity of the liver disease. It was also observed that
1-4 mg/dL -->1 point patients suffering from ALD were more at risk of
mortality than non – alcoholic liver disease patients.
4-10 mg/dL -->2 points
Table 1-Comparion between the studied groups regarding age and liver function
Group-A Group-B
Parameter Total Subjects
(ALD Patients) (Non-alcoholic)
Age (yrs.) 48.8±10.4 52.1±13.6 49.8±10.2
n (subjects) 60 60 120
Child-Pugh A 9 (15%) 13 (21.67) 22 (18.33)
Child-Pugh B 34 (56.7) 32 (53.34) 66 (55%)
Child-Pugh C 17 (28.34) 15 (25%) 32 (26.67%)
On the first visit by the patients in OPD clinic, 73.33% of the total patients were suffering from deficiency of
protein calorie malnutrition (PCM) with 41.67% of them having moderate and severe degree of PCM. A higher no.
of prevalence of non-PCM and mild energy protein deficiency were observed among Child-Pugh-A patients rather
than the patients classified in Child-Pugh B and C (Table 2).
Table 2-Classification according to nutritional status of patients with regard to liver function
Child-Turcotte-Pugh
Nutritional status A B C
(N=120) n (%) n (%) n (%)
Non PCM 12 (54.54%) 12 (18.18%) 8(25%)

Mild PCM 6 (27.27%) 22 (33.03%) 10 (31.5%)
Moderate PCM 4 (18.18%) 26 (39.4%) 10 (31.25%)
Severe PCM 0 (0%) 6 (9.09%) 4(12.5%)
Total patients 22 (18.33%) 66 (55%) 32 (26.66%)

There was insignificant difference between both groups in daily food intake in terms of energy, proteins,
carbohydrates and fats (Table 3). All patients were taking less calories and more protein than recommended dietary
allowances (RDA for reference sedentary adult male). It was also observed that subjects were taking more total fat
than RDA.
According to mid arm muscle circumference (MAMC), observed that ALD patients showed more symptoms
of malnutrition in relation to frequency than non-alcoholic liver disease sufferers. But when both the groups were
compared in terms of etiology, there was non-significant difference was found between alcoholic and non-alcoholic
disease patients (Table 4).
Table 3-Daily food consumption of the ALD patients and non-alcoholics
ALD patients
Nutrient Non-alcoholics (Group B) P value
(Group A)
Energy (kcal)
1970.06±678.60 1850.44±548.98 0.17
Protein (gm) 77.36±29.97 76.05±27.98 0.84
Carbohydrate (%) 53.06±12.09 51.68±11.01 0.21
Total fat (%) 35.46±13.98 34.07±7.96 0.1
Values are given as mean ± standard deviation
Energy and proteins are given as kcal and in g/kg of ideal weight/d
Table 4. Classification of the nutritional profile of 60 ALD patients with 60 Non-alcoholics according to
mid muscle circumference (MAMC)
Nutritional profile
Non PCM Mild PCM Moderate PCM Severe PCM
MAMC
n (%) n (%) n (%) n (%)
ALD Patients (Group
16 (26.66%) 14 (23.33%) 18 (30%) 12 (20%)
A)
Non-alcoholics
17 (28.33%) 19 (31.66%) 13 (21.66%) 11 (18.33%)
(Group B)
X2=4.02, NS
Discussions OPD (Carvalho et al., 2006)4.
Malnutrition (PCM) is very common feature found Alcoholism is the main cause for chronic liver
in ALD patients, with severe consequences for their disease found in many other studies including present
nutrition and overall health status (Nompleggi et al., study and highest no. of cases were males. The mean of
1994; Levinson et al., 1995; Figueiredo et al., 2005)21,8,6. all age in present study was 49.8 years comparable with
Most of the researchers mainly focused to performed other studies (Mendenhall et al., 1984; Merli et al., 2002;
nutritional studies on patients who were hospitalized, Carvalho et al., 2006)14,17,4.
but there are few studies on prevalence, consequences
There are several methods used for classification
and recovery of PCM associated with liver diseases.
of PCM, because it is very difficult to assess the
In this study the occurrence of PCM was evaluated
anthropometric and biochemical parameters separately
in both ALD and non ALD patients. A previous study
(Abad et al.,1993; Madden et al., 1995; Roongpisuthipong
also evaluated the occurrence of PCM only in cirrhotic
et al., 2001; Tajika et al., 2002)1,15,25,27. In this study, the
patients which can be seen at a secondary level service
sufferers were diagnosed nutritionally by using the PCM
score proposed by MENDENHALL et al. (Mendenhall 1984)11,13,14. This frequent deterioration in muscle mass
et al., 1986)16. Similar method of investigation for in patients having ALD is probably linked directly the
nutritional assessment was adopted by a previous study effect on skeletal muscle metabolism (Campillo et al.,
(Carvalho et al., 2006)4. 2003; Plauth et al., 1997; Riordan et al., 1999)3,22,24.
24-hr dietary recall of patients showed that both the Conclusion

groups were deficient in calories but most of the calories
The present study revealed that the lack of
were coming from fats and proteins. Other studies
nutritional reserves in patients having ALD precedes
showed a deficient energy protein intake (Yunsheng et
their hospitalization, further deteriorates the condition.
al., 2009; Cornu et al., 2000; Bories et al.,1994)31,5,2. In
Nutritional assessment and evaluation of these patients
a study, patients suffering from severe and moderate
must be the part of the routine of OPD checkups
PCM did not meet the 70% of the nutrient needs in
regardless of the reasons pertaining to the disease.
terms of calorie and protein (Carvalho et al., 2006). A
decline nutritional profile in chronic liver disease has Conflict of Interest: None
been associated with more controlled diets due to severe
complications of ALD like ascites, anorexia and loss of
weight. The patients also undergo in a hypermetabolic Ethical Clearance: Ethical clearance were taken
state because of various complications and become more from hospital authorities, concerned doctor. Consent
prone of catching risk of infections (Mendenhall et al., was also taken from individual patients.
1984,1986)14,16. References
The present study also revealed the association with 1. Abad-Lacruz A, Cabre E, Gonzalez-Huix F,
PCM and liver functioning which is already reported Fernandes-Banares F, Esteve M, Planas R, Llovet
by many researchers (Lautz et al., 1992; Mendenhall et JM, Quer JC, Gassull MA. Routine tests of renal
al., 1984; Nomplezzi., 1994)7,14,21. While only 18.18% function, alcoholism, and nutrition improve
of Child-Pugh A presented moderate and severe PCM, the prognostic accuracy of Child-Pugh score in
approx. 50% in Child-Pugh B and 44% in Child-Pugh C nonbleeding advanced cirrhotic. Am J Gastroenterol.
category. Similar results were reported in a study where 1993; 88:382-7.
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(Carvalho et al., 2006)4. nutritional status, hepatic function and serum lipid
pattern. Br J Nutr. 1994; 72:937-46.
There was no significance difference found between
two groups in nutritional status, hence ALD and Non- 3. Campillo B, Richardet JF, Scherman E, Bories PN.
ALD patients as reported by others (Lautz et al., 1992; Evaluation of nutritional practice in hospitalized
Lolli et al., 1992; Mendenhall et al., 1984; Nomplezzi., cirrhotic patients: results of a prospective study
1994)7,10,14,21. Malnutrition in ALD patients is a result assessing nutritional status. Nutrition. 2003; 19:515-
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JM. A prospective randomized study of preoperative
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DOI Number: 10.5958/0976-5506.2018.00649.6
Identification and Characterization of Non-Tuberculous
Mycobacteria Isolated from Extrapulmonary Tuberculosis
Suspects by Heat Shock Protein 65 by PCR – RFLP
V Praveen Kumar1, V Sreenivasulu Reddy2, P Suresh1, P Vamsi Muni Krishna1

1
Ph.d Scholar, Bharath University, Agaram Road, Selaiyur, Chennai, Tamilnadu,
2
Professor, Dept. of Microbiology, Sri Lakshminarayana Institite of Medical Sciences, Pondicherry
ABSTRACT
The genus Mycobacteria contains more than 170 officially recognized species. In the last decades, the
reports of nontuberculous mycobacteria (NTM) associated with extrapulmonary diseases are increasing.
The aim of this study is to know the prevalence of NTM among extrapulmonary tuberculosis cases in a
tertiary care hospital in south India. This study was conducted from Mar 2017 to December 2017. Diagnosis
was performed by Ziehl-Neelsen staining followed by culture in BacT/ALERT and Lowenstein Jensen
culture medium. We applied conventional biochemical test like growth on the LJ medium containing PNBA
(para nitro benzoic acid) to differentiate M.tuberculosis and NTM and PCR- restriction fragment length
polymorphism analysis (PRA) of the hsp65 gene for species identification. We identified 96 non-tuberculous
infection cases from 1138 (AFB) – Positive tuberculosis suspects. The diversity of NTM species were
Mycobacterium abscessus 17(45.9%) followed by Mycobacterium fortuitum 10(27%), Mycobacterium
chelonae 8(21.6%) and Mycobacterium simiae 2(5.4%). Regular documentation and reporting of these
NTMs from clinical settings along with their sensitivity profile is essential to be aware of the clinical
spectrum of disease associated and preferred treatment options.
Keywords: Heat shock protein 65; Non-tuberculosis mycobacteria; PCR – RFLP; Rapidly growing
mycobacteria.
Introduction of clinical infection is low, but infections due to NTM

are reported to have increased in the past few years. 3,4,5
The nontuberculous mycobacteria (NTM) are a
group of Mycobacterium species other than the obligate Non ruberculous mycobacteria (NTM) were reported
pathogens Mycobacterium tuberculosis complex as important agents of infection in immunosuppressive
and Mycobacterium leprae.1,2 The American Thoracic patients. However, there has been an increasing incidence
Society in their statement endorsed the name Non in recent years of infections in immunocompetent hosts.
tuberculous mycobacteria (NTM). NTM are ubiquitous NTM infections in immunocompetent individuals are
in nature and widely distributed in water, soil and dust secondary to direct inoculation either contamination from
they were considered saprophytic organisms for many surgical procedures or penetrating injuries rather than
years but now are recognized as human pathogens. hematogenous dissemination.4,6 Despite a considerable
Although humans are routinely exposed to NTM, the rate increase in knowledge about NTM infections, they
still represent a diagnostic and therapeutic challenge
Corresponding author: for several reasons: 1) pathogenic isolates may be
V Praveen Kumar indistinguishable from contaminant or saprophytic
Ph.D Scholar, Sri Lakshminarayana Institute of Medical isolates; 2) timely and reliable identification of isolates
Sciences (Affiliated to Bharath University) may depend on proper communication between clinicians
Pondicherry – 605502, Mobile: 91 8142037662, 91 and laboratory staff; 3) lack of standardized susceptibility
7674038096, Email: [email protected] testing makes adoption of tailored therapies unrealistic;
and 4) lack of treatment guidelines exposes patients to Smear examination, Culture and differentiation
toxic drugs and disappointing outcomes.7 of M.tuberculosis and NTM: The specimens were
processed on the same day for microscopy and the
NTM pulmonary disease is the most common, specimens from unsterile sites such as sputum, urine
comprising more than 90% of all NTM infections. The and gastric juice were decontaminated and concentrated
cases of extrapulmonary like in the CNS, genitourinary by N-acetyl-L-cystine-NaoH concentration method
tract and abdomen, the bacterial load is much less (LYFECTOL, Tulip Diagnostics). Sterile body fluids such
as compared to the pulmonary tuberculosis (PTB).7,8 as blood, CSF and pleural fluid were processed without
Many molecular methods like multiplex PCR, DNA decontamination. The samples were simultaneously
probes and /or DNA sequencing, High performance inoculated on LJ medium, for each isolate two tubes
liquid chromatography, Restriction Fragment Length of Lowenstein-Jensen medium (Hi Media) were used,
Polymorphism (RFLP) using various target regions one containing plain media and the other LJ medium
including heat shock protein 5 KD gene (hsp 65), ITS containing Para nitro benzoic acid and incubated at 37°C
and rpoB, have made the characterization of NTM temperature under aerobic conditions. AFB cultures
species less ambiguous, more precise, rapid, cost- were also performed simultaneously in BACT/ALERT
effective and can be used directly on clinical samples. culture media as well.
Hsp 65 gene is used widely for identification of NTM to
species level because of its variability compared to some In case of keratitis with NTM the type of specimen is
other conserved genes.6 corneal scrapings. The corneal scrapings were smeared
on glass slides for Gram’s stain and 10% KOH mount.
The therapy of the disease caused by NTM is often Specimens were inoculated directly on blood agar,
long, strenuous and not always successful. Thus it is chocolate agar, brain heart infusion broth, thioglycollate
important to differentiate infections due to M.tb and broth and sabouraud dextrose agar are used for culture.
NTM at the early stage of the disease.9 The objective of Acid fast stain was done as a routine and was included
the present study was to differentiate the mycobacterium only if the clinical picture was suggestive of NTM.
species isolated from extrapulmonary clinical samples
suspected of having tuberculosis. DNA extraction: Extraction of DNA was done by
using NucleoSpin® Microbial DNA from MACHEREY-
Material and Method NAGEL GmbH & Co. KG. 0.5ml of culture from BACT/
This study includes the isolation of specimens ALERT culture media was taken using sterile disposable
NTM from suspected extrapulmonary tuberculosis from syringe cultures were centrifuged at 10,000 rpm to form
March 2017 to December 2017. The aim of this study is a pellet. Add 100 μl Elution Buffer BE to the pellet and
to know the prevalence of NTN among extrapulmonary resuspend the cells. Transfer the cell suspension into
tuberculosis cases in tertiary care hospital in south India. the NucleoSpin® Bead Tube Type B (provided). Add
40 μl Buffer MG. Then, add 10 μl Liquid Proteinase
Sample collection: Since NTM are ubiquitous K and close the tube. Agitate the NucleoSpin® Bead
in nature and a possible laboratory contaminant, the Tube on a swing mill or vortexer device. Centrifuge
isolation of these organisms from specimens should the NucleoSpin® Bead Tube 30 seconds at 11,000 xg
meet certain criteria to confirm their etiological to clean the lid. Add 600 μl Buffer MG and vortex for
significance such as, a). Repeated isolation of the same 3 seconds, Centrifuge for 30 sec at 11,000 xg. Transfer
organism from the patient b). Associated positive clinical the supernatant (~500–600 μl) into the NucleoSpin®
and radiological evidence and c). Histopathological Microbial DNA Column, placed in a 2 ml Collection
condition.3 The specimens included are blood, CSF, Pus, Tube (provided). Centrifuge for 30 s at 11,000 xg.
wound swabs, lymphnode aspirate, tissue and corneal Discard collection tube with flow-through. Put column
scrapings from suspected cases of EPTB. Patients from into a fresh collection Tube (2 ml, provided). First wash:
all ages were included in the study. Ethical clearance Add 500 μl Buffer BW. Centrifuge for 30 s at 11,000
was obtained from Institutional Ethical Committee of xg. Discard flow-through and place the column back into
Sri Lakshminarayana Institute of Medical Sciences, the Collection Tube. Second wash: Add 500 μl Buffer
Pondicherry. B5 to the column and centrifuge for 30 s at 11,000 xg.
Discard flow-through and place the column back into the
Collection Tube. Centrifuge the column for 30 s at 11,000 extrapulmonary sites. The predominant age group in
x g. Elute highly pure DNA - Place the NucleoSpin® our study was 51 - 60 years 14 (37.8%) followed by
Microbial DNA Column into a 1.5 ml nuclease-free tube 41 - 50yrs 9 (24.3%), 61 – 70 yrs 5(13.5%), 31 – 40yrs
and add 100 μl Buffer BE onto the column. Incubate at 4 (10.8%), <20yrs 3 (8.1%) , 21-30 yrs 1(2.7%) and
room temperature for 1 min. Centrifuge 30 sec at 11,000 71 -80 1 (2.7%). Demographic characters of patients
xg. were mentioned in the Table:1. Of these 94.5% (35/37)
were rapidly growing mycobacteria (RGM) and 5.4%
Hsp65-PRA – based identification assay: An
(2/37) were slow growing mycobacteria (SGM). The
approximately 439-bp region of hsp65 gene was
distribution of NTM species is summarised in the table:2.
amplified by PCR using two specific primers. The
The most predominant NTM species among RGM was
primers of hsp65 (TB 11/12) insertion gene were
Mycobacterium abscessus 17 (45.9%) followed by
TB11(5’-ACCAACGATGGTGTGTCCAT-3’) TB12
Mycobacterium fortuitum 10(27%), Mycobacterium
(5’-CTTGTCGAACCACATACCCT-3’). The PCR
chelonae 8 (21.6%) and Mycobacterium simiae 2 (5.4%).
was performed with PCR reaction setup, consisting of
1µl of DNA, forward and reverse primers 0.25µl each, Table 1: Demographic characteristics of the 37
master mix 5µl and 3.5µl distilled water. The first PCR extrapulmonary non tuberculosis cases.
was performed by denaturing the samples 3min at 94°C,
then 40 cycles including 94°C for 1min, 56°C for 1min, Characteristic Patient %
72°C for 1 min and final extension at 72°C for 10 min. Sex
Amplification of 439-bp product of the hsp65 gene was Male : 26 (70.2%)
detected by 2% agarose gel electrophoresis. Female: 11 (29.7%)
Restriction fragment length polymorphism Age

(RFLP): After PCR 65kDa hsp 65 gene amplifier <20 3 (8.1 %)
was aliquoted in to two tubes both clinical and quality 21 – 30 1 (2.7%)
control strains were digested with the enzymes BstEII
31 – 40 4 (10.8%)
and HaeIII for 3 hours at 37°C. The digested products
41 – 50 9 (24.3%)
were visualized on 3% agarose gel electrophoresis and
the RFLP patterns were analyzed according to fragment 51 – 60 14 (37.8%)
sizes.10,11,12 61 – 70 5 (13.5%)
71 – 80 1 (2.7%)
Results
Previous TB treatment 4 (10.8%)
Out of 1138 positive cultures for AFB, 96 (8.4%) HIV infection 1 (2.7%)
were considered as Non tuberculous mycobacteria.
Type II Diabetes mellitus 3(8.1%)
Of the 96 Non tuberculous mycobacteria, 59(61.4%)
Characteristics of tuberculosis patients (n=37)
were from pulmonary sites and 37 (38.5%) were from
Table - 2: Distribution of NTM species from pulmonary clinical isolates.
Pus from Wound corneal

NTM species Pleural fluid Urine Tissue Blood CSF
other sites swab scrapping
M.abscessus 6 5 2 2 1 1 - -
M.fortuitum 1 3 - 3 - 2 1 -
M.chelonae 3 2 - 2 - - - 1
M.simiae 2 - - - - - - -
Total 13(32.4%) 10(27%) 2(5.4%) 7(18.9%) 1(2.7%) 3(8.1%) 1(2.7) 1(2.7)

Discussion In our study M.fortuitum (27%) and M.chelonae

(21.6%) were the second and third most prevalent NTM
Non tuberculous mycobacteria have gained a lot species isolated, in contrast a study by A.K.Maurya
of clinical significance in the last couple of decades et al from Lucknow reported M.fortuitum as the most
in immunocompromised and immunocompetent common species accounted for 25.7% among NTM
individuals or patients. Mycobacteria detection to species species isolated from pulmonary and extra pulmonary
level is necessary and provides useful information on specimens.20 M.V.Jesudasan et al reported M.fortuitum
epidemiology and facilitates successful treatment of and M.chelonae were the predominant isolates from pus
patients. Improvement in isolation and identification and biopsy specimens of skin and soft tissue infections.3
techniques has led to an increased awareness of the
importance of NTM as human pathogens.13,14 Conclusion
NTM were characterized phenotypically like Infections with NTM are difficult to diagnose
growth rate, pigment production, growth on LJ medium because of lack of appropriate protocol in routine
containing Para nitro benzoic acid (PNBA), macroscopic diagnostics. A high degree of suspicion and adequate
and microscopic morphological characters has been knowledge of diagnostic procedures are required to
applied. eradicate infections with NTM. rapid identification and
differentiation to species level by molecular assay may
Many studies applied 16S-23S rRNA internal help in targeted therapy and management of infections
transcribed spacer (10) and hsp 65 genomic loci for caused by different mycobacterial species Regular
molecular characterization of NTM.6,13 In our study, documentation and reporting of these NTMs from
we used hsp 65 gene for identification of mycobacterial clinical settings along with their sensitivity profile is
species. The polymerase chain reaction and restriction essential to be aware of the clinical spectrum of disease
enzyme analysis were carried out by following the associated and preferred treatment options.
techniques described by wong et al.15
Conflicts of Interest: No conflicts
Many studies from India have reported a variation
in the incidence of Non tuberculous mycobacteria Source of Funding: Self
infections. A study by Chakrabarthi et al from
Ethical Clearance: Institutional ethical clearance
Chandigarh reported 7.4% incidence of NTM from
obtained
various clinical specimens, similarly Das B.K. et al
reported 8.3% of NTM incidence in their study and References
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DOI Number: 10.5958/0976-5506.2018.00650.2
The Influence of Health Education to Change Domain
Competencies Interprofessional Collaboration on
Handling of Malnutrition Case
Risnah1, Veni Hadju2, Ridwan Amiruddin3, Sukri Palluturi4, Citrakesumasari5, Untung Sujianto6
1
Lecturer Nursing Fak.Kedokeran Science and Health Science UIN Alauddin, 2Professor of nutrition Community
Health Fak. Unhas University of Makassar, 3Professor Epidemiology Community Health Fak.Unhas University
of Makassar, 4Professor Health Policy Administration Health Fak.Unhas University of Makassar, 5Lecturer at the
science of nutrition Fak.Community Health University of Hasanuddin Makassar, 6Lecturer of Science Nursing Fak.
University Medical Dipenogoro Semarang
Abstract
Health problems that are very complex requires handling together involving of all health professionals
and good collaboration efforts. Malnourished Children become one of health problems and it is important to
prepare for the generation of high quality. Health education is expected to increase the knowledge of health
workers about collaboration across the profession. competency that will affect the performance of health
workers to improve the quality of health services in general. This research aims to assess the difference
between the competencies collaboration across health professions in handling the cases of malnutrition
in children before the training and three months after the training on the clinic. Using the research design
“Quasi experiment” with research design using “pretest and posttest with a control group design”. There
are 40 the respondents divided into 20 respondent treatment groups and 20 people in the control group.
Sampling techniques Stratified random sampling. The results of the study showed that the average knowledge
of treatment group pre-intervention and post intervention to have the value of the p domain of 0.330 purpose.
The value of the p domain the role of 0.811, value p domain communication 0.000 (<0.05), the value of the
p domain 0.000 process (<0.05), the value of the p domain 0.343 cooperation, the value of the p domain
0.031 leadership (<0.05) and the value of the p domain structure of 1000. Recommended researchers next to
design health education which is able to improve competency on a different domain.
Keywords: Interprofessional Collaboration, competencies, malnutrition, health workers
INTRODUCTION organizational level2. Working together become very

important for the individual to reach interprofessional
Collaboration is a mutually beneficial relationship perspective and the benefits of the work in the working
and defined with good agreed by two or more team and the client4. Interprofessional collaboration
organizations to achieve a common goal1. This is have positive effects on the patient satisfaction, reduce
the term which is generally used in research and clinical uncertainty and improve the management of the
practice and health professional education,. until the hospital5. Interprofessional collaborative practice is
collaboration occurred in almost every aspect of health2. very important for the improvement of the results of the
The problems on the health of very complex requires Ministry of Health in patients / clients and family6.
settlement together with involving all health profession3.
The Consequences of team work which are not
The Benefits of interprofessional collaboration effective, patients suffer through excessive procedures,
allows the participants to achieve a more together miscommunication and lack of coordination in the
than they obtain individually, serve groups of people ministry7. Cause patient complaint repeatedly complain
who are larger and grow at the individual level to the that the service provider does not coordinate
maintenance, so that provide the same information Indonesia12. In the year 2007 until 2011, the proportion
to different health team members8. Now many health of poor people in Indonesia a decline of 16.6 - 12.5 %, but
systems in the countries in the world that implements nutritional problems do not show declines significantly10.
the fragmented health services which in the end is not
Jeneponto Regency reported to have enough
able to solve the health problems in the country itself9.
nutrition problem cartilage that one result is the death
The problem of malnutrition is a result of various on the high enough. Have the status of malnutrition and
factors that complicated and complex, various researches malnourished categories are problems of tumbling 26.4
in various countries that done by many institutions, percent while malnutrition cases as much as 7 people
has been producing various models of determinant of (0.04%)13 Infant mortality (AKB) year 2014 as much as
nutritional problems, this is related to the difference 10 per 1000 live births and 2015 as much as 12 per 1000
of socio-culture of the society in each area. One of the live births13.
problems caused by poor nutritional status is a condition
that is not a maximum of the growth and development
MATERIAL AND METHIOD
of a child. To resolve the problem of malnutrition cross- The design of this research is the “Quasi
sectoral action required10. Experiment” with research design using “pre-test and
posttest with a Control Group Design». Treatment
Globally, 45 % the death of children under the age
groups following the training activities and collaboration
of 5 years caused by various conditions of malnutrition11.
given the module, while the control group was given
The growth of maximum not suffered by around 8
only the module. Sampling techniques using stratified
million Indonesian children, or one of the three sons of
random sampling.
RESULTS
Table 1. Analysis of the characteristics of respondent health officials
The treatment Controls
The value
The characteristic The frequency The percentage of The frequency The percentage of
of the p
N = 20 % N = 20 %
Age
20 - 30 years 10 50 14 70 0,819
31 - 40 years 8 40 2 10
41 - 50 years 1 5 4 20
51 - 60 years 1 5 0 0
Gender 1,000
Male 3 15 3 15
Women 17 85 17 85
Education
S1 10 50 10 50 1,000
A Diploma 10 50 10 50
Working Time
1 - 5 years 8 40 11 55 0,978
6 - 10 years 4 20 4 20
11 - 15 years 6 30 2 10
16 - 20 years 2 10 2 10
Cont... Table 1. Analysis of the characteristics of respondent health officials
21 - 25 years 0 0 1 5
The Profession
The doctor 2 10 0 0
Nurses 6 30 7 35
Midwives 6 30 5 25
0,978
Nutrisionis 4 20 4 20
Sanitarian 1 5 4 20
The officer Promke 1 5 0 0
In table 1 have the entire value of p > 0.05 on the characteristics of participants treatment groups and intervention
groups which means that there is no initial differences in the characteristics of respondents in both groups.
Table 2. The differences average domain competencies professional traffic collaboration between
groups Pre and Post Intervention gift
The value of
The value of the p Δ
Domain Pre-Post the p
The group
Domain
The purpose of
The treatment 4.00 5.00 0.020 1 0.330
Controls 4.45 5.45 0.020 0.95
The role
The treatment 2.60 2.70 0.752 0.1 0.811
Controls 2.65 2.80 0.529 0.15
Communication
The treatment 2.60 6.95 0.000 4.35 0.000
Controls 4.65 6.60 0.286 1.95
The Process
The treatment 6.90 8.10 0.000 1.20 0.000
Controls 8.35 7.60, 0.279 -0.75
The Cooperation
The treatment 4.40 6.00 0.042 1.60 0.343
Controls 5.00 6.15 0.677 1.15
The Leadership
The treatment 5.40 6.45 0.000 1.05 0.031
Controls 7.65 7.55 0.033 -0.10
The structure of the
The treatment 3.60 3.30 0.281 -0.30 1000
Controls 4.00 3.70 0.108 -0.30

Table 2. On the treatment group has a value completing a job or task in accordance with the specified
p=0.330. Domain has a value p=0,811 role. performance standards21.
Communication Domain has a value p=0.000. The
The framework is divided into 6 domains
domain of the process of no value p=0.000. Domain can
that contribute to the purpose of interprofessional
complete the value p 0.343 Cooperation, domain has a
collaboration. Sixth the domain is; 1) clarification
value p=0.031 leadership and domain structure have a
roles, 2) centered on the patient/client, 3) Working
value p=1000.
Team, 4) Collaboration leadership, 5) interprofessional
DISCUSSION communication and 6) related to interprofessional
conflict. Treatment is centered on the patient and
In the results of the study showed that the average
interprofessional communication is the elements that
knowledge of treatment group pre-intervention and
affect the 4 other domains6.
post-intervention to have the value of the p=0.330. The
value of the p domain the role of 0.811, value p domain It is said that the Collaboration interdisciplinary
communication 0.000 (<0.05), the value of the p domain curriculum and team work requires components for
0.000 process (<0.05), the value of the p domain 0.343 collaborative communication that occurred between
cooperation, the value of the p domain 0.031 leadership members of the team in setting the acceptance of
(<0.05) and the value of the p domain structure of 1000. the house maintenance. The interaction of the team
requires trust, confidence, and equal efforts by all of
Quality children born from a healthy pregnant
the team members. Effective communication can be
mother so since in the womb many efforts have been
achieved through communication collaboration between
made to produce the son as a generation with high
members of the team in interdisciplinary curriculum or
quality14. Government support for the pregnant mother
professional traffic. So concluded that collaboration
has also presents various government program one of
in the house maintenance and palliative care settings
the warranty program delivery15. Although there are still
influenced by effective communication22.
areas in Indonesia that implement a program of the health
of mothers and children is not running as expected16. Although it is understood that the communication
occurs when collaborate in collaboration across the
Nutrition problems occur in each cycle of human
profession but the thing that must be noted when
life, started since in the womb (fetus), the baby, children,
collaborate is the existence of mutual respect and mutual
mature and elderly. Nutritional problems in the fact of
trust. As with any other profession the attitude to consult
the matter is that the public health problem and the
when there is something that is not understood is an
factors causing the disruption of nutrition is a multi-
important element for noted in practice collaboration
factor regarding, for that approach and managements
across the profession. The term used to describe the
must involve various sectors related17. Many factors that
ordinary Interprofessional clinical practice involving the
affect the nutritional status of one of them is the pattern
patient and the problem of the patient will be handled
of breastfeeding and MP of breast milk18. In fact, the
independently or separately in accordance with the
exclusive breastfeeding in Jeneponto Regency in 2013
competence of each of the profession as the responsibility
of 67, 7%, yet to reach national targets namely 80%19.
of the area handled by the appropriate kind23. In
The competencies literally come from the communication occurs giving the right information can
word competence, which means the ability, authority affect the client satisfaction24.
and skill. In terms of the etymology, competency means
Understood together that to improve the quality
merits, expertise from the behavior of a person or leader
of health services, needed a system that is coordinated
employees which have a knowledge and skills that good
and a collaborative effort between stakeholders. Good
behavior. The characteristics of the competencies which
coordination to improve the quality of health services
is something that becomes part of the personal character
in patients, create a more efficient quality and optimum
and become part of prioritizing the person in carrying
care. This requires coordination and collaboration
out a job task20 so it can be deduced that the competency
between health service line in this health officials. The
is defined as the ability of a person who can be observed
interactive communication is the elements of the founder
includes the knowledge, skills and work attitude in
of the collaboration between the professional. The price 5. SAN MARTIN-RODRIGUEZ, L, D’AMOUR, D.
of good self-able to improve relations between the actors & LEDUC, N. 2008. Outcomes of interprofessional
in the health system and supports the initiative and the collaboration for hospitalized cancer
ability to adapt25. variability. Cancer nursing, 31, E18-E27.
This is in line with the opinion of26 which 6. BAINBRIDGE MCCULLOCH, P., LOUISE
concluded that health care involves the participation of NASMITH, M. & WOOD, V. 2010. Competencies
patients, family and various health professional team that for interprofessional collaboration. The Journal of
is often and very special. The involvement of all members Physical Therapy Education, 24, 6.
of the team in a cooperation with the way that being 7. GRUMBACH, K. & BODENHEIMER, T. 2004.
coordinated is very important to provide exceptional Can health care teams receiving complain primary
health services. Structural factors, psychological and care practice? The Juma, 291, 1246-1251.
education can also determine collaborative behavior in 8. GREINER, A. C. & KNEBEL, E. 2003. The Institute
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Education Summit. Health professions education:
CONCLUSION
A bridge to quality. Washington, DC: National
The conclusion from this article shows that there Academy Press.
are differences in the domain of collaboration across 9. The World Health Organization 2010. Framework
health professional competencies in handling the cases for Action on Interprofessional Education &
of malnutrition in children before the training and three Collaborative Practice. 64.
months after the training on the clinic in Jeneponto
10. UNICEF 2012. A summary of the study of the health
Regency. It is recommended to do the training activities
of mothers and children.
ongoing and program to be accomplished with good to
improve competency collaboration across the profession 11. BLACK, R. E., VICTORA, C. G., WALKER, S.
of health. P., BHUTTA, Z. A., Christian, P., DE ONIS, M.,
EZZATI, M., GRANTHAM-MCGREGOR, S.,
Ethical Clearence: Nil KATZ, J. & MARTORELL, R. 2013. Maternal and
Child undernutrition and overweight in low-income
Source of Funding: Self-funding
and middle-income countries. The lancet, 382, 427-
Conflict of Interest: Nil 451.
12. The basis, R. K. 2013. RISKESDAS 2013. The
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DOI Number: 10.5958/0976-5506.2018.00651.4
Molecular Identification of Rapidly Growing Mycobacteria
Isolated from Pulmonary Specimens at a Tertiary Care
Hospital in Pondicherry
V Praveen Kumar1, V Sreenivasulu Reddy2, P Vamsi Muni Krishna1, P Suresh1

1
Ph.D Scholar, Bharath University, Selaiyur, Chennai, 2Professor, Sri Lakshminarayana
Institute of Medical Sciences, Osudu, Pondicherry
Abstract
Background: The prevalence of Rapidly Growing Mycobacteria (RGM) infections has been increasing
worldwide. RGM have emerged as important human pathogens that cause a variety of diseases ranging from
localized cutaneous infections to disseminated infections. Clinical diagnosis is difficult because there are no
characteristic clinical features. Materials and Method: This study was conducted from Aug 2014 to Mar
2017, aimed to identify species of Rapidly Growing Mycobacteria from specimens suspected with pulmonary
tuberculosis. We applied conventional biochemical test like growth on the LJ medium containing PNBA
(para nitro benzoic acid) to differentiate M.tuberculosis and NTM and PCR- restriction fragment length
polymorphism analysis (PRA) of the hsp65 gene for species identification. A 439 bp fragment of hsp65 gene
was amplified and digested by two restriction enzymes, BstEII and HaeIII. Digested products were analyzed
using polyacrilamide gel electrophoresis. Results: Thirty seven rapidly growing mycobacteria were isolated
and identified by growth characters and conventional biochemical tests. PCR-RFLP of hsp65 gene of 37
isolates revealed M.abscessus 27 (72.9%), M.chelonae 7(18.9%) and M.fortuitum 3 (8.1%). Conclusion:
This study proved that PCR-RFLP of hsp65 gene in Mycobacteria is more sensitive, specific and effective
method for identification of NTM at the species level than conventional phenotypic methods.
Keywords: Non-tuberculosis mycobacteria, Rapidly growing mycobacteria, Heat shock protein 65, PCR-
RFLP.
Introduction recommend that RGM should be identified to the species

level is important to direct the antimicrobial treatment.6
Rapidly growing mycobacteria (RGM) are The species of RGM have different virulence levels in
ubiquitous environmental acid-fast bacilli that are diverse clinical settings and also have different drug
important human and animal pathogens and are susceptibility patterns.7 The gene for 65kDa heat shock
characterised by their growth in culture medium within protein exhibits greater interspecies and intraspecies
7 days of post-inoculum.1 Nearly one hundred rapidly polymorphism than the 16S rRNA. Restriction fragment
growing mycobacteria (RGM) have been identified, length polymorphism (RFLP) analysis of DNA
they cause infections in both immunocompetent and amplimers generated by PCR for the identification of
immunocompromised individuals, most commonly mycobacteria provides a rapid means for detecting these
manifesting as pulmonary or skin and soft tissue species-specific polymorphisms.8
infection, and less frequently as a cause of bacteremia,
osteomyelitis, endocarditis, peritonitis, lymphadenitis, Materials and Method
post-surgical infections, or catheter-related infection.2,3,4
This study included the isolation of RGM from all
The increasing number of infections caused by these suspected cases of pulmonary tuberculosis received
organisms has made it clinically important to quickly from Aug 2014 to Mar 2017 in the department of
identify mycobacterial species.5 The American Thoracic Microbiology, Sree Lakshminarayana Institute of
Society and the Infectious Disease Society of America Medical Sciences, Pondicherry. Ethical clearance was
taken from Institutional ethical committee. the NucleoSpin® Microbial DNA Column, placed in a
2 ml Collection Tube (provided). Centrifuge for 30 s
Sample collection: Since NTM are ubiquitous
at 11,000 xg. Discard collection tube with flow-through.
in nature and a possible laboratory contaminant, the
Put column into a fresh collection Tube (2 ml, provided).
isolation of these organisms from specimens should meet
First wash: Add 500 μl Buffer BW. Centrifuge for 30 s
certain criteria to confirm their etiological significance
at 11,000 xg. Discard flow-through and place the column
such as, a. Repeated isolation of the same organism from
back into the Collection Tube. Second wash: Add 500
the patient b. Associated positive clinical and radiological
μl Buffer B5 to the column and centrifuge for 30 s at
evidence and c. Histopathological condition.6 Three
11,000 xg. Discard flow-through and place the column
early morning sputum specimens, broncho alveolar back into the Collection Tube. Centrifuge the column
lavage, pleural fluid and bronchial wash specimens were for 30 s at 11,000 x g. Elute highly pure DNA - Place
received from patients with clinical and radiological the NucleoSpin® Microbial DNA Column into a 1.5
findings suggestive of tuberculosis. All the specimens ml nuclease-free tube and add 100 μl Buffer BE onto
were collected under aseptic conditions in sterile leak the column. Incubate at room temperature for 1 min.
proof containers and transported to the laboratory. Centrifuge 30 sec at 11,000 xg.
Microscopy & AFB culture: The specimens were Hsp65-PRA – based identification assay: An
processed on the same day for microscopy and culture approximately 439-bp region of hsp65 gene was
using standard procedures.9The specimens were amplified by PCR using two specific primers. (fig:1)
digested and decontaminated using the NALC (N-acetyl The primers of hsp65 (TB 11/12) insertion gene were
L-cysteine) NAOH method. ZN staining was done TB11(5’-ACCAACGATGGTGTGTCCAT-3’) TB12
directly as well as after concentration. AFB cultures was (5’-CTTGTCGAACCACATACCCT-3’). The PCR
performed by the conventional LJ method and BACT/ was performed with PCR reaction setup, consisting of
ALERT culture media as well. 1µl of DNA, forward and reverse primers 0.25µl each,
Biochemical tests: Differentiation of M.tuberculosis master mix 5µl and 3.5µl distilled water. The first PCR
and NTM was done on the basis of susceptibility of the was performed by denaturing the samples 3min at 94°C,
isolate to PNBA (para nitro benzoic acid). The PNBA then 40 cycles including 94°C for 1min, 56°C for 1min,
test was performed by inoculating the specimen in to two 72°C for 1 min and final extension at 72°C for 10 min.
LJ medium tubes with and without PNBA (Himedia). If Amplification of 439-bp product of the hsp65 gene was
the test strain was sensitive to PNBA indicated by no detected by 2% agarose gel electrophoresis.
growth, it was identified as Mycobacterium tuberculosis Restriction fragment length polymorphism
complex. Growth of the test strain within the tube is (RFLP): After PCR 65kDa hsp 65 gene amplifier
indicated by the presence of NTM. H37RV strain was was aliquoted in to two tubes both clinical and quality
used as control strain. control strains were digested with the enzymes BstEII
DNA extraction: Extraction of DNA was done by and HaeIII. for 3 hours at 37°C. The digested products
using NucleoSpin® Microbial DNA from MACHEREY- were visualized on 3% agarose gel electrophoresis and
NAGEL GmbH & Co. KG. 0.5mL of culture was the RFLP patterns were analyzed according to fragment
taken using sterile disposable syringes cultures were sizes.10-13
centrifuged at 10,000 rpm to a pellet. Add 100 μl
Results
Elution Buffer BE to the pellet and resuspend the cells.
Transfer the cell suspension into the NucleoSpin® Bead Patient characteristics of the 37 suspected
Tube Type B (provided). Add 40 μl Buffer MG. Then, tuberculosis cases were shown in the table 1: of The
add 10 μl Liquid Proteinase K and close the tube. Agitate 37 stains isolated 26 (70.2%) were from males and
the NucleoSpin® Bead Tube on a swing mill or vortexer 11(29.7%) from females. RFLP patterns of the hsp65
device. Centrifuge the NucleoSpin® Bead Tube 30 gene from the isolates and are shown in Fig.1. BstEII
seconds at 11,000 xg to clean the lid. Add 600 μl Buffer and HaeIII digestion of the isolate resulted in fragments
MG and vortex for 3 seconds, Centrifuge for 30 sec at of different base pairs. The combined digestion pattern
11,000 x g. Transfer the supernatant (~500–600 μl) into analysis for BstEII and HaeIII. was identical to that of M.
abscessus, M. chelonae and M. fortuitum. M. abscessus Cont... Table 1: Patient characteristics of the 37
27 (72.9% accounted for majority of isolates followed suspected tuberculosis cases
M.chelonae 7(18.9%) and M.fortuitum 3(8.1%), shown
21 – 30 -
in the table 2.
31 – 40 4 (10.8%)
Table 1: Patient characteristics of the 37
41 – 50 7 (18.9%)
suspected tuberculosis cases
51 – 60 13 (35.1%)
Characteristic Patient %
61 – 70 8 (21.6%)
Sex
71 – 80 2 (5.4%)
Male : 26 26 (70.2%)
Previous TB treatment 7 (18.9%)
Female: 11 11 (29.7%)
HIV infection -
Age
Other respiratory symptoms 16 (43.2%)
<20 3 (8.1%)
Characteristics for suspected tuberculosis patients (n=37)
Fig-1: PCR product run in 2% Agarose Gel Electrophoresis ( PCR product size is 439bps).
Table - 2: Distribution of NTM from different of awareness among clinicians coupled with lack
clinical specimens. of laboratory capacity to diagnose these infections.
Identification of NTM is of clinical relevance as most of
Specimens M.abscessus M.chelonae M.fortuitum the NTM is notably resistant or only partially susceptible
to the standard anti-tubercular drugs and the treatment
Sputum 9 2 1 strategies and the duration of these infections differ
Bronchial
from MTB. The most common genomic loci applied
14 4 2 in molecular detection of NTM are the 16S-23rRNA
washings
Bronchoalveolar internal transcribed spacer, hsp65, 16S rRNA and rpoB
3 1 -
lavage gene.14 In this study we used hsp65 gene for the detection
of mycobacterial species. The polymerase chain reaction
Pleural fluid 1 - -
and restriction enzyme analysis (PRA-hsp65) were
Total 27(72.9%) 7(18.9%) 3(8.1%) carried out using the techniques described by wong et
al.15
Discussion In our study, three (n=3) different mycobacterial
Prevalence of NTM is unknown in India as NTM species other than Mtb were identified. According to the
disease is not a reportable condition and there is lack present study’s results infections in our patients including
Mycobacterium abscessus, Mycobacterium chelonae 2. L García-Agudo · P García-Martos. Clinical

and Mycobacterium fortuitum using the two restriction significance and antimicrobial susceptibility of
enzymes, BstEII and HaeIII. were determined. rapidly growing mycobacteria. Science against
microbial pathogens: communicating current
In the present study the most common type of NTM
research and technological advavces. January 2011;
was Mycobacterium abscessus. These results were
363-377.
consistent and inconsistent with a number of studies
3. Redelman-Sidi G, Sepkowitz KA (2010) Rapidly
in India. A study from Bhopal by Prabha Desikan et al
growing mycobacteria infection in patients with
reported M.abscessus as the most frequently reported cancer. Clin Infect Dis 51: 422–434. [PubMed]
species.16 Paramasivan et al from Chennai, South India
4. Han XY, De I, Jacobson KL (2007) Rapidly growing
has reported NTM from sputum specimens of patients in
mycobacteria: clinical and microbiologic studies of
BCG trial area, M.avium/intracellularae was the was the 115 cases. Am J Clin Pathol 128: 612–621.
most frequently isolated in their study.17
5. Sarika Jain, Manimuthu M Sankar, Navneet
In the present study, M.chelonae (18.9%) was the Sharma, Sarman Singh, and T D Chugh. High
second most prevalent and M.fortuitum was the third prevalence of non-tuberculous mycobacterial
disease among non-HIV infected individuals in a
most prevalent NTM isolated in pulmonary samples.
TB endemic country – experience from a tertiary
MV Jesudasan from Vellore reported M.chelonae (8.1%) center in Delhi, India. Pathog Glob Health. 2014
as the most prevalent isolate followed by M.fortuitum, Mar; 108(2): 118–122
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6. Jesudason MV1, Gladstone P. Non tuberculous
specimens where as in our study accounted.6 mycobacteria isolated from clinical specimens at a
tertiary care hospital in South India. Indian J Med
Conclusion
Microbiol. 2005 Jul;23(3):172-5.
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(RGM) remains problematic because of evolving significant rapidly growing mycobacteria. Year :
taxonomy, limitations of current phenotypic methods and 2011, Volume : 29, Issue : 4, Page : 343-352.
absence of a universal gene target for reliable speciation. 8. S. Moises Hernandez, Glenn P. Morlock, W.
This study evaluated a novel method of identification Ray Butler, Jack T. Crawford, and Robert C.
of RGM by amplification of the mycobacterial hsp65 Cooksey*Identification of Mycobacterium Species
gene followed by RFLP. Regular documentation and by PCR-Restriction Fragment Length Polymorphism
Analyses Using Fluorescence Capillary
reporting of these NTMs from clinical settings along
Electrophoresis. Journal of Clinical Microbiology,
with their sensitivity profile is essential to be aware of
0095-1137/99/$04.0010 Nov. 1999, p. 3688–3692.
the clinical spectrum of disease associated and preferred
9. Koneman EW, Allen SD, Janda WM, Schrekenberger
treatment options.
PC, Winn WC JR. Colour atlas and textbook
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Conflicts of Interest: No conflicts Company; 1997. P.877-996.
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Identification of nontuberculous mycobacteria
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DOI Number: 10.5958/0976-5506.2018.00652.6
Potential of Lactobacillus Strains with Antimicrobial Activity
against Acinetobacter baummanii
Suresh P¹, V Sreenivasulu Reddy2, V Praveen kumar1, P Vamsimuni krishna1

1
Ph.D Scholars at Bharath University Thambram, 2Professor, Department of Microbiology,
Srilaxmi Narayana Institute of Medical Sciences (SLIMS) Osudu,Puducherry, India
ABSTRACT
Bacterial infection constitutes a major public health problem worldwide and excessive use of antimicrobials
in health care settings leads to microbial resistance. Increasing antibiotic resistance of pathogens associated
with Bacterial infections has also become a major therapeutic challenge for physicians. Thus development
of alternative treatment protocols, such as the use of probiotics may help in countering alarming situation of
drug resistant and multidrug resistant bacteria. Lactobacillus species bacteria which are one good prototype
of probitic are considered useful in minimizing antimicrobial use. The aim of this research was to determine
the antagonistic properties of Lactobacillus acidophilus and Lactobacillus casei isolated from the manually
prepared buffalo milk curd against Acinetobacter baumannii causing wound infections in humans. Three
hundred samples of wound infections were collected and processed for bacterial isolation and antimicrobial
susceptibility testing following standard bacteriologic techniques & Vitec –II Campact system. The antibiotic
susceptibility test was performed by the disk diffusion method, and antagonistic effect of Lactobacillus
strains was investigated by well diffusion method. Total 500 pus samples were collected from patients with
wound infection at Tertiary care hospital in Pondicherry, India and processed as CLSI guidelines and with
help of Vitec-II campac system, 268 isolates were identified as Acinetobacter baumannii. Of these 268
isolates, a total of 109 strains of A. baumannii showed high resistance to tested antibiotics. Lactobacillus
acidophilus and Lactobacillus casei isolated from the manually prepared buffalo milk curd were tested
for the antimicrobial inhibitory property against Acinetobacter baumannii. Lactobacillus acidophilus had
antagonistic properties against A. baumannii. These results are in agreement with other published reports
from different countries that indicate that infection control efforts may be achieved with Lactobacillus
species. We believe that more attention should be paid to these areas, particularly to create a standardized
approach.
Keywords: Lactobacillus species, antimicrobial susceptibility, Acinetobacter baumannii infections.
Introduction susceptibility patterns make empirical and therapeutic

decisions even more difficult.
The challenges of treating multidrug-resistant
bacteria continue to be a problem in the clinician’s The association of A. baumannii with pneumonia,
practice in providing care for the hospitalized bacteremia, wound infections, urinary tract infections,
patients. Acinetobacter baumannii has proven to be an and meningitis has been well described.¹ Acinetobacter is
increasingly important and emerging causative pathogen a gram-negative coccobacillus that has emerged from an
in health care associated infections. The drug-resistant organism of questionable pathogenicity to an infectious
nature of the pathogen and its unusual and unpredictable agent of importance to hospitals worldwide. The
organism has the ability to accumulate and exhibit diverse
Corresponding author: mechanisms of resistance, leading to the emergence of
Suresh P strains that are resistant to all commercially available
E-mail: [email protected] antibiotics.
Acinetobacter baumannii is one of the ESKAPE method on Mueller-Hinton agar. All the samples were
pathogen, a group bacteria which are of clinically primarily investigated for morphologic and biochemical
important pathogens, predominantly implicated in characteristics, including Gram stain, motility, catalase,
health care-associated infections that have the potential oxidation and fermentation, growth at 42°C, indole and
for substantial antimicrobial resistance.² esculin test. Antimicrobial susceptibility testing was
performed by the agar diffusion method on Mueller-
One of the important features of probiotic
Hinton agar. Based on biochemical properties and
Lactobacilli is to achieve antagonistic activity against
with help of Vitec-II campac system Acinetobacter
bacterial pathogens because of their capacity to produce
baumannii was identified. 268 isolates were identified as
lactic acid and other organic acids that lower the pH and
Acinetobacter baumannii. Of these 268 isolates, a total
to produce H2O2 and bacteriocin, thereby establishing
of 109 strains of A. baumannii showed high resistance
a hostile environment for the growth and survival of
to tested antibiotics. These 109 strains of A. baumannii
various human pathogenic bacteria. Moreover, antibiotic
were transferred into tryptic soy broth after adding 15%
resistance of the Lactobacillus is a required probiotic
glycerol in a 1.5 ml microtube and stored at −20°C.
property helpful, for the survival of Lactobacillus in
presence of antibiotics, especially for those strains Preparation of Lactobacillus strains
that are co-administered with antibiotics. However,
Using the standard procedure, Lactobacillus
such resistance among the probiotic Lactobacillus
acidophilus and Lactobacillus Isolated from buffalo
be essentially innate and non-transferable in nature.
milk curd and identified after comparing with ATCC
The probiotics having innate resistance to kanamycin
Quality control organisms, Lactobacillus acidophilus-
(K), streptomycin, gentamicin (GEN), vancomycin
ATCC9224 and Lactobacillus casei –ATCC27139.
(VA) and nalidixic acid suggest the preventive and
Lactobacilli Isolated from buffalo milk curd were stored
therapeutic administration of such strains in treating
under frozen conditions in the liquid MRS plus glycerol
bacterial infection in the cases of co-administration
at -70°C.
with antibiotics.³ Various health and nutritional effects
of lactic acid bacteria have been described, including These frozen isolates were cultured in MRS solid
improvement of the quality of human and animal foods, and incubated in a Co2 incubator and were incubated for
metabolic stimulation of the synthesis of vitamins and 48 hours. The Lactobacilli grown on solid MRS medium
enzymes, stabilization of the intestinal micro flora, was inoculated in liquid MRS medium, and after 24 hour
competence with intestinal pathogens of the host, innate in liquid MRS broth was removed and transferred to
immune boost, production of antimicrobials, reduction another tube of MRS broth in order to strengthen growth.
of the risk of colon cancer by neutralizing carcinogens
and suppression of tumors by modulating of the probiotic Antogonistic test
strains.4,5
To test the antagonistic effect of Lactobacillus against
The aim of this research was to study the effect the Acinetobacter baumannii following procedure was
of Lactobacillus acidophilus and Lactobacillus casei followed.
isolated from the Common curd and reducing the rates
Stored 109 strains isolates of Acinetobacter
of Acinetobacter baumannii causing infection.6
baumannii were first cultured on MacConkey and then
MATERIAL AND METHOD on nutrient agar.
In total 500 pus samples were collected from The stored Lactobacillus acidophilus and
patients with wound infection at Tertiary care hospital in Lactobacillus casei isolated from the manually prepared
Pondicherry, India and processed as CLSI guidelines. All buffalo milk curd were inoculated into de Man, Rogosa
the samples were primarily investigated for morphologic and Sharpe (MRS) broth and incubated in anaerobic jar
and biochemical characteristics, including Gram at 37°C for 24 hours.
stain, motility, catalase, oxidation and fermentation,
Using a sterile swab, Acinetobacter baumannii
growth at 42°C, indole and esculin test. Antimicrobial
of 1/10 McFarland dilutions were inoculated into the
susceptibility testing was performed by the agar diffusion
surface of nutrient agar. On the surface of nutrient
agar plate, holes 5 mm in diameter and depth were Table 1: Antagonistic effect (inhibition zone)
created under sterile conditions. The MRS broth of Lactobacillus Acidophilus, Lb. casei against
containing Lactobacillus was centrifuged at 6000 rpm Acinetobacter baumannii isolates
for 10 minutes. Supernatant was filtered with a
bacteriologic filter. Then 100 μL of solution of each of MIC(Minimum inhibition concentration)
Lactobacillus
lactobacilli was poured into a separate well. The media species
were kept in the refrigerator for 2 hours until the liquid (-) (+) (++) (+++) Average
was absorbed, then transferred into the incubator and

Lactobacillus 19-
incubated for 14 to 15 hours at 37°C. After incubation, acidophilus
Nil Nil
22mm
Nil 20mm
the diameter of the inhibition zones (mm) around the

Lactobacillus 14-
well was measured using a ruler.⁸ The antagonistic effect casei
Nil
16mm
Nil Nil 16mm
of lactobacillus against Acinetobacter baumannii was
interpreted on the bases of inhibitory growth zones as Inhibitory growth zones were interpreted as follows:
follows: negative (−) was <11 mm; medium (+) was 11 negative (−) at <11 mm; medium (+) at 11–16 mm;
to 16 mm; strong (++) was 17 to 22 mm; and very strong strong (++) at 17–22 mm; very strong (+++) at >22 mm.
(+++) was >22 mm. separate plates were used to test
for the antimicrobial inhibitory effect of Lactobacillus Discussion
acidophilus and Lactobacillus casei which were isolated Eradication and treatment of infections caused
from buffalo milk curd. by A. baumannii are difficult because of their high
Results resistance to antibiotics and disinfectants ¹°,¹¹ . These
bacteria can cause serious infections in hospitalized
The 109 strains of Acinetobacter baumannii were patients because they can grow under a variety of
chosen to test the antimicrobial inhibitory effect of different conditions and have acquired widespread
Lactobacillus acidophilus and Lactobacillus casei. These antibiotic resistance. They therefore result in problematic
lactobacillus species showed significant antagonistic infections that impose high costs on healthcare ¹².
effect on A. baumannii. Lactobacillus acidophilus Lactobacilli are harmless microorganisms capable of
exhibited more antagonistic effect than Lactobacillus producing acid secretion, bacteriocins and other by-
casei. Details are shown in Fig. 1. products that can neutralize some pathogens, can regulate
the inflammatory response of the immune system and can
be used in the treatment of gastrointestinal disorders¹³,¹⁴.
Our results showed that lactobacilli had an inhibition

growth effect on A. baumannii . These results are in
agreement with previously reported findings that different
strains of lactobacilli inhibit the growth of bacteria
such as Staphylococcus aureus, Escherichia coli, P.
aeruginosa, Klebsiella pneumoniae, and Burkholderia
cepacia¹⁵, ¹⁶. Others have reported that lactobacilli
had an inhibitory effect on the growth of both Gram-
negative and Gram-positive bacteria ¹⁷. In addition, there
Fig. 1. is also in vitro report of probiotics against pathogenic
Inhibition zone of Acinetobacter baumannii caused bacteria ¹⁸. Several previous studies have shown that
by Lactobacillus spp. (Top left) Lb. casei (16 mm). (Top probiotic factors other than lactic acid, such as bacteriocins,
right) Inhibition zone of A. baumannii caused by Lb. proteinase, peroxidase and exopolysaccharide, can exert
acidophilus (19 mm). (Bottom) Lb. acido philus with antibacterial effects ¹⁵. Some studies have reported that
0.5 McFarland (17 mm). lactobacilli such as Lb. plantarum, Lb. paracasei, Lb.
fermentum, Lb. bokash and Lb. boots isolated from
the stool of infants had inhibitory activity against
food-contaminated bacteria such as E. coli, S. aureus,
Yersinia enterocolitica and Bacillus cereus,⁹ ¹⁹. A 13. Published online 2016 sep28.doi:10.1016/
previous study demonstrated the antibacterial effect jnmni.2016.09.03.
of Lactobacillus isolated from breast milk against the 7. Clinical and Laboratory Standards Institue(CLSI).
gastrointestinal pathogenic bacteria E. coli, Shigella, Performance standards for antimicrobial
Pseudomonasand, Salmonella¹⁹. Another study found disk susceptibility testing:approved standard
that strains of lactobacilli lower the effect of production wayne. PA: Clinical and laboratory standards
of elastase and biofilm formation¹². Institue:2012. M100-s22 vol.32 No.3.
CONCLUSION 8. Gita Eslami sudabeh Taheri Eznollah Azargashb,
Raheleh karimiravesh Inhibitory Effect of
Lactobacillus acidophilus and Lactobacillus casei Lactobacillus rhamnosus on pathogenic bacteria
present in common curd (buffalo milk curd) had good Isolated from women with Bacterial Vaginosis.
effects on preventing the growth of A. baumannii. These Novel Biomed 2014;2(2):64-68.
results are in agreement with other published reports
9. Tsai CC, Lin p.p., Hsieh Y.M. Three Lactobacillus
from different countries that indicate that infection
strains from healthy infant stool inhibit
control efforts may be achieved with probiotic bacteria.
enterotoxigenic Escherichia coli grown in
We believe that more attention should be paid to these
vitro. Anaerobe.2008:14:61-67.
areas, particularly to create a standardized approach.
10. McDonnell G., Russell A.D. Antiseptics and
Ethical Clearance- obtained from Institutional disinfectants: activity, action, and resistance. Clin
Ethics Committee (Human Studies) Ref.no. IEC/ Microbiol Rev. 1999;12:147–179.
C-p/49/2014.
11. Karlowsky J.A., Draghi D.C., Jones M.E.,
Source of Funding- Nil Thornsberry C., Friedland I.R., Sahm D.F.
Surveillance for antimicrobial susceptibility
Conflict of Interest - Nil among clinical isolates of Pseudomonas
aeruginosa and Acinetobacter baumannii from
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DOI Number: 10.5958/0976-5506.2018.00653.8
Dole-Dole Tradition in Health Seeking Behavior of Buton
Society, Southeast Sulawesi
Andi Asrina1, Sukri Palutturi2, Andi Tenri3
School of Public Health, Muslim University of Indonesia, Makassar Indonesia, 2School of Public Health,
1
Hasanuddin University, Makassar Indonesia, 3School of Social and Political Sciences of Dayanu Ikhsanuddin
University, Baubau Indonesia
ABSTRACT
Background: The cause of the disease is naturalistic and personalistic. Perception of the cause and cure of
the disease is personalistic and also very close to the habits of the people of Buton.
Objective: The purpose of this study is to examine and analyze the pattern of Buton community health-
seeking behavior on infants and under five years based on personalistic etiology.
Materials and Method: This research used a qualitative ethnographic approach. The research site was
conducted at Baubau. 12 informants were interviewed: 4 regular informants, 4 key informants, and 4
supporting informants. Data collection processes were by observation technique, in-depth interview,
documentation, and FGD. Selection of informants was purposive sampling. Data were analyzed in the
cultural domain for the category according to the research focus.
Results: The results showed that the pattern of treatment seeking in infants and under five years who
experience diseases starting from home treatment, then to health services and traditional medicine. This may
be reversed by the general pattern of treatment seeking that starts from the traditional to the health service,
but in the dole-dole tradition the last option is to carry out this ceremony for healing. This tradition is passed
down through generations and is considered a way which is powerful in prevention, immunization, and
healing in the Buton community especially in infants and under five years who experience health problems.
Conclusions: The conclusion of this study is that the pattern of treatment seeking of the Buton society is
based on the belief in traditional healing performed by heredity and is considered more successful than
medical treatment. It is suggested that the provision of information increase public understanding of the
belief in health (medical) services without leaving a belief in local traditions.
Keywords: Health, Seeking, Behavior, Treatment, Tradition, Dole-Dole, Buton
BACKGROUND of culture has their respective perceptions about the

treatment and cure of a disease that is difficult to receive
Indonesia is known for its cultural diversity which medically. Although society has entered the modern era
influences many people’s social life, including in health and experienced the development of mindset, including
field 1,2. Health and culture adopted by the community socio-cultural development, still many traditions are
are closely related to the main deterrents of healthy- maintained until now. This also applies to the culture
sick perception; causes and cures3-5. Every adherent of Buton people who always maintain their traditions,
including their health. One of the traditions of the
Corresponding author: Butonese society that is considered a healing is the dole-
Sukri Palutturi, dole tradition 6-8. The dole-dole tradition is a traditional
E-mail: [email protected] immunization activity in infants and toddlers in Buton
Phone : +62 811 4453033 culture. This tradition is especially for children who are
often sick or this tradition as a provision of immunity related to the pattern of treatment seeking. Selection
against the possibility of disease and less normal growth. of informants was conducted by purposive sampling,
with criteria: the Buton community who conducted a
Historically, dole-dole originated from the era
traditional treatment seeing known as dole-dole tradition.
Sipanjonga (one of Mia Patamiana, founder of the
The focus of this research is to analyze the perception
kingdom of Buton). Sipanjonga’s marriage with
of informants about the sign, the perceived symptoms
Sibaana (brother of Simalui) gave birth to a son named
and the way of healing that is believed by the people of
Betoambari. It is said that, since infancy, Betoambari
Buton.
always experience sickly. Seeing this condition,
Sipanjonga then held a ritual ceremony of treatment RESULTS
for his son. As a result, after the treatment ceremony
Characteristics of informants
was completed, Betoambari was gradually healed. This
ceremony is called dole-dole (Munafi, et al, 2015). Until Table 1 shows the characteristics of informants in the
now, this tradition is believed to cure diseases, especially Dole-Dole Tradition study on the Buton. 12 informants
in children. Dole-doles are always carried out when the have different educational backgrounds: entrepreneurs,
children of the Buton tribe are affected by the disease housewives, religious leaders, community leaders,
and do not recover even after receiving medical services. humanists and health workers. They have different
levels of education from elementary school to post-
According to the beliefs of Buton people, children
graduate. Bisa’generally educated elementary or junior
who have passed the dole-dole ceremony will be spared
high school.
the disease and will recover from the illness suffered.
This community belief is based on the ancestors who The table illustrates that all age-old informants
hold fast the dole-dole tradition and no one dares to indicate if dole-dole traditions have been inherent in
break unless it will be affected even worse. This shaped their lives. The educational background and work of
the behavior of the Buton community in the pattern of informants varied from the lowest to higher education
seeking treatment when there are health problems in not necessarily disregarding the traditions that had long
children. been adhered to by their ancestors. This shows that in
the dole-dole tradition does not recognize the level of
The Buton people who believe in the dole-dole
education and age and even work. Anyone with a low
tradition as a way to cure the disease are the outcome
or high educational background will always continue to
and the internalized response in their lives thus shaping
preserve it as long as it becomes a belief.
and influencing behavior. This behavior is not expected
to have a negative impact on the belief of the Butonese Health seeking behavior
people on health care in the pattern of seeking treatment.
Based on the background that has been described The results of the search for in-depth information
previously, so the purpose of this research is to examine were made to the baby’s parents who carried out the
and analyze the pattern of treatment of Butonese people doles and believed to be the healing endeavors such as
in infants and under five years. the following informant’s expression:
MATERIALS AND METHOD “My first child used to walk the week after the doles.
Before in the dole-dole, there is a belief that my child
This type of research used a qualitative ethnographic will recover ... this kind of like obligations so it must be
approach 9-11 to explore the phenomenon of Buton dole-dole. This is part of the traditions of the people here,
community treatment seeking. The research site was meaning there is confidence and always as expected. My
conducted at Baubau. The 12 informants in this study child is already taking medicine, immunization is also
were interviewed, consisting of 4 regular informants, but not yet healed because it has not dole-dole. This is
4 supporting informants namely shaman (bisa’) and not just conservation but belief if it is not implemented
health workers and 4 key informants ie religious figures, then there will always be hurdles such as sickly, weak,
community leaders, and local humanist. Data collection disadvantaged, and so on .. “(Srd, 42 years, March 15,
processes were by observation techniques, in-depth 2017).
interviews, documentation and Focus group Discussion
It can be described that informants consider dole- to be dole-dole. This information is reinforced by local
doles as mandatory because there will be consequences community leaders, as follows:
obtained if they are negligent. Despite having wandered
“Actually, people do dole-dole with the hope to
away they will return to Buton to carry out the dole-dole
get the desired results. This hope becomes confidence
tradition, especially for treatment. The same thing was
because it has been to health services but has not healed
revealed by another informant:
so that psychologically can feel healing. Not only that,
“... what the children feel, the name is kaepeta .. this belief is supported by the intention of being able to
everything that is felt just if not take it will not heal, then ‘... in essence, people’s belief in this tradition (dole-dole)
we have children will not heal. Usually parents see the can heal and it happens, let alone one who is full of hope
situation, usually, parents say this not in dole-dole “(As, for the healing of his child. Some do not do it because
45 years, date May 04, 2017) their ancestors did not do it, that’s fine “(Lm.Ars, 49,
May 14, 2015).
Based on the informants’ expression that this
tradition has been carried out since their ancestors, the The explanation from local community leaders
signs and symptoms suffered by their children can be confirms that the doles are executed with intention and
identified and the treatment according to what is believed hope to heal so that they get psychic psychically.
Table 1. Characteristics of informant
No. Informants Age (year) Education Level Occupation
1. Srd 42 Senior High School Private
2. Nrm 42 Vocational High School Private
3. Wa.M 50 Senior High School Housewife
4. As 45 Bachelor Degree Teacher
5. Mr. 62 Elementary School Bisa’
6. Sm 62 Elementary School Bisa’
7. Nr 72 Junior High School Bisa’
8. LM.Ars 49 Master Degree Religious leader
9. H.SlH 62 Secondary Technical School Religious leader
10. H. Srl 62 Senior High School Community leader
11. IK 25 Master Degree Humanist
12. Ms 53 Bachelor Degree Health provider

Source: Primary Data, 2017
DISCUSSION carried out by the predecessors of the Buton community

and became a preserved heritage.
Based on the research results, it is found that the
dole-dole tradition is done through the inheritance According to Koentjaraningrat 12, that at the initial
process from generation to generation. Despite the stage of the socialization process, a child is exposed,
modern times but the people of Buton still closely with among others, how to eat, what food to eat, how to
the traditions that become his life cycle including, dole- urinate, and others. These habits continue to be done
dole tradition. They believe that the tradition brings until the child is mature and even old. These habits
blessings and health and for the future for the child. This strongly affect the behavior of health that is very difficult
tradition became an option in medicine because it was to change 12.
Although, in general, people who preserve the-dole early pattern of its treatment seeking until it was healed,
dole hard to explain how the tradition can heal, but it still believes that dole-dole is the solution for those
can be said that the belief of Buton people will ritual who inherit this tradition. This is in line with research
in life comes from his understanding of the cause of conducted by Syahrun on the traditional medicine of the
the disease. This is the same disclosed by Foster and Butonese people that the Buton society’s view of disease
Anderson (1986), that there are two kinds of causes of is a series of cultural processes.
disease that is the cause of personalistic and naturalistic.
According to Foster, Anderson 15, the symptoms that
In the dole-dole tradition, there are two kinds appear to each individual will be in different responses as
of treatment based on the perceived cause, but more well. When the symptoms that appear on the body is not
dominant is the personalistic-oriented illness or too felt by people who seek treatment until the disease
perceived illness. Buton Society’s view of the illness worsens, otherwise people who are more sensitive to the
experienced that when the child has felt or the Butonese emergence of symptoms will be faster in seeking medical
call it Kaepeta, then the method of healing is to carry out help and get a fast treatment as well. When associated
the dole-dole tradition. Involvement of shaman (bisa’) with the dole-dole tradition, the symptoms of the disease
who leads dole-dole rituals is believed to be healing that appear and demonstrated by the child will be known
because of his personalistic treatment, through prayers by the parents so that the treatment in accordance with
on the basis of the beliefs of the child’s parents to heal. the stages of healthy behavior is believed. This tradition
became an option in medicine because it was carried
Based on research, Buton people do dole-dole
out by the predecessors of the Buton community and
tradition is intended to prevent the occurrence of
became a preserved heritage. At the initial stage of the
things that are not desirable in children such as growth
socialization process, a child is introduced, such as how
and developmental delays, weakness of the physical
to eat, what food to eat, how to urinate and others. These
condition or the disease.
habits continue to be done until the child is mature and
According to bisa’, for treatment, there is really no even grow old. These habits greatly affect health behavior
age limit as long as there is a request from the parent that is very difficult to change 12. The distinctive signs
or family to do dole-dole. But in general, dole-dole is and symptoms identified by the Butonese community
done at the age of five because according to the beliefs of shape their behavior in the search for a treatment of the
Buton people at that age usually have to show symptoms dole-dole tradition.
of typical illness such as scabies so it must be done dole-
CONCLUSIONS
dole. Safitri 13, revealed the implementation of dole-dole
is not determined at what age the child. Whenever it can The Buton community in this study has used health
be done the origin of “good days” please take place. services, but the treatment-seeking behavior is based on
Related to the theory of Lawrence Green 14, that which the signs and symptoms that the traditional healing of
facilitates the formation of behavior is a predisposing dole-dole tradition is considered to be more successful
factor such as the existence of tradition held by the than medical treatment. It is suggested that the provision
community. of information increase public understanding of the
belief in health (medical) services without leaving a
Analyzing information from dole-dole actors, as
belief in local traditions
well as efforts to treat the disease in children, there are
two patterns made by the people of Buton, ie there are Source of Funding: The Ministry of Research,
first visited the health service but not healed finally treat Technology and Higher Education, Republic of
by doing dole-dole. Indonesia.
There are also people from the beginning have been Conflict of Interest: None declared
convinced that what is felt or suffered by his son can
Ethical Clearance: Taken from ethical committe/
only be treated with dole-dole ceremony, but when later
research letter from Faculty of Public Health, Muslim
not healed also just take advantage of health services.
University of Indonesia, Makassar Indonesia
Based on in-depth interviews, this study also found that
the health behavior of the Butonese community, the
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West Sumatra, Indonesia. Asia Pacific journal of
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clinical nutrition. 2001;10(1):10-16.
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3. Adane M, Mengistie B, Mulat W, Kloos H,
9. Creswell JW, Poth CN. Qualitative inquiry and
Medhin G. Utilization of health facilities and
research design: Choosing among five approaches.
predictors of health-seeking behavior for under-
Sage publications; 2017.
five children with acute diarrhea in slums of Addis
Ababa, Ethiopia: a community-based cross- 10. Bernard HR, Wutich A, Ryan GW. Analyzing
sectional study. Journal of Health, Population and qualitative data: Systematic approaches. SAGE
Nutrition. 2017;36(1):9. publications; 2016.
4. Vygen S, Tiffany A, Rull M, et al. Changes in 11. Silverman D. Qualitative research. Sage; 2016.
health-seeking behavior did not result in increased 12. Koentjaraningrat. Manusia dan Kebudayaan di
all-cause mortality during the Ebola outbreak Indonesia. Yogyakarta: Djambatan; 2002.
in Western Area, Sierra Leone. The American
13. Safitri SW. Tradisi Dole-Dole sebagai Determinan
journal of tropical medicine and hygiene.
Masalah Kesehatan Ibu dan Anak pada Masyarakat
2016;95(4):897-901.
Buton Kota Baubau Provinsi Sulawesi Tenggara.
5. Sachs J, Bharadwaj R, Khadse S, et al. Makassar, Universitas Muslim Indonesia; 2016.
The Impact of Health Seeking Behavior on
14. Notoatmodjo S. Promosi Kesehatan: Teori dan
Community-Acquired Multi-Drug Resistant
Aplikasi. Jakarta: Rineka Cipta; 2005.
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DOI Number: 10.5958/0976-5506.2018.00654.X
Salivary Diagnostics in Cardiovascular Disease–A Review
Sunil M Eraly1, Mithra N Hegde2, Raksha Bhat3, Preethesh Shetty3, Aditya Shetty4
Head of the Department, Department of Conservative Dentistry & Endodontics, Malabar Dental College,
1
KUHAS University, Kerala; 2Head of the Department, 3Assistant Professor, 4Additional Professor,
Department of Conservative Dentistry & Endodontics, A. B. Shetty Memorial Institute Of Dental Sciences,
Nitte University, Deralakatte, Mangalore
Abstract
Saliva is secreted by major salivary glands; namely parotid, submandibular, sublingual and various other
minor glands present in the oral cavity. Secreted systematically, it has been known to possess multiple
informative proteins and peptides, which may serve as biomarkers in the early detection of various diseases.
Early detection of diseases is vital not only to reduce the severity of the disease and avoid complications,
but is also critical in increasing the success rate of treatment. In recent years, saliva has been researched
extensively as a proficient diagnostic tool due to its ease of sampling and non-invasive access. This review
will update on recent advances in salivary biomarkers to diagnose cardiovascular diseases.
Keywords: Saliva, cardiovascular disease, biomarkers
Introduction data subsequent to biochemical analysis of blood and/or

urine samples to determine the levels of ions, antibodies,
Cardiovascular diseases account for majority of the and hormonal levels as well as a broad series of disease-
systemic human ailments attaining global significance. specific biomarkers. However, oral samples were only
However, determination of the prognosis and diagnosis considered under the suspicion of an oral infection or
of these diseases poses to be a challenge, necessitating an oral malignancy. Nevertheless, given the rationale
auxiliary clinical evaluation followed by laboratory of salivary diagnostics, there has been increased interest
tests [1]. According to the World Health Organisation, in the use of saliva as a biomarker for the diagnosis of
cardiovascular diseases account for approximately 31% oral and systemic diseases. The possibility of obtaining
of deaths occurring at a global level annually, with the collateral information from an oral sample, which is
most common being acute myocardial infarction[2]. The relatively easy to obtain without any invasive procedures,
other most common cardiovascular diseases include helps in handling pediatric and geriatric patients, and
coronary heart disease, ischaemic heart disease, also for easier sample collection by trained individuals
stroke and heart failure [3]. Presently, the diagnosis of in remote geographical areas when access to health care
cardiovascular diseases is based on clinical evaluation is limited and phlebotomists are unavailable. A survey
followed by confirmatory laboratory tests such as done evaluating the dentist’s attributes towards chair side
electrocardiogram and various serum biomarkers[4,5]. screening of medical conditions revealed that the dentist’s
Systemic diseases are generally diagnosed are willing to carry out chair side diagnosis of systemic
following collection of the subjective and objective diseases if salivary samples are to be collected.[6]
Saliva is an excellent medium to explore and monitor

Corresponding Author: systemic diseases. According to the World Oral Health
Dr. Raksha Bhat Report in 2003, an direct relationship exists between
MDS [Conservative Dentistry & Endodontics] oral health status and systemic health as poor oral health
A. B. Shetty Memorial Institute Of Dental Sciences, is associated with major chronic diseases; poor oral
Nitte University, Deralakatte, Mangalore-575018 health causes disability; the common risk factors are
Phone: 9902634770 shared between oral health and major systemic diseases
Email: [email protected] and the systemic health diseases may cause or worsen
oral health conditions [7]. In light of these conditions, it’s auxiliary to electrocardiography in initial diagnosis of
prudential to evaluate and analyze human saliva as a myocardial infarction, as myoglobin is known to be
substitute to serum. released swiftly from an infarcted myocardium than
other biomarkers such as troponin and Creatine Kinase
Salivary Biomarkers: Around1000 different proteins MB which is usually detected as early as two hours after
and 19,000 unique peptide sequences have been detected a myocardial infarction [21]. Myoglobin has been found
in saliva [7,8,9]. Saliva, a plasma filtrate is a mixture of to appear in both serum and saliva biofluids. Studies
varied secretions produced by the major and minor by Miller et al, Mirzaii-Dizgah & Riahi and Florianio
salivary glands, gingival crevicular fluid, transudations et al established the salivary myoglobin levels to be
from the mucosa, serum and blood sheds from oral higher within 48 hours of the onset of angina in acute
wounds, desquamated epithelial cells, acquired pellicles, myocardial infarction patients, and to be in correlation
by products of various bacteria, viruses and fungi, with serum myoglobin. Hence, this proves salivary
cellular components and food debris [9–14]. diagnosis of myoglobin to be useful in detecting acute
Biomarkers are defined as biological molecules myocardial infarction [15, 19,22].
found in blood, saliva and other body fluids or tissues Creatine Kinase MB: Myocardial muscle creatine
that are signs of normal and abnormal processes, or kinase is found in the heart. In earlier times, creatine
of a condition or a disease [15]. These biomarkers have kinase MB was established to be a gold standard for
been classified as strong, questionable and potential. quantitative assessment of myocardial infarction and as
The biomarkers basically represent the physiological an adjunct to diagnosis as well [23, 24]. Creatine kinase MB
and pathological changes occurring in the human body. levels rise up within 3 to 5 hours of myocardial infarction
The sources of salivary biomarkers mainly include, Host and reaches a peak in the next 24 hours [25]. According
derived biomarkers associated with bone destruction, to recent studies, the specificity and sensitivity of the
Host –derived inflammatory biomarkers, Host-derived isoforms of creatine kinase MB were measured to be
biomarkers associated with soft tissue destruction upto 95.5% and 93.9%, respectively [26]. Literature
and bacteria derived biomarkers. These biomarkers demonstrates a higher value of creatine kinase MB in
enter saliva through blood by passive diffusion, active patients with acute myocardial infarction in comparison
transport or extracellular ultra-filtration. Hence, saliva is to non-acute myocardial infarction controls [15,27]. Studies
considered to be the mirror of body’s health [16]. have also proven a strong link between levels of serum
and salivary creatine kinase MB establishing the role of
SALIVARY BIOMARKERS IN
saliva based tests as an efficient as well as a convenient
CARDIOVASCULAR DISEASE DETECTION
way of delivering point-of-care testing of cardiovascular
Myoglobin, Cardiac troponin I and T, Creatine diseases [17].
phosphokinase MB, Myeloperoxidase, brain natriuretic
Cardiac troponin I AND T: Lately, cardiac troponin T
peptide, Exosomal miRNA, C-Reactive Protein, Matrix
and I have replaced myoglobin and creatine kinase-MB
metalloproteinase-8, and tissue inhibitor of MMP-8 have
as the preferred biomarkers of cardiovascular injury [2].
been proven to be the salivary biomarkers important in
During an event of any irreversible myocardial damage
the diagnosis of cardiac disease [17-19].
troponin is released by the myocytes. Troponin, a
Myoglobin: Myoglobin, a 17,800-d heme protein protein is known to be highly specific to cardiac tissue
present in cardiac muscle and skeletal muscle, is briskly and also accurately diagnose any cardiovascular disease
discharged into the blood stream subsequent to any with a history of ECG changes reflecting ischaemia or
muscle injury in a transient pattern. In patients with acute ischaemic pain. However, cardiac troponin levels are
myocardial infarction, the serum myoglobin level is dependent on the size of the infarct, thus postulating it
known to become abnormal in about 2 hours, then peaks to be an indicator for the prognosis and diagnosis after
in about 6 - 9 hours, and again becomes normal in 24-36 a myocardial infarction [4]. Cardiac troponins T and I are
hours after the infarction [20]. Hence, the measurement of known to be highly specific and sensitive with respect
myoglobin between 2 and 12 hours after the myocardial to cardiovascular damage. Serum cardiac troponin levels
infarction has high clinical sensitivity and specificity. The increase within 3 to 12 hours from the onset of pain in
levels of serum myoglobin are known to be an effectual the chest, peaks at 24 to 48 hours, followed by return to
baseline values over 5 to 14 days [1]. However, cardiac phases of atherosclerosis. Myeloperoxidase enzyme
troponin levels may not be detectable for upto six hours converts low density lipoprotiens into an atherogenic
after the onset of myocardial cell injury. Literature form, eclectically modifies apolipoprotein A-I, forms
demonstrates strong correlation between cardiac dysfunctional high-density lipoprotein, stimulates
troponin –T and cardiac troponin-I in saliva of patients endothelial dysfunction, develops plaque, promotes
with acute myocardial infarction [19,22,28]. A study by myocardial dysfunction and abnormal ventricular
Mirzaii-Diazgah et al demonstrated that both stimulated remodeling subsequent to myocardial infarction [34].
and unstimulated saliva had a strong correlation with Kossaify et al. and Mirzaii-Diazgah et al determined
serum cardiac troponin T levels [22]. Due to the high that salivary myeloperoxidase shared similarities to
specificity, sensitivity and it being an evidence base serum biomarkers [27, 35]. Studies in literature proving
for the prediction of the outcome of the disease, the salivary myeloperoxidase to be a diagnostic tool for
measurement of cardiac troponin I was established as the cardiovascular disease have shown to have a sensitivity
gold standard test for myocardial infarction [22]. Hence, of 90–100% [5].
due to the strong correlation between salivary and serum
cardiac troponin levels, salivary diagnostics would prove Exosomal miRNA: Cells upon fusion of multivesicular
efficient in cardiac patients. bodies with the plasma membrane form exosomes.
The envelope of exosomes reflects their cellularity and
Brain Natriuretic Peptides: The European Society of surface and internal contents including predominant
Cardiology advocates the analysis of B-type natriuretic signaling components. They possess a wide array of
peptide and the N-terminal part of the propeptide of brain proteins, lipids, RNAs, non-transcribed RNAs, miRNAs
natriuretic peptide in evaluation of patients with suspected
and small RNAs, which are representative to the origin
cardiovascular disease [29]. The cardiac brain natriuretic
of their cellularity and alternate between donor and
hormones are known to be secreted by cardiomyocytes
recipient cells. Exosomes are thought to play major roles
and possess both smooth muscle relaxing effects, both
in various pathological conditions, therefore helping in
diuretic and vascular [30]. High concentrations of these
hormones in serum are known to be directly proportional the development of non-invasive salivary diagnostics.
to the poor prognosis in myocardial infarction [31]. Exosomal miRNAs have been known to demonstrate
According to literature, a significant relationship exists potential as diagnostic biomarkers for cardiovascular
between salivary and serum brain natriuretic peptide diseases and renal fibrosis [36]. Despite the relative facility
and plasma NT-pro brain natriuretic peptide [15, 32,33]. to collect exosomes from biological fluids, the actual use
Also, salivary brain natriuretic peptide was observed to of exosome-derived proteins or miRNAs as biomarkers
be significantly higher in symptomatic cardiovascular has not been yet implemented in clinical practice [37,15].
patients. As symptoms improve, the levels of brain
natriuretic peptide are known to disappear. Hence, the C Reactive Protien: C Reactive protien has been
levels of brain natriuretic peptide in saliva helps us identified as a strong, independent risk factor associated
differentiate cardiovascular patients who are in the phase cardiovascular disease, and is the most extensively
of decomposition, whereas low levels of brain natriuretic studied area. In recent studies Arroyo Espliguero et al.
peptide were seen to be associated with improvement and Raposeiras Roubín have concluded that C Reactive
in symptoms [32]. The similarities observed between protien is an independent predictor of cardiovascular
salivary proteins and plasma proteins, along side the disease [38,39]. The magnitude of myocardial necrosis is
important role of brain natriuretic peptide, follow-up, reflected in the serum by the presence of high levels
and treatment planning encourages the detection of this of C Reactive protein. Serum C Reactive protien
factor in saliva in patients with cardiovascular ailments. concentrations increase subsequent to the activation of
Myeloperoxidase: Myeloperoxidase is a leukocyte- cytokines in the initial hours of myocardial infarction
derived enzyme, which catalyzes the formation of various
[40].
Several studies have demonstrated elevated C
reactive oxidant species. Various myeloperoxidase- reactive protein levels were detected in saliva collected
catalyzed reactions are attributed to be taking place from patients in accordance with the plasma levels in
throughout the evolution of cardiovascular disease, ischemic cardiovascular disease in comparision with
including initiation, propagation, and acute complication healthy controls [41,42,43].
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Conflict of Interest: Nil peptides: Types and role in the oral cavity. Saudi
Pharm. J. 2015, 24, 515–524.
Sorce of Funding: Self
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Ethical Clearance: Not Required Raza, S.Q.; Zohaib, S.; Sefat, F.; Zafar, M.S.
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DOI Number: 10.5958/0976-5506.2018.00655.1
Antibacterial Activity of Lactobacillus (LB) Strains Isolated
from Goat Milk against ESBL Producing E. coli Causing
Wound Infections
Suresh P.¹, V. Sreenivasulu Reddy2, V. Praveen kumar1, P. Vamsimunikrishna1

Ph.D Scholar, Bharath University Thambram,Chennai. 2Professor, Department of Microbiology,
1,3
Sri LakshmiNarayana Institute of Medical Sciences (SLIMS), Puducherry, India
Abstract
Lactobacillus (LB) species are well known probiotics with beneficial effects to human health. Their
antimicrobial activity is one of the most important probiotic characteristics. Wound infections are the
most frequent bacterial infections encountered in community settings. Extended spectrum β-lactamases
(ESBLs) are enzymes produced by pathogenic bacteria that enable such pathogenic bacteria as multi drug
resistant. Treatment of infections by these drug resistant bacteria require newer anti microbialsthat are
highly expensive and possibility of many side effects. Microbial products consideredas the best source
for therapeutic agents worldwide. Lactobacillus species were isolated from 2 days fermented goat Milk.
Theantimicrobial activity of cell-free supernatant and partially purified bacteriocin was determined by well
diffusion method and equal mixed culture method. All isolated ESBL were processed and identified as
per theCLSI guide lines. The organism was identified by GN ID and AST 280 of Vitec-II campact system
and AES (Advance extended spectrum) tests. The current study showed that ESBL E. coli resistant to
Cefazoline (96.6%), Ceftazidime (43.3%), Ceftriaxone (3.3%), Ciprofloxacin (76.6%), Meropenem (0%),
Tobramycin (43.3%), Cefotaxime (93.3%), Ceftazidime + cluvalonic acid (3.3%), Cefotaxime + cluvalonic
acid (3.3%), Cefperodoxime (96.6%), Piperacillin + Tazobactam (0%), Ampicillin (100%). Lactobacillus
species exhibited an antibacterial effect on a narrow range of ESBL strains. However invitro effect is better
than large number broad-spectrum antibiotics such: third-generation cephalosporins
Keywords: PUS, ESBL,CLSI,GN ID,AST280,VITEC-II CAMPACT system(AES).
Introduction commonly Escherichia coli.² One group of β lactamases,

extended-spectrum β lactamases (ESBLs), have the
Recent trends show extended spectrum β-lactamase ability to cause resistance to various types of the newer
(ESBL) producing bacterial pathogen cause various β-lactam antibiotics, including the expanded-spectrum
life threatening infections that lead to sepsis related (or thirdgeneration) cephalosporins (eg, cefotaxime,
mortality. The ESBLs can make the infection caused ceftriaxone, ceftazidime) and monobactams (eg,
by the bacteria much difficult to treat.Wound infection aztreonam), but not the cephamycins (eg, cefoxitin and
could result in prolonged hospital stay and higher cost cefotetan) and carbapenems (eg, imipenem, meropenem,
of treatment. Gram negative bacteria have been reported and ertapenem).³
to be the major cause of wound infections.¹Extended
spectrum β-Lactamases (ESBL) are enzymes produced Lactobacillus have long been considered as
by pathogens belonging to Enterobacteriaceae, most protective microflora, able to displace and inhibit
different pathogens. The Lacto bacillus (LB) are well
known probiotics with beneficial effects to human
Corresponding Author: health.⁵ Their antimicrobial activity is one of the most
Suresh P important probiotic characteristics.⁶ The production
Ph.D Scholar, of antimicrobial substances by resident or transit
Bharath University Thambram, Chennai Lactobacillus micro flora, to remove the pathogens is
Email: [email protected] under extensive study in recent times.⁷, ⁸ Lactobacillus
species L. fermentum, L. gasseri and L. salivarius guide lines and GN ID,AST280 of advance
isolated from normal flora were tested against antibiotic- extension spectrumAES(VITEC-II campact
resistant clinical isolates. In vitro growth inhibition of system) semi Automated system of microbiology
Acinetobacter baumannii and Pseudomonas aeruginosa lab. The antibiotics disk used were Amikacin
strains was observed.⁴ However, the basis of the inhibition (30μg), Ceftriaxone (30μg), Ceftazidime (30μg),
of the Gram negative antibiotic-resistant pathogens have Ceftazidime/Clavulanicacid, Terimetoperim
not been well established. The widespread antibiotic & Sulfomethoxazole, Gentamicin (10μg),
usage exerts a selective pressure that acts as a driving Ciprofloxacin (5μg), Meropenem (10μg),
force in the development of antibiotic resistance.⁹ which Pipercillin/Tazobactum, Cefazoline (30μg),
became a serious global problem.It is also evident Tobramycin (10μg), Cefotaxime/Clavulanic
that newly introduced antimicrobials also becoming acid, Cefotaxime (30 μg), Cefpodoxime (30),
ineffective in short periods due to rapid selection and Ampicillin (10μg). Standard protocols were used
spread of resistance bacteria. Scientific understanding to detected and confirm ESBL producing strains.¹²
of the mechanisms of competition between “good
D. Isolation and Identification Lactobacillus
bacteria” and pathogens is very vital. In the present from 2 days fermented goat milk: Two days
study antagonistic activity of 46 Lactobacillus strains fermented goat milk was serially diluted in saline
isolated from fermented Goat milk against drug resistant (0.85%) and 100 μl of each dilutions (10-1 - 10-6)
Gram positive and Gram negative human pathogens was were spread plated onto MRS (De Man Rogosa
observed. These observations of in vitro antimicrobial and Sharpe) to isolate the Lactobacillus spp and
trials could guide microbiologists for further study incubated at 37°C for 48 - 72 h at condation
on the appropriate recommendation of probiotics for anerobic jar.¹⁴ isolates was selected for further
clinical practice in health care settings.¹° studies. It was identified on the basis of growth,
cell morphology, gram staining and catalase
activity. Further, identification was performed
AIM
according to carbohydrate fermentation patterns
The aim of this research was to study the effect and growth at 15°C and 45°C in the MRS broth
of Lactobacillus species isolated from the two day based on the characteristics of the lactobacilli as
fermented goat milk against ESBLproducing Escherichia described in Bergey’s Manual of Determinative
Bacteriology and 16s rRNA sequencing.¹⁵
coli causing wound infections.
E. Quality control reference of the Lactobacillus
MATERIAL AND METHOD isolates: For QC reference, Lactobacillus strains
(ATCC NO:9224) which was Frozen in the liquid
A. Collection of samples: After obtaining the MRS plus glycerol at -70°C fridge, were cultured
Consent from the patients, pus samples were in MRS solid and incubated in a Co2 incubator
collected from the patients with wound infection and were incubated for 48hours. The lactobacilli
admitted in a tertiary care hospital. Samples were grown on solid MRS medium was inoculated
collected under aseptic precautions. Total 120 pus in liquid MRS medium, and after 24hour liquid
samples were collected over a period of 6 months. MRS broth was removed and transferred to
another fresh MRS broth, in order to strengthen
B. Culture and Identification E. coli: Pus samples the growth of lactobacilli.¹³
were immediately inoculated onto Blood agar &
MacConkeys agar media and incubated at 370c F. Antimicrobial Activity Determination: Using
a sterile swab, ESBL E.coli strain adjusted
for 24hrs. Identification of bacteria from positive
to 1/10 McFarland dilutions were inoculated
cultures was done with standard a microbiological
into the surface of Muller Hinton agar. On the
technique which includes AES (Vitec-II Campact
surface of Muller Hinton agar plate, holes 5 mm
system) Grams stain, biochemical reactions.¹¹ in diameter and depth were created under sterile
C. Confirmation of ESBL: A total of 85 E. coli conditions using a Pasteur pipette. The MRS broth
isolated from the pus collected from infected containing Lactobacillus was centrifuged at 6000
wounds were ESBL producing. All samples rpm for 10 minutes. Supernatant was filtered with
were processed and identified as per the CLSI a bacteriologic filter. Then 100 μL of solution
of each of lactobacilli species was poured into a Standard Lb. fermentum, Lb. acidophilus and Lb.
separate well. Plates were kept in the refrigerator casei, Lb.gasseri. Obtained from the Department of
for 2 hours until the liquid was absorbed, then Microbiology, srilaxmi naraya institute of medical
transferred into the incubator and incubated for sciences Osudu Pondicherry was used as a control.
14 to 15 hours at 37°C. After incubation, the
diameter of the inhibition zones (mm) around
Results
the well was measured using a ruler.¹⁶ The
antagonistic effect of lactobacillus against ESBL Among the 120 samples, a total of 85 isolates were
E.coli was interpreted on the bases of inhibitory identified as ESBL E.oli and remaining are non ESBL
growth zones as follows.¹⁷ E.coli and other organisms. In this study Lb. fermentum,
Inhibition zone <11 mm = negative (−) Lb. acidophilus and Lb. casei, Lb. gasseri had shown
antagonistic properties on ESBL E.coli. All the tested
Inhibition zone 11 to 16 mm = medium (+) Lactobacillus strains had a significant antagonistic effect
on ESBL E.coli. Lb.fermentum, Lb. acidophilus had
Inhibition zone 17 to 22 mm = strong (++)
more significant effect compared to the other lactobacilli
Inhibition zone >22 mm = very strong (+++) (Table 1) & (Table 2).
Table 1: Antagonistic effect (inhibition zone) of Lactobacillus fermentum, Lactobacillus Acidophilus,

Lb. casei, lactobacillusgasseriagainst ESBL E.coli Isolates
Inhibitory zone in mm
Lactobacillus Genus
(-) (+) (++) (+++) Average
Lb.fermentum Nil Nil Nil 36-44mm 39mm
Lb.acidophilus Nil Nil Nil 23-30mm 30mm
Lb.casei Nil 14-16mm Nil Nil 15mm
Lb.gasseri Nil Nil 17-22mm Nil 20mm
Inhibitory growth zones were interpreted as follows: Inhibition zone <11 mm = negative (−)
Inhibition zone 11 to 16 mm = medium (+), Inhibition zone 17 to 22 mm = strong (++),
Inhibition zone >22 mm = very strong (+++)
Table 2: Based on turbidity zone of inhibition
Name of the organism Turbitidity concentration of ESBL E.coli in mac forland

Lactobacillus sps 0.5 Macforland 1Macforland 1.5Macforland
Lb.fermentum 44 mm 40 mm 35 mm
Lb.acidophilus 35 mm 28 mm 24 mm
Lb.casei 16 mm 13 mm 10 mm
Lb.gasseri 23 mm 21 mm 17 mm
Inhibitory growth zones were interpreted as follows: Lb.acidophilus based on turbidity average zone of
negative (−), <11 mm; medium (+), 11–16 mm; strong inhibition: 63%
(++), 17–22 mm; and very strong (+++), >22 mm.
Lb.casei based on turbidity average zone of
Above the values Lactobacillus specious average inhibition: 29%
zone size 35-44mm.
Lb.gasser based on turbidity average zone of
Lb.fermentum based on turbidity average zone of inhibiton: 44%
inhibition: 84%
Discussion Source of Funding: Self
According to the results obtained in this study, MIC Conflict of Interest: Nil
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DOI Number: 10.5958/0976-5506.2018.00656.3
Analysis of Nuptiality Data through Life Table Approach
Chitra Rani Chauhan1, A. K. Maini1, Ajay Bhagoliwal2, Anju Gahlot2

1
Assistant Professor, 2Professor, Rama Medical College Hospital Research Centre Kanpur
Abstract
Nuptiality has a strong association with socio demographic and economical change in society. So, it has
immense importance to study the female age at marriage in society. In rural India, mostly marriages take
place at early ages. In this study, gross nuptiality tables for female nuptiality of rural population of Uttar
Pradesh, India have been constructed for the five consecutive decades 1951-61, 1961-71, 1971-81, 1981-
91 and 1991-2001. It is observed that nuptiality rates are changing with time. Initially, the rate is small at
the age group of 10 and increase rapidly till reaches to maximum at the age group 20. We also calculate
expected number of years of single life remaining to a single person at age x. It is also observed that the age
at marriage is increasing as the time passes.
Keywords: Nuptiality Estimation, Cohort, Life Table
Introduction of the rise in nuptiality witnessed in certain countries;

in other instances the increased mobility has mainly
A complicated individual phenomenon like resulted in a considerable reduction of the number of
marriage, with very strong familiar and social interlocks consanguineous marriages [4].This work attempts to
can be studied from different angles and at different examine the scenario of marriage in Uttar Pradesh state
levels. Numerous studies have found that the process of India.The aim of current work is to construct nuptality
of union formation happens in a systematic way. The table for rural settings of Uttar Pradesh
pattern of marriage is undergoing some discernible
changes throughout the world. It has played a major role Theoretical perspectives and previous findings: There
in determining the growth rate of population through its are more adolescents in India today than ever before.
linkage to marital fertility. According to the law and age at marriage for females in
India by (Pathak, K.B. (1980) near the beginning of study
Historically changes in the Nuptiality pattern has period, 1992, India had 38 million adolescent women;
played very significant role with respect to demographic by 2005, that number had grown by nearly half, to 50.5
transitions in many of the European countries (Van de million (Pathak, K.B. (1980)[5]). The three states with the
Wale, 1972)1. The experience of several less developed largest female adolescent populations—Andhra Pradesh,
countries where population growth rate has recently Maharashtra and Uttar Pradesh—together account for
slowed down also demonstrates this aspect (Das et al., one-third of all adolescent women in the country, with
1998)2. nearly 16% of the total living in Uttar Pradesh alone.
The changes increases in respect of marriage age and Within most states, 15–19-year-old women now make
age at consummation of the marriage and the resultant up at least 10% of the state’s population.5 An earlier start
reduction in proportion of women remaining in married to a general decline in fertility is evident in the three
state are directly linked to fertility and thus determine low fertility states of Goa, Kerala and Tamil Nadu, as
the future trend of demographic transition. In India, adolescent women account for a smaller proportion of
major shifts have been observed in the age at marriage [3]. the total state population in those three states (8–9%) than
they do elsewhere (10–13%)[6].Young women’s marital
The age of female at the time of marriage is very and reproductive behaviors are conditioned by where
important due to many reasons. These reasons depend on they live, and most adolescents still live in rural areas.
many factors such as social, economic, and demographic Fewer than three in 10 women aged 15–19 currently
changes in population. This is probably one of the causes reside in urban areas. That proportion has increased, on
average for the country as a whole, by an annual rate of Data and Methodology
about 1% (i.e., the percentage residing in urban areas
rose from 25% in 1992 to 28% in 2005)[7]. However, Study area: The study is conducted in the area of
the pace of urbanization has varied from state to state. Rural Health Training Centre(RHTC), Department of
Community Medicine, Rama University, Kanpur.
It was most rapid in the northeastern state of Arunachal
Pradesh, where the proportion of adolescent women Study participants: Study subjects are local residents
residing in urban areas increased by 6% each year. As of selected the village from RHTC area in Kanpur.
expected, urban adolescent women are generally better
off economically than their rural counterparts: Only 27% Inclusion criteria for subjects: Women, who were ever
of the former group live in households in the lowest married and born in between 1931 to 2001, be included
three wealth quintiles, compared with 79% of the latter in the study.
group. As of 2006(Report on Population projection,
Exclusion criteria for subjects: The following category
Government of India, 2006)[7], 28% of all 15–19-year-
of women be excluded from study-
old women were members of scheduled tribes or castes,
groups that have historically been socioeconomically zz Who are unmarried.
disadvantaged; the proportion was higher in rural areas zz Born before 1931 and after 2001.
than in urban areas (31% vs. 22%). Currently, fewer
than half of adolescent women in Bihar and Jharkhand zz Who are unable to give their history because of
in the East, and in Rajasthan in the North, have been mental illness, physical disability.
to school for at least six years. On the other end of the zz Who were not signing the informed consent.
spectrum, Goa in the West, Himachal Pradesh in the
North and Kerala in the South had already virtually met Ethical approval: The study has been approved by the
the primary school completion goal for 2015 as of 2006, Ethics Committees of Rama University, Kanpur. Informed
with 92–98% of 15–19-year-old women receiving this consent in the local language will be taken from subjects
much schooling. Although till date, marriage is universal during filling designed questionnaire, in written.
in the Indian context, there are certain shifts observed in Questionnaire and tools for measurement: Subjects be
the age at marriage, i.e., a consistent increasing trend in interviewed with the help of pre-designed and pre tested
respect of mean and median age at marriage over cohorts schedule to elicit the information pertaining to socio-
born since 1916 for males and since 1921 for females[8]. demographic characteristics such as religion, caste, type
and size of family, educational level, age atconsummation
In Uttar Pradesh, marriage age increased by 1year
of the marriage, age at first pregnancy etc.
during 1901-1951 and by 1 year per decade thereafter.
33% of females aged 10-14 years were married in 1971, Sampling technique, Data Collection & Analysis
but under 1% were married at this early age in 1992- method: A cross sectional study design is adopted for
1993. A similar sharp decline occurred among females this study in a community area. In the first stage 30
clusters will be selected from 25 villages of Kanpur
aged 15-19 years; by 1992-1993 only 40% were married
District, where cluster defines a village whose population
at this early age. The difference in ages between men
is more than 2500. In each cluster we divide all eligible
and women has remained at around 4 years [9]. Uttar population into seven birth cohort and in each cohort
Pradesh being the most populous and having almost we do complete enumeration by conducting house to
lowest level of the mean age at marriage in the country house survey using designed questionnaire. The birth
received increasing attention to know what is happening cohorts will be taken from1930 to 2000 with decade
to the age at marriage especially among females at the difference. Data is analyzed by using R3.1.1 package &
individual level. So there is need to have a detailed SPSS 21.0 Version software.Following method is used
picture of the age patterns of marriage in these states. for nuptiality estimation:
Women in Uttar Pradesh tend to marry at an early age Nuptiality Table method: In this method, the basic
(Singh S & Samara R (1996)[10].32% of women age 15- data for the calculation of nuptiality rates will be the
19 are already married, and an additional 8% that they proportions in the decade synthetic birth cohorts 1931-
were married but “gauna” has yet to be performed. 1940, 1941-1950, 1951-1960, 1961-1970, 1971-1980,
1981-1990 and 1991-2000. The decade synthetic lx: Number single at age x
cohort for a particular decade will a hypothetical
cohort subjected to the average marriage experience 5
Lx: Number of years lived as never married in the year
of the decade in question. The method followed for the of age (x, x+5)
estimation of nuptiality rates for a decade will be adopted
Tx: Number of years lived as never married above age x
from that of Mertens (1965) [19]. Then retrospectively
trace all cohorts of single persons over time from the ex0: Expected number of years of single life remaining to
youngest age at which marriage may occur. We assume a single person at age x
the incidence of mortality to be the same for the single
as for the total population and the single population to be
Result & Discussion
depleted by two modes of decrement, namely, marriage
and death. The following symbols will be used: The gross nuptiality tables for female nuptiality of
x: Age at years; rural population of Uttar Pradesh, India for the periods
1951-61, 1961-71,1971-81,1981-91 and 1991-01 have
n : Five-year nuptiality rate for a single life at age x;
5 x been constructed in the table 1-5 respectively.
Table 1: Gross Nuptiality Tables for Female Nuptiality of Rural Population of Uttar Pradesh, India for the
Period 1951-1961
x n
5 x
Lx 5
Lx Tx ex0
0 --- 133 665 2640 20
5 --- 133 665 1975 15
10 0.0677 133 643 1310 10
15 0.4435 124 483 668 5
20 0.9275 69 185 185 3
25 --- 5 -- 0 0
Period 1961-1971
x n
5 x
Lx 5
Lx Tx ex0
0 --- 335 1675 6738 20
5 --- 335 1675 5063 15
10 0.0299 335 1650 3388 10
15 0.4492 325 1260 1738 5
20 0.9330 179 478 478 3
25 --- 12 --- 0 0
Period 1971-1981
x n
5 x
Lx 5
Lx Tx ex0
0 --- 547 2735 11603 21
5 --- 547 2733 8868 16
10 0.0128 546 2713 6135 11
15 0.2690 539 2333 3423 6
20 0.8934 394 1090 1090 3
25 --- 42 --- 0 0
Period 1981-1991
x n5 x
Lx 5
Lx Tx ex0
0 --- 278 1390 6023 22
5 --- 278 1385 4633 17
10 0.0036 276 1378 3248 12
15 0.1418 275 1278 1870 7
20 0.9958 236 593 593 3
25 --- 1 --- 0 0
Period 1991-2001
x n
5 x
Lx Lx 5
Tx ex0 x
0 --- 465 2320 10523 23 0
5 --- 463 2308 8203 18 5
10 0.0348 460 2260 5895 13 10
15 0.0766 444 2135 3635 8 15
20 0.5366 410 1500 1500 4 20
First of all, it is observed that nuptiality rates for married at an early age; 57 percent of women who are
females are changing with time. However, no particular now age 45-49 married before they were 15, compared
trend is observed for nuptiality rate for all the periods with 20 percent of women age 15-19.
considered in the study. The rates decline in the period
1961-71 for all the age group with respect to the period
1951-61 and similar trend is observed for all the
considered period. Initially, the rate is small at the age
group of 10 and increase rapidly till reaches to maximum
at the age group 20.
The expected number of years of single life remaining

to a single person at age x is same for both the periods
1951-61 and 1961-71. Although, expected number of
years increase for further periods that indicates that as
time passes the age at marriage increases slowly but
still it is more or less same at the age of 20 and 25. We
have also attempted to show the trend through figure and
Although this indicates that the proportion of women
from figure 1, we can clearly see that expected number
who marry young is declining rapidly, 62 percent of young
of single life to a single person at age x is low for the
period 1951-61 and high for the period 1991-01 i.e. women age 20-24 in Uttar Pradesh still marry before
clearly indicating that the age at marriage is increasing reaching the legal minimum age of 18 years. On average,
as the time passes. women are more than four years younger than the men
they marry.There were lots of studies related to fertility
Rural areas lagged behind urban areas in the shift and mortality but very little, to nuptiality. One reason
to a later marriage age. The median age at first marriage for this might be that striking changes have occurred in
among illiterate females in the aged 25-29 years was the past in fertility and mortality with little change in
14.4 years, and it was 20.4 years among females with marriage. In India there is a trend of early marriage. The
a high school degree. In rural areas of Uttar Pradesh, states like Madhya Pradesh, Bihar, Rajasthan and Uttar
marriage age varied by region. In rural areas, almost Pradesh have substantially lower age at marriage (NFHS-
half of women age 15-19 have already married. Older III). So there was need to have a detailed picture of the
women are more likely than younger women to have age patterns of marriage in these states.
The female marriage pattern exhibits wider variations 6. Sureender, S. (1992): Correlates of female age at
from state to state in India with regard to magnitude and marriage and an overview of legislation, marriage
direction. But from the following table it was observed practices in Pondicherry. Unpublished Ph.D.
that in rural Uttar Pradesh highest frequency occurs in thesis, IIPS Mumbai.
10 - 15 age group. 7. Government of India, Population Projections for
India and States 2001-2026, Report of the Technical
Conclusion Group on Population Projections Constituted by
the National Commission Population, New Delhi:
Uttar Pradesh being the most populous and having Government of India, 2006(8).
almost lowest level of the mean age at marriage in the 8. Goyal, RP (1988). Marriage Age in India. Delhi:
country received increasing attention to know what is B R Publishing House.
happening to the age at marriage especially among 9. Pandey Ajay; Pandey Arvind: Analyzing Female
females at the individual level. So, it has immense Nuptiality Pattern at Micro Level: A Case of Uttar
important for analyzing the marriage habits of a Pradesh. IASSI Quarterly. 1997. 16 (3&4).
population, a systematic construction and analysis of 10. Singh S & Samara R (1996) Early Marriage among
nuptiality tables for the Indian population has not women in developing countries. International
been attempted so far. In the field of marriage for the Family perspectives 22(8-9): 148-157, 175.
Indian population, it is proposed that construction and 11. Bloom, D (1982). What’s happening to the age at
analysis of nuptiality tables over different periods would first birth in the United States? A study of recent
constitute a definite advancement in the study of Indian cohorts. Demography 19(11,14):351–70.
nuptiality. A comparative study of nuptiality tables over
12. Coale, A(1971) Age patterns of marriage.
different periods may help us to determine the extent
Population Studies 25(11,16):193–214.
to which marriage rates with probabilities of marrying
13. Coale AJ and McNeil DR (1972) The distribution
and the changing pattern of mean ages at marriage. In
by age of the frequency of first marriage in a
view of the above, this study examines nuptiality status
female cohort. Journal of the American Statistical
in rural U.P., with particular reference to changes in
Association 67(11, 14-15):743–49.
marriage age over time.
14. Hobcraft, J and TrussellJ. (1980) A note on the
Conflict of Interest: Nil Analysis of Maternity Histories by Birth Order.
WFS/TECH 1305. London: World Fertility
Source of Funding: Self Survey(11,14).
15. Kaneko, R (2003) Elaboration of the Coale-
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DOI Number: 10.5958/0976-5506.2018.00657.5
Prevalence of Group a Streptococcal Infection among Healthy
School Children in Chennai
B. Krishna Prasanth1, S. Kalpana2, N. Aravindha babu3, K. M. K. Masthan4, S. Bhuminathan5

1
Assistant Professor & Epidemiologist, Department of Community Medicine, Ponnaiyah Ramajayam
Institute of Medical Sciences, Manamai-Nallur, Chennai; 2Research Officer, Department of Epidemiology,
The Tamilnadu Dr. MGR Medical University, Chennai; 3Professor, 4Professor& Head, Department
of Oral pathology, Sree Balaji Dental College & Hospital, Bharath Institute of Higher Education &
Research,Chennai; 5Registrar, Bharath Institute of Higher Education & Research,Chennai
Abstract
Objective: To study the prevalence of Group A Streptococcal (GAS) carriers among healthy school children
residing at Chennai.
Methods: A total of 730 school children were screened and enrolled to this study. Two throat swabs were
collected from all the children irrespective of their symptoms. Throat swabs were cultured and bacterial culture
was isolated and confirmed by streptococcal group identification kit. Beta haemolytic streptococci isolates
were further sero-grouped by agglutination tests by using specific antisera.
Results: 730 school children between the age of 5 to 15 years were enrolled in this study. The mean age of
the study group was 7.6 years. Out of the 313 culture positive cases, 217 (29%) were Group A Streptococci,
64 (8%) were Group B Streptococci , 18(2.4%) were Group C Streptococci ,2(0.27%) were Group D
Streptococci , 1(0.1%) were Group F Streptococci , 2 (0.27%) were Group G Streptococci and 9(1.2%) were
mixed Group C and F Streptococci. Among the 29% GAS positive children, 64% were transient carriers,
27% were recurrent carriers and 9% were chronic carriers.
Conclusion: All the GAS positive cases were referred to Primary Health Centre for treatment. Identification
of the GAS and treating them, not only prevents them from developing non -suppurative complications, but
also prevent the spread of GAS to their family members and other children.
Keywords: Group A Streptococcus, carrier throat swab, asymptomatic children
INTRODUCTION children and isolation rate of GAS in children with

pharyngitis have ranged from 4.2% to 13.7%(1, 2), which
The Group A Streptococci (GAS) is a form of is comparable to the rates reported from other developed
β-hemolytic Streptococcus which causes several countries. The Group A Streptococcus (GAS) associated
suppurative and nonsuppurative infections.It is diseases and sequelae continues to have a devastating
responsible for most cases of sore throat/pharyngitis and effects on the public health and the national economy,
rheumatic fever. Other types (B, C, D, F and G) may as they mainly affect children and young adults(3). GAS
also cause throat infection. In India ,Sore throat remains frequently gets colonized in the throats of asymptomatic
the most common problem encountered in school going persons. There are few studies which have described the
natural history of the pharyngeal carriage with GAS(4).
Corresponding Author: A streptococcal carriage has been defined as the recovery
Dr. B. Krishna Prasanth of GAS from the nasopharynx or the oropharynx in the
Assistant Professor & Epidemiologist, absence of any evidence of an acute infection(5).GAS has
Department of Community Medicine, remained a significant human pathogen for centuries.
Ponnaiyah Ramajayam Institute of Medical Sciences, It causes a wide variety of infections in humans, which
Manamai-Nallur, Chennai range from mild upper respiratory and skin infections
to non-suppurative sequelae like Acute Rheumatic Fever were collected and inoculated to 5% sheep blood agar
(ARF) and Rheumatic Heart Disease (RHD). Although plates The streaked plates were incubated at 37°C for
ARF and RHD have declined in many parts of the world, 24 to 48 hours. All the beta haemolytic colonies were
they continue to be major causes of cardiovascular identified and sero grouped by the latex agglutination
morbidity and mortality in India(6). Prompt diagnosis method .The latex kit identifies the groups A, B, C, D, F
and treatment not only shortens the duration of clinical and G of the Lancefield group of Streptococci.
illness and the transmission of disease, but also helps
Two swabs were collected at an interval of 2 months
in preventing complications such as Rheumatic fever
to classify them as transient (first culture- positive and
& Acute glomerulonephritis. Irrational use of antibiotics
the subsequent two cultures- negative), recurrent (first
should be avoided in individuals who turn out negative
two cultures- positive and the third culture- negative)
on throat culture.
and chronic carriers (all the three cultures positive).

Results
A total of 730 (400 boys and 330 girls) healthy school
Totally 730 children were enrolled in to this study.
children from Chennai,studying in class V were enrolled
The mean age of the study group was 7.6 years. Out of
in to this study. The age of the study group ranged from the 313 culture positive cases, 217 (29%) were Group
5-15 years.The school children were selected based on A Streptococci, 64 (8%) were Group B Streptococci ,
the inclusion criteria such as absence of URT infection, no 18(2.4%) were Group C Streptococci ,2(0.27%)
antibiotic treatment in the past one month before taking were Group D Streptococci , 1(0.1%) were Group F
the samples and no history of adenoids or tonsillectomy. Streptococci and 2 (0.27%) was Group G Streptococci
Those who had undergone treatment previously were and 9(1.2%) were mixed Group C and F Streptococci.
excluded from the study. Institutional ethical clearance Among the 29% GAS positive children, 64% were
was obtained and after obtaining informed Consents/ transient carriers, 27% were recurrent carriers and 9%
assent from the school authority and the parents, the were chronic carriers. Male children were more affected
students were enrolled in to the study. Two throat swabs with GAS infection than females according to this study.
Table 1: Age distribution of GAS positives cases

Age in years GAS GBS GCS GDS GFS GGS Mixed Total
5-8 107 18 8 0 0 0 8 141
8-10 34 38 3 2 1 0 1 79
10-12 36 8 5 0 0 2 0 51
13-15 40 0 2 0 0 0 0 42
Total 217 64 18 2 1 2 9 313
Table 2: Gender wise distribution of GAS positive cases

Age in years GAS GBS GCS GDS GFS GGS Mixed Total
Gender M F M F M F M F M F M F M F
5-8 77 30 15 3 6 2 0 0 0 0 0 0 5 3 141
8-10 19 15 27 11 2 1 2 0 1 0 0 0 1 0 79
10-12 25 11 8 - 4 1 0 0 0 0 2 0 0 0 51
13-15 32 8 0 0 - 2 0 0 0 0 0 0 0 0 42
Total 153 64 50 14 12 6 2 0 1 0 2 0 6 3 313
DISCUSSION reported that the carrier status of GAS were between

2.5-14.3% (7,8), 8.4% in Chennai(9),2.3% in Vellore. The
In the present study, the carrier status of GAS (29%) epidemiological picture of streptococcal infections in
among culture positives seems to be very high compared India is quite different from that of other developed
to other studies done in India. Other studies have
countries, suggesting the existence of some serotypes REFERENCE

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of GAS and may lead to major complication like acute 6. Gupta R, Prakash K, Kapoor AK. Subclinical
renal failure and hence this study highlights the need for streptococcal throat infection in school children.
preventive measures and awareness among school going Indian Pediatrics, 1992, 29: 1491–1494.
children about personal cleanliness, mode of transmission 7. Charmaine A C Lloyd Pharyngeal carriage of
of the disease, identifiaction of symptoms and prompt group A streptococci in school children in Chennai
referral to the physician when in need. This study also Indian J Med Res 124:195-8. 2006
throws insight in to the importance of providing clean 8. Brandt ER, Teh T, Relf Wa, Hobb RI, Good MF.
water, proper drainageand hygenic sanitation in schools Protective and non protective
as a community prevention measure. 9. Manual of reference procedures in streptococcal
bacteriology. New Delhi, WHO Regional Office
CONCLUSION for South-East Asia, 1987 (unpublished document
SEA/HLM/230)
This study highlights the importance of regular
10. Lindbaek M, Høiby Ea, Lermark G, Steinsholt
surveillance to keep the GAS carriage in control, by IM, Hjortdahl P. Clinical symptoms and signs in
treating the infected children with antibiotics at the sore throat patients with large colony variant beta-
appropriate time. Identification of GAS carriers and haemolytic streptococci groups C or G versus
treating them, not only prevents these children from group a. Br J Gen Pract 2005; 55 : 615-9.
developing non -suppurative complications, but also 11. Reed BD, Huck W, French T. Diagnosis of group
prevents the spread of GAS infection to their family A-hemolytic Streptococcus using clinical scoring
members and others in community. criteria, Directigen 1-2-3 group A streptococcal
test, and culture. Archives of Internal Medicine,
Ethical Approval: This study was appoved by the 1990, 150: 1727–1732.
ethics committee of The Tamilnadu Dr.MGR Medical
12. Sarkar S et al. A study on sore throat and beta-
University with reference ECMGR0309030 hemolytic streptococcal pharyngitis among rural
school children in Varanasi with reference to age
Conflicts of Interest: none
and season. Indian Journal of Public Health,
Source of Funding: Self 1988, 32: 191–198.
DOI Number: 10.5958/0976-5506.2018.00658.7
A Retrospective Study of Clinical and Ultrasound Correlation
in the Diagnosis of Acute Appendicitis
N. Parthiban1, N Sundharrajan2, B. Krishna Prasanth3, N Pavan Kumar4, Thota Siddhartha5

1
Assistant Professor, 2Post Graduate, Department of General Surgery, Aarupadai Veedu Medical College
and Hospital, Pondicherry; 3Assistant Professor & Epidemiologist, Department of Community Medicine,
Ponnaiyah Ramajayam Institute of Medical Sciences, Chennai; 4Post Graduate, Department of Radiology,
Sree Balaji Medical College and Hospital, Chennai; 5Post Graduate, Department of General Surgery,
Aarupadai Veedu Medical College and Hospital, Pondicherry
ABSTRACT
Acute appendicitis is a one of the common abdominal emergency with a lifetime prevalence of about
7 %1. Diagnosis of acute appendicitis includes clinical examination, laboratory tests, diagnostic scoring
systems, computer programs as physician aids and imaging examination. The clinical diagnosis of acute
appendicitis remains a challenge to physicians and surgeons with a significant portion of patients initially
misdiagnosed due to atypical clinical presentations and nonspecific laboratory tests. Diagnostic scoring
systems show wide variance in the diagnostic accuracy of the condition. Hence imaging modalities
like ultrasound has gained major importance in the diagnostic work-up of patients with suspected acute
appendicitis in order to keep both the negative appendectomy rate and the perforation rate low. Delay in
diagnosis increases the risk of perforation and associated complications. Now, Ultrasonography (USG) is
used to facilitate the diagnosis of acute appendicitis in an increasing extent in the current scenario in order
to minimize the chances of both its under-diagnosis and over-diagnosis. The objective of this study is to
determine if USG could change the clinical decision in the management of suspected acute appendicitis.
Keywords: acute appendicitis, ultrasound, appendicectomy
INTRODUCTION acute appendicitis and therefore to ascertain whether

Acute appendicitis is one of the most frequently preoperative ultrasonography would alter the clinical
encountered acute surgical emergencies and the decision in the management of a suspected acute
diagnosis can often be made clinically2,3. Even in typical appendicitis.
presentation, the diagnosis of acute appendicitis can be a
little challenging. On the other hand, atypical presentation Methodology
is never uncomplicated, thus patients may end up either
in negative appendicectomies (i.e. false positive cases) This is a retrospective analysis of a prospectively
or the surgery may be delayed with adverse outcomes3. maintained data and therefore no ethical clearance
Alvarado has pioneered a scoring system which was was sought for. Records of patients who underwent
later modified by Kalan et al4,5. Including a valuable appendicectomy from March 2015 to September 2016
diagnostic tool like ultrasonographic imaging to clinical in a tertiary level care hospital were analyzed. A total of
diagnosis has been considered to upgrade the positive 66 patients who had full records of Modified Alvarado
predictive value of acute appendicitis. And this has aided Score (MAS) assessed by a consultant, ultrasound
in minimizing the negative appendicectomy rates6,7. Both scan findings, operative findings and postoperative
Ultrasound scan and computed tomography have been histopathological reports were selected. The elements of
shown to be efficacious in this aspect. Yet the decision MAS together with values assigned to each parameter
making continues to be a diagnostic challenge. are as follows,
Ÿ Migratory right iliac fossa pain (1 point)
The aim of this study was to determine the accuracy
of clinical and radiological assessment in diagnosing Ÿ Tenderness in the right iliac fossa (2 points)
Ÿ Rebound tenderness in the right iliac fossa (1 The third set of patients comprised of those who
point) underwent appendicectomy with MAS of 2-3 with
positive ultrasound findings.
Ÿ Anorexia (1 point)
Those who were taken up for surgery had it done
Ÿ Nausea/vomiting (1 point)
either laparoscopically or by the conventional open
Ÿ Fever >37.5°C (1 point) method depending on the practicality of the emergency
list. All laparoscopic and open appendicectomies were
Ÿ Leukocytosis (2 points) undertaken by a consultant surgeon.
Ultrasound was performed by a consultant Definitive diagnosis of appendicitis was made either by
radiologist for the respective purpose. Ultrasound
detection of a non-compressible blind ending tubular zz Macroscopic appearance intraoperatively and/or
structure of more than 6mm in diameter noted in the zz Histologically in case of less obvious macroscopic
right iliac fossa (RIF) (or right hypochondrium (RHQ)), findings.
free fluid in RIF, presence of appendicolith and or
increased appendicular vascularity were considered Macroscopic appearance such as noncompressible
positive for acute appendicitis radiologically. Failure distended appendix with features of red serosa and with
to spot appendix or detection of normal appendix was prominently distended vessels along the whole length of
regarded as a criterion for negative ultrasound scan. appendix contributes to a diagnosis of a grossly inflamed
These 66 patients were divided into 3 categories. appendix. Meanwhile, only distension of appendix with
dilated vessels coursing along the appendix without
First category was those patients whose score was
inflamed serosa is considered as minimally inflamed
7 or more points in MAS and they were considered to
appendix. Histological diagnosis of appendicitis was made
be having clinical appendicitis. They were taken up for
in cases with transmural infiltration of appendix with
appendicectomy irrespective of ultrasound scan findings.
neutrophils or scattered neutrophils in appendeceal mucosa.
Others with a lesser score underwent appendicectomy
only when the ultrasound scan showed a positive finding.
RESULTS
The second category comprised of those who
underwent appendicectomy despite a MAS of 4-6 and Over the study period, 56 patients aged from 9 to 83
negative ultrasound scan findings. This group was years underwent preoperative ultrasonography. Male to
observed for progression of symptoms without starting female ratio was 57:43. 40 patients underwent laparoscopic
antibiotics. Since their score either remained the same appendicectomy and 16 patients, open appendicectomy.
or escalated over the ensuing 1-2 days, they were also Patients who underwent appendicectomy includes those
deemed to be clinically positive for acute appendicitis. from MAS of 2-9 (Table 1).
Table 1: Summary of Distribution of Patients in Each Category of MAS

Non Inflamed Appendix
Total number of Findings of
Alvarado score Inflamed Appendix (Macroscopic or
patients Ultrasonography
Microscopic)
Positive-10
2-4 10 8 2
Negative-0
Positive -5
5-6 8 8 0
Negative -3
Positive -26
7-9 38 36 2
Negative -12
There were 10 patients who scored MAS of 2 to 4. Their sonographic findings confirmed all of them to have
appendicitis, out of which only 8 patients had inflamed appendices.
Five out of eight patients in the category of MAS 5-6, out of which 39 patients had appendicitis. Out of 15
were detected to have sonographic evidence of inflamed negative sonographic findings, 13 actually had inflamed
appendices. Sonographic findings of acute appendicitis appendices. Therefore, ultrasonography in our study
were evident in 26 out of 38 patients admitted with has an overall sensitivity, specificity, positive predictive
MAS of 7, 8 and 9. Out of the remaining 12 patients value (PPV), negative predictive value (NPV) and
in this category, 10 had inflamed appendices in spite disease prevalence of 75%, 50%, 95%, 13.3% and
of not being visualized by USG. Overall, 41 out of 56 92.86% respectively (Table 2).
patients were reported positive via ultrasonography,
Table 2: Summary of Overall Comparison of USG and Clinical Findings

Ultrasonography Clinical Examination
Positive Negative Positive Negative
Inflamed 39 13 46 8
Non Inflamed 2 2 0 2
Sensitivity 75% 85%
Specificity 50% 100%
Positive Predictive Value 95% 100%
Negative Predictive Value 13.3% 20%
Disease Prevalence 92.86 % 96.4%
Inflamed appendices were found in 44 out of 46 10 of these 18 patients did not have clinical
patients, who were clinically positive for appendicitis. features strong enough to warrant appendicectomy on
8 out of 10 patients who were clinically negative had clinical grounds alone (all of these patients had their
inflamed appendices. Overall, for clinical examination, Full Blood Count done as a part of MAS and the urine
our results showed sensitivity, specificity, PPV, NPV reports excluded urinary tract infection as the cause for
and disease prevalence of 85%, 100%, 100%, 20% and abdominal pain). Nevertheless, their USG suggested
96.4% respectively (Table 2). acute appendicitis and hence all of them (10 patients)
proceeded to appendicectomy. While 8 of them had
DISCUSSION appendicitis, 2 had normal appendices. These 10 patients
with MAS of 2-6 did not have compelling features to
In routine clinical practice, the decision to undertake undergo appendicectomy on clinical grounds alone. If
appendicectomy hinges on clinical grounds and it is not for the positive USG findings, they would have either
usually undertaken without preoperative imaging in most been prematurely discharged or kept under observation
of the cases. However, this strategy is likely to result which would have ultimately extended the period of
in negative appendicectomies particularly in atypical their hospital stay.
presentations. It is extensively believed that preoperative
imaging with USG and computerized tomography (CT) Therefore, it can be inferred that those 10 patients
scan can curtail the negative appendicectomy rate6,7. We were operated promptly, attributed to the additional
made a retrospective analysis to ascertain if performing evidence provided by the USG. Accordingly, USG in
a routine preoperative USG would change the clinical this category of patients has allowed not only timely
decision in undertaking appendicectomy. intervention with overall presumed benefit of reduced
hospital stay, but also has minimized the potential
There were 18 patients admitted belonging to MAS complications associated with delayed diagnosis.
of 2-6. Consequently, it could be argued that ultrasonography, in
our study, has positively contributed to change the mode
3 out of the 18 patients had negative findings in USG. of management of 10 patients in otherwise clinically
However, owing to persistent pain over the subsequent unsuspected acute appendicitis.
1-2 days, they were suspected to have appendicitis
clinically, in spite of a negative finding in USG. After Although this approach, i.e., USG directed surgical
they underwent appendicectomy, it was found that all decision in this category has given rise to negative
three of them had inflamed appendices. appendicectomy rate of 20% (2/10) it still within the
acceptable negative appendicectomy range8. It is far Patients getting admitted with a typical history
below the negative appendicectomy rate of 40% (2/5) of appendicitis with MAS of 7-9 are unlikely to be
observed for clinically guided appendicectomy in this benefitted from the findings of USG and performing a
category of patients. Ultrasonography, in evaluating this preoperative scan in this group is perhaps not mandatory.
group of patients has shown superior sensitivity, PPV,
NPV and disease prevalence in comparison with those Conflicts of Interest: None
of clinical examination. Source of Funding: Self
Contrarily, USG paints a different picture in
assessing patients having high probability of acute References
appendicitis. Total number of patients belonging to 1. Gwynn LK. The diagnosis of acute appendicitis:
this category (MAS of 7-9) was 38 and all of them clinical assessement versus computed tomography
underwent appendicectomy based on clinical diagnosis evaluation. J Emerg Med. 2001;21:119–123.
alone. All, except 2 patients had inflamed appendices. 2. Markar SR, Karthikesalingam A, Cunningham
Ultrasonography, however, detected inflamed J, Burd C, G Bond-Smith, Kurzawinski TR
appendices in only 68% cases (26/38), all of whom had Increased use of preoperative imaging and
appendicitis. Only 2 of the remaining 12 patients had laparoscopy has no impact on clinical outcomes
normal appendices while others (10 patients) clearly had in patients undergoing appendicectomyAnn R
inflamed ones. The assessment of patients with USG in CollSurgEngl2011; 93: 620–623
this cohort seems to be inferior to clinical assessment 3. Petroianu A Diagnosis of acute appendicitis
as shown by high sensitivity, PPV and NPV for clinical International Journal of Surgery 2012;10 115-119
examination, each rated above 95%. Although USG 4. Alvarado A. A practical score for the early
has marginally higher PPV, it has a very low NPV of diagnosis of acute appendicitis. Ann Emerg Med
13%. Therefore normal USG in this cohort is unreliable, 1986; 15:557.
because such negative findings are unlikely to change
5. Kalan M, Talbot D, Cunliffe WJ, Rich AJ.
the mode of management in this category (with MAS of
Evaluation of the modified Alvarado score in the
7-9) of patients. This finding in our study supports the diagnosis of acute appendicitis: a prospective
conception of performing appendicectomy on clinical study. Ann R CollSurgEngl1994; 76:418.
grounds alone irrespective of USG findings in those
6. Raja AS, Wright C,Sodickson AD et al. Negative
admitted with typical history of acute appendicitis.
appendicectomy in the era of CT: an 18-year
perspective. Radiology 2010; 256: 460-465.
CONCLUSION
7. GullerU,Rosella L, McCall J et al. Negative
Ultrasound scan is an important and inevitable appendicectomy and perforation rates in patients
imaging modality in evaluating patients with suspected undergoing laparocopic surgery for suspected
acute appendicitis with equivocal presentation with appendicitis. Br J Surg2011; 98:589-595
MAS of less than 6 points. It is likely to deliver important 8. Binnebösel M, Otto J, Stumpf M, Mahnken AH,
decision making findings to the overall management of Gassler N, Schumpelick V, Truong S. Acute
patients in said category. Henceforth, performing USG appendicitis. Modern diagnostics--surgical
in this category is recommended. ultrasound) Chirurg2009 Jul; 80(7):579-87.
DOI Number: 10.5958/0976-5506.2018.00659.9
Association of HbA1c Levels with Body Mass Index in a
Patient Diagnosed with Polycystic Ovary Syndrome
Zeina F. Fuad1, Enas Jaleel Alobaidy2

1
Department of Biochemistry, 2Department of Obstetrics and Gynecology, College of Medicine,
University of Diyala, Iraq
ABSTRACT
Polycystic ovary syndrome (PCOS) is thought to be the most well-known endocrine issue in ladies of
regenerative age manifested with various metabolic disturbances and a wide spectrum of clinical features
such as menstrual abnormalities, obesity, and hyperandrogenism. This study was aimed to measure the
association between HbA1c and body mass index (BMI) in PCOS women. This study was performed in AL-
Batool hospital for obstetric and gynecological diseases in Ba’quba city/ Iraq May 2017 to January 2018.
It includes 42 patients with PCOS aging from 20-37 years and 42 healthy control. Fasting venous blood
samples were obtained for analysis of fasting blood glucose (FBG), hemoglobin (Hb) and HbA1c. BMI was
calculated for all study participants by the present weight in Kg dividing by the square of height in meters.
This study involved 42 cases of PCOS (case group) and other 42 participants were free of disease (control
group). The mean age among patients of case group was significantly higher than that in control group
(26.95 ± 4.77 versus 23.9 ± 2.71, P=0.015). 90.5% of patients in control group had normal BMI level while
42.9% of patients in the case group were class I obese. Mean of BMI among patients of case group was
significantly higher than that of the control group (29.84 ± 4.22 versus 22.8 ± 2.02, P=0.001). According to
HbA1c level, all patients in control group and 90.5% of patients in the case group were non-diabetic. The
mean of HbA1c among patients of case group was significantly higher than that in control group (4.76 ± 0.88
versus 3.9 ± 0.6, P=0.001). In the present study, it was found that there is a significant positive correlation
between HbA1c and BMI (r= 0.567, P= 0.001). BMI is positively correlated with HbA1c and associated
with glycemic control in PCOS.
Keywords: Correlation, HbA1c, BMI, PCOS
INTRODUCTION most common cause of anovulatory infertility 3. Patients

with PCOS are at a higher risk for coronary heart disease
The most common endocrinopathy in women of (CHD) compared with healthy women (OR = 1.2 - 12.9),
reproductive age is Polycystic ovary syndrome (PCOS) CVD (OR = 2.8 - 3.4), dyslipidemia (OR = 2.9 - 3.2),
which affecting about 21% of patients 1. It manifested hypertension (OR = 1.4), impaired glucose tolerance
with various metabolic disturbances and a wide spectrum (IGT) (OR = 2.5), myocardial infarction (MI) (OR =
of clinical features like menstrual abnormalities, obesity, 2.6 - 4.2), metabolic syndrome (OR = 2.1) and obesity
and hyperandrogenism. The current incidence of PCOS (OR = 1.9 - 2.4), type 2 diabetes mellitus (T2DM) (OR
in women is related to change in lifestyle and stress 2. = 2.2 - 3.6) 4, 5, 6. Insulin resistance is proposed as a key
Manifestations of androgen excess (e.g., hirsutism) may pathophysiological feature of PCOS contributing to both
cause substantial distress in patients, and the PCOS is the metabolic and reproductive disturbances 5. Increased
insulin leads to increased androgen production from
the ovarian thecal cells and this hyperandrogenemia
is responsible for androgenic obesity 10. Among
Zeina F. Fuad
women with PCOS, there is increasing attention on the
Department of Biochemistry,
complications related to metabolic disturbances. An
College of Medicine, University of Diyala, Iraq
economic evaluation reported that about 40% of the
Contact: +9647703926080
financial expenses of PCOS can be ascribed to T2DM in
the USA. This highlights the requirement for prevention intake and pregnancy. Fasting venous blood samples
of long-term complications by appropriate screening, were obtained for analysis of fasting blood glucose
diagnosis and management 7. International Diabetes (FBG), hemoglobin (Hb) and HbA1c.
Federation defined PCOS as a significant non-modifiable
For determination of the concentrations of FBG and
risk factor associated with T2DM 8 and patients with
Hb in serum, the sensitive electrochemiluminescence
PCOS are also expected to have a more rapid conversion
immunoassay (ECLIA, Roche Diagnostics) on Cobas
from IGT to T2DM 9. A widely used marker of chronic
Integra 400 plus was used, while for HbA1c, Sysmex
glycemia is Hemoglobin A1c (HbA1c) which reflects
XT-2000i hematology analyzer was used which based
the average blood glucose levels (BGL) over a two to on fluorescence flow cytometry technology. For
three months’ duration. It can be assessed in the non- anthropometric measurement, all study participants
fasting state as it has a higher repeatability than fasting were measured by using a calibrated weighing scale and
glucose 11. It may be affected by genetic, hematologic, stadiometer. BMI is calculated by the present weight in
and illness-related factors 12. In patients with PCOS, Kg dividing by the square of height in meters.
the present screening recommendations for T2DM
incorporate the measurement of fasting plasma glucose
RESULTS
(FPG) and the utilization of an oral glucose tolerance
test (oGTT, 75 g oral dextrose) in obesity, advanced age, This study involved 42 cases of PCOS (case group)
individual history of gestational DM or family history of and other 42 participants were free of disease (control
T2DM cases 13. High HbA1c concentrations have been group). Study patient’s age was ranging from 20 to 37
linked with other risk factors for CVD and the existence years with a mean of 25.42 years and standard deviation
of metabolic syndrome in many other non-PCOS clinical (SD) of ± 4.13 years. The mean age among patients of
conditions and populations 14. It appears that a one case group was significantly higher than that in control
percent increase in the absolute HbA1c concentration group (26.95 ± 4.77 versus 23.9 ± 2.71, P=0.001). BMI
in patients with or without PCOS is related to a 10- of study patients was ranging from 18.9 to 38.2 Kg/m²
20% increase in the risk of CVD 14, 15, 16. Worldwide, the with a mean of 26.32 ± 4.83 Kg/m². 90.5% of patients
prevalence of high HbA1c in patients with PCOS has not in control group had normal BMI level while 42.9% of
yet been set up. Previous studies have stated that high patients in the case group were class I obese. Mean of
BMI among patients of case group was significantly
HbA1c concentration was seen in 10% of patients with
higher than that of the control group (29.84 ± 4.22 versus
PCOS in Turkey and Austria 16, 17 and 31% in Korea 18.
22.8 ± 2.02, P=0.001) as shown in table (1).
PATIENTS AND METHOD

Table 1: Age and BMI among patients’ study groups
This study was approved by the approval of the
Research Ethics Committee of Diayla university, Iraq Study Group
which were performed at AL- Batool Teaching Hospital Control P-
Variable Case Group
of Obstetric and Gynecological in Baquba city/ Iraq from Group value
(Mean ± SD)
May 2017 to January 2018. It includes 42 patients with (Mean ± SD)
PCOS aging from 20-37 years and BMI of 25 to40kg\ Age
26.95 ± 4.77 23.9 ± 2.71 0.001
m2, who achieved criteria of PCOS (amenorrhea or oli- (Years)
goameanorreha and clinical or biochemical evidence of BMI
29.84 ± 4.22 22.80 ± 2.02 0.001
hyperandrogenism after excluding other pathology) , and (Kg/m²)
42 healthy control with regular menstrual cycle and not
on any management were registered as controls. After In this study, normal FBS was seen in 83.3% of
getting printed consent from the cases and controls, study patients (100% in control group and 66.7% in
full history was gained and noted in their respective case group). Regarding hemoglobin level, 76.2% of
preform. They were subjected to physical examination patients in case group had normal Hb level while 52.4%
and anthropometric measurements, a pregnancy test was of patients in control group were anemic. About HbA1c
done to rule out pregnancy, ultrasonography of abdomen level, all patients in control group and 90.5% of patients
and pelvis were achieved in all subjects of this study. in the case group were non-diabetic (HbA1c < 6).
And exclude patients who had a history of any drug (Figures 2, and table 2).
Figure 1: Distribution of study patients’ groups by FBS level
Figure 2: Distribution of study patients’ groups by Hb level
Table 2: Distribution of study patients’ groups by significantly higher than that in control group (12.82
HbA1c level ± 1.14 versus 12.03 ± 0.6, P=0.001). About HbA1c,
the mean of HbA1c among patients of case group was
Study Group
significantly higher than that in control group (4.76 ±
Case Control Total
HbA1c level 0.88 versus 3.9 ± 0.6, P=0.001).
Group Group No. (%)
No. (%) No. (%)
Table 3: Comparison between study groups by
Normal 38 (90.5) 42 (100.0) 80 (95.2)
means of FBS, HB, and HbA1c
Pre-Diabetes 4 (9.5) 0 (0) 4 (4.8)
Total 42 42 84 Study Group
Control P-
Comparison between study groups by means of Variable Case Group
Group value
FBS, HB, and HbA1c is shown in the table (3). We (Mean ± SD)
(Mean ± SD)
noticed that the mean of FBS among patients of case
FBS (mg/dl) 95.87 ± 12.59 88.09 ± 5.27 0.001
group was significantly higher than that in control group
Hb (g/dl) 12.82 ± 1.14 12.03 ± 0.6 0.001
(95.87 ± 12.59 versus 88.09 ± 5.27, P=0.001). Regarding
Hb, the mean of Hb among patients of case group was HbA1c (%) 4.76 ± 0.88 3.90 ± 0.6 0.001
In the present study, it was found that there is a significant positive correlation between HbA1c and BMI (r=
0.567, P= 0.001). (Figure 3)
Figure 3: Correlation between HbA1c and BMI (r = 0.567, P = 0.001)
DISCUSSION were found that the prevalence of obesity was 24.8%

and overweight was 21.8% among PCOS women. This
HbA1c is a commonly used marker of chronic might be explained by a fact that excess triglycerides
glycemia, and it reflects the average BGL over a two enter into cells and activate proteins kinase C-ε and
to three-month duration. ADA (American Diabetes C-θ, ultimately reducing the glucose uptake. This leads
Association, 2013) has been suggested HbA1c as a to compensatory hyperinsulinemia which can stimulate
screening tool due to its advantages over FG and OGTT excess fat deposition by hypertrophy and hyperplasia
such as greater convenience (fasting is not required) of adipose cells in the excess calorie environment. This
and less day-to-day variability during periods of stress is further aggravating insulin resistance by increasing
or illness 16. HbA1c is formed by the condensation of obesity as a vicious cycle 22.
glucose with the N-end of each beta chain to form an
unstable Schiff base. The Schiff base may dissociate This study showed a significantly higher mean of FBS,
or may undergo an Amador rearrangement to form a Hb, and HbA1c among patients had PCOS than that among
stable ketamine called as HbA1c. It has been established control patients. In comparison, Bala M et al 10 was found
that HbA1c is an index of long-term blood glucose a higher mean of FBS and Hb among patients had PCOS
concentrations and as a measure of the risk for the than that among control patients but this difference was
development of microvascular complications in patients statistically not significant while it showed a significantly
with diabetes mellitus 10. Severe anemia can show false higher mean of HbA1c in patients with PCOS than that in
high HbA1c value as the old red blood cell (RBC) control patients, while Medeiros et al23 concluded amongst
population is higher than non-anemic conditions. In amazonian PCOS women, that HbA1c was elevated in
hemolytic anemia, the HbA1c value is falsely low as the approximately 40% of PCOS patients and had a positive
lifespan of RBC is less. Therefore, it is mandatory to rule association with a number of anthropometric, metabolic
out anemia in this study to avoid false results 19. In this causes and androgen levels15, 23.
study, class I obesity was seen in 42.9% in patients with
PCOS while 33.3% of them were overweighed (76.2% In the current study, observations showed that
of patients with PCOS were above the normal BMI 17 cases (81%) had increased BMI (≥ 25 Kg/m2) and
level)20. Both Lerchbaum Metal and Gomathi K et al 20,21 two cases of them (9.5%) had an increased HbA1c
(prediabetes). No cases had both normal BMI and 4. Wild S, Pierpoint T, McKeigue P, Jacobs H.
increased HbA1c levels. Among controls, we found Cardiovascular disease in women with polycystic
that 9.5% of them had increased BMI and no one had ovary syndrome at long-term follow-up: a
increased HbA1c. Though obesity is more prevalent retrospective cohort study. Clin Endocrinol (Oxf).
among PCOS women, about 19% of PCOS women are 2000;52(5):595-600.
not obese. Hyperinsulinemia causes direct hypothalamic
5. Moran LJ, Misso ML, Wild RA, Norman RJ.
effects which lead to abnormal appetite and gonadotropin
Impaired glucose tolerance, type 2 diabetes
secretion resulting in increased LH secretion in PCOS.
and metabolic syndrome in polycystic ovary
This increased level of LH causes excessive androgen
syndrome: a systematic review and meta-analysis.
production in the ovaries 24.
Hum Reprod Update. 2010;16(4):347-363.
In the present study, it was found that there is a 6. de Groot PC, Dekkers OM, Romijn JA, Dieben
significant positive correlation between HbA1c and BMI SW, Helmerhorst FM. PCOS, coronary heart
(r = 0.567, P = 0.001). This result was in accordance with disease, stroke and the influence of obesity:
Kumar A et al and Medeiros et al 23,25 were are found that a systematic review and meta-analysis. Hum
HbA1c had a positive correlation with BMI (r = 0.265, P Reprod Update. 2011;17(4):495-500.
= 0.001). Another agreement had been reported in a study
conducted with Bala M 10 when it concluded a positive 7. Azziz R, Marin C, Hoq L, Badamgarav E,
correlation of HbA1c with BMI (r = 0.439, p =.001). Song P. Healthcare-related economic burden
of the polycystic ovary syndrome during the
reproductive lifespan, J Clin Endocrinol Metab ,
CONCLUSION
2005, vol. 90 (pg. 4650-4658).
HbA1c was elevated in nearly 9.5% of PCOS 8. Alberti KG, Zimmet P, Shaw J. International
patients and it showed a positive correlation with BMI, Diabetes Federation: a consensus on type 2
so BMI could be associated with glycemic control in diabetes prevention, Diabet Med, 2007, vol. 24
PCOS. Future clinical studies ought to be led to better (pg. 451-463).
understand the association and correlation of HbA1c
with BMI in PCOS patients. 9. Norman RJ, Masters L, Milner CR, Wang JX,
Davies MJ. The relative risk of conversion from
Conflict of Interest: The author declares no conflict of normoglycaemia to impaired glucose tolerance
interest. or non-insulin dependent diabetes mellitus in
polycystic ovarian syndrome, Hum Reprod, 2001,
Source of Funding: This research did not receive any vol. 16 (pg. 1995-1998).
specific grant from funding agencies in the public,
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DOI Number: 10.5958/0976-5506.2018.00660.5
Appraisal of Nurses’ Knowledge and Attitude Regarding
Infection Control Measures
Dergham Majeed Hameed1, Ali Hussein Ali Aldakheel2, Sameer Razzaq Oleiwi3
1
Assistant Professor, PHD Degree in Nursing Science, 2Assistant Instructor, Master Degree in Nursing
Science, 3Instructor, PHD in Nursing science, AL Muthanna University, Iraq Al Muthanna city
Abstract
Background: Infection control continuously is a major part of nursing role. This role increasingly became
a primary preventive cause of many diseases well as a vital part in decreasing hospital risks, stay and cost
which are a vital aim of all medical care and nursing precisely.
This study aims to: Assess the nurses’ knowledge and attitude toward infection control, Al Hussein General
Hospital, 2018.
Method: Descriptive design was used. In total 140 nurses in Al Hussein General Hospital were self-
administered questionnaire, including five parts to assess their knowledge and attitude regarding infection
control.
Results: Showed that knowledge level and attitude regarding prevention and control of infection.
Conclusion: Nurses’ knowledge and attitudes needs frequent training to update their knowledge and
attitudes toward infection control.
Recommendations: Providing specific pre-service and in-service training program periodically about
infection control to up to date knowledge, attitude, and experience.
Keywords: nurses; infection control; knowledge; prevention.
Introduction staff has the opportunity to increase the risk of infection

or decrease it according to their level of performance
The millstone of prevention of almost all contagious regarding infection control of diseases and accordingly
diseases is proper infection control policy and application. decrease hospital stay and affect patients’ wellness (4).
Nurses are the primary health team member in fighting The World Health Organization (WHO) and the Centers
infection inside and outside the hospitals by their for Disease Control and Prevention (CDC) mentioned
knowledge, attitude and application of infection control that, health care–associated infections (HAIs) are an
all the time in all health care settings (1). Elisabete et al important issue in medical care aspect as they 7.6% of
2013, support these aspects regarding the importance of hospitalized patients will acquire a HAI (3, 5, 6).
nursing adherence to infection control measures (2).
Infection control in hospital includes isolation
Contagious are diseases caused by infectious precautions and specific organism infection control and
agents. These agents mainly present in hospital among second part is crucial parts of nursing care inside and
patients (3). Alnoumas, et al mentioned that health care outside the hospital (7).
The Standard Precautions as published by the

Corresponding Author: CDC in 1996 and updated in 2015; are thither protocol
Dr. Dergham Majeed Hameed wander prepare for transmission of infection in different
Assistant Professor healthcare settings (8,). Infection transmission occurs
PHD Degree in Nursing science instantaneously enclosing the 6 elements of the “Chain
AL Muthanna University, Iraq Al Muthanna city of Infection” is present and compatible (9).The most
Email: [email protected] important thing is application of this knowledge into
actual practice all the time mainly by nurses (10). Standard Fourth part concerned with nurses’ compliance of
safety measures to break the Chain of disease are the application of infection control measures. Fifth part
fundamental and best way to anticipate transmission of includes questions regarding the conditions of applying
contamination. infection control measures or not. All parts were modified
by the researchers with scientific jury consultation after
Here it come the importance of collecting data about
reviewing literatures.
nurses’ knowledge and attitude toward infection control
in order to maximize these knowledge and enforce Statistical analysis of the data (12)
positive attitude toward infection control practice.
Information was encouraged to the PC and
The point of the investigation: investigated utilizing IBM SPSS programming bundle
adaptation 20.0. (Armonk, NY: IBM Corp) (13) Subjective
This investigation means to: To survey medical
information was portrayed utilizing number and percent.
caretakers’ learning and state of mind with respect to
Quantitative information was depicted utilizing range,
counteractive action and control of contamination, in Al
mean, and standard deviation. The criticalness of the
Hussein General Hospital, 2018.
acquired outcomes was judged at the 5% level.
Material & Method Scoring system of knowledge:
Research Design: The unmistakable research Incorrect Correct

configuration was utilized to complete this examination. answer answer
Score 0 1
Setting: This investigation was directed at Al Hussein Percent score = sum score/max. score x100
General Hospital.
Subjects: 140 of medical caretakers took an interest in METHOD

this examination were chosen from attendants working in
To carry out the study:
most healing center wards, and consented to take part in
the investigation and finish the survey were incorporated 1. Authorization to lead the investigation was
into the investigation. acquired from the senior of the Faculty of Nursing,
the director and the nursing director of Al Hussein
Subjects Estimation method: General Hospital.
Epi info Program version 7 2. Tool was adopted from Mitchell (2014) and
modifications were done by the researchers after
Population size =280 consultation jury of five expertise’s in medical-
Surgical nursing and nursing education for
Expected frequenc5%
validity of the tool in our society.
Acceptable error=5% 3. Reliability of the tool using test-retest and proved
to be reliable (r= 0.955).
Confidence coefficient=90%
4. Pilot study was carried out on approximately 10%
Minimum size=140 of the sample to test the clarity and applicability of
the tool. Accordingly, the necessary modifications
Tool: One tool was used for data collection “Nurses’
were done.
knowledge and attitude of infection control “, self-
administered questionnaire, it consisted of five parts (11). 5. Tool was distributed for data collection to nursing
First part was regarding demographic profile, nurses’ in all hospital units after explaining the purpose of
qualifications, educational and training background and the study, the researcher stayed with the nurses to
their knowledge source. Second part was regarding explain any misconceptions and the expected time
using standard precautions regarding different infectious for completing the tool was about 30 minutes.
diseases. Third part was concerned with using of 6. After completion of data collection, the necessary
equipment to protect nurses from infection transmission. statistical analysis was done.
Results Table 2: Nurse’s knowledge scores about infection

control measures domains
The investigation was completed to evaluate medical
attendants’ information and attitude regarding control Mean value
of contamination, in Al Hussein General Hospital, Knowledge regarding using standard precautions
2018. Dispersion of the examined cases indicated by Total score
demographic-statistic information, they divided into Min. – Max. 7.0 – 32.0
nurses and nurses assistant, studying nursing years with Mean ± SD. 21.07 ± 5.53
mean 3.91 ±1.33 and experience years mean 9.26 ±8.68. % score
Min. – Max. 16.67 – 76.19
Table 1: Dispersion of the examined cases according Mean ± SD. 50.17 ± 13.16
to demographic data (n = 140) Attitude regarding application of infection control
measures
No. %
Total score
Job Min. – Max. 0.0 – 14.0
Nursing 120 85.7 Mean ± SD. 8.02 ± 3.18
Nursing assistant 20 14.3 % score
years of studying nursing Min. – Max. 0.0 – 87.50
Min. – Max. 1.0 – 9.0 Mean ± SD. 50.13 ± 19.90
Mean ± SD. 3.91 ± 1.33 Barriers of disease infection control
Years of experience Total score
Min. – Max. 0.01 – 36.0 Min. – Max. 0.0 – 10.0
Mean ± SD. 9.26 ± 8.68 Mean ± SD. 4.98 ± 2.29
% score
Table (2): the mean value of nurses’ knowledge Min. – Max. 0.0 – 100.0
regarding using standard precautions was (21.07 ± 5.53). Mean ± SD. 49.79 ± 22.87
As regard to nurses’ attitude toward infection control
measures the mean value was (8.02±3.18). Regarding Table (3): there was no factual noteworthy between
barriers of disease infection control the mean value was medical attendants’ learning of contamination control
(4.98±2.29). measure areas with statistic information.
Table 3: Relation between nurse’s knowledge of infection control measures domains with demographic data
Knowledge regarding Attitude regarding

Barriers of disease
using standard application of infection
infection control
precautions control measures
Job
Nursing 68.91 ± 11.94 68.18 ± 15.73 72.08 ± 17.48
Nursing assistant 67.38 ± 11.06 63.13 ± 12.65 66.0 ± 19.30
t(p) 0.535(0.593) 1.363 (0.175) 1.419 (0.158)
Qualification
School 70.24 ± 5.67 67.19 ± 7.86 67.50 ± 9.57
Diploma 68.36 ± 12.16 65.83 ± 14.69 68.44 ± 20.88
Technical 66.34 ± 11.24 68.01 ± 16.89 74.12 ± 18.13
BSC 72.35 ± 12.83 69.15 ± 15.39 72.58 ± 13.16
Master 76.19 ± 6.73 56.25 ± 8.84 60.0 ± 0.0
Others studies 68.71 ± 9.95 69.64 ± 14.63 67.14 ± 17.04
F(p) 1.194(0.315) 0.420(0.834) 0.786(0.562)
t, p: t and p values for Student t-test (2016) found that about half of their studied nurses had
poor knowledge (20), while, Yang Luo et al. found that
F,p: F and p values for ANOVA test nurses had average level of knowledge about infection
*: Statistically significant at p ≤ 0.05 control (21).
The findings of the present study showed that most

Discussion studied nurses had moderate attitude about infection
control as they comply to infection control guideline as
As indicated by the WHO, 7.1 million instances of
they comply with the routine policy of the hospital and
HAI happen each year. One out of each 20 individuals
they missing the role model either from head nurses or
experiences healing facility disease. This prompts 99,000
physicians. Findings of Sarani etal. (2016) is consistent
instances of death consistently and forces an expected with the present findings as they reported that the nurses
cost of $ 32 million to society (14). The major important in their study had a moderate attitude toward infection
concept to prevent infection is using the professional control (20). Also, Ibrahim and EL-Shafie concluded
knowledge and adopting positive and right attitude to that the overall attitude of medical understudies is
carry out the universal precautions to prevent infection an uplifting demeanor toward contamination control
(15)
. At the same time, through doctor’s facility treatment measures yet does not impact consistency with the
for intense maladies, individuals with long haul infections affirmed disease control rules (22). In contrary of that
will cure as well and clinic treatment will turn out to be Chisanga (2017) found that nurses had positive attitude
more modern and subsequently healing center stay will toward infection control but they had not enough time
be longer which this leads in to (16).The imperative way to comply with guidelines and they are work loaded (23).
in preventing infection is the understanding of infection Naderi study (2017), the participants gained high scores,
control basics as universal precautions. There was a which speaks to that most work force demonstrated an
significant relation between infection rate in health care uplifting demeanor towards disease control accepts (24).
setting and increasing awareness among health care
team members (17). As for the connection between medical attendants’
information of contamination control measures area
Nurses are the first line and the most important health and their statistic information, there was no noteworthy
team members in preventing infection as they contact connection between medical attendants’ involvement
patients each moment daily (16). Subsequently, the point and their insight scores; this has concurred with El-Syed
of this examination was to evaluate medical attendants’ etal. (2015) as she found the discoveries (25) while the
learning and state of mind with respect to avoidance and consequences of the two examinations negating with
control of disease, in Al Hussein General Hospital 2018. Whyte, Ward, and Eccles (2009) who consider the
connection amongst information and clinical execution
The aftereffects of the present examination
in the learner and experienced basic care medical
demonstrated that 89.3% of medical attendants detailed
caretakers and discovered expanded when encounter
that they are in need to enhance their insight about
expanded (26).
disease control measures. In this quintessence, Kable,
Visitor, and McLeod (2011) found that only 33% of
their contemplated medical attendants went to in-benefit Conclusion
instructional classes about contamination control to
This study was conducted on nurses and nurses
improve their knowledge (18). In this regards, (Rasslan,
assistant in at general hospital in Al Hussein - Iraq to
2011) decided that it is very important to have a more
assess their knowledge and attitude toward infection
complete and comprehensive training program in order
control. This study confirms that nurses’ needs frequent
to have qualified professionals to take over infection
training to update their knowledge and as a result
prevention and control activities (19). improve their attitudes toward infection control.
As regard for knowledge regarding using standard Recommendation: Based on the present study results
precautions the studied nurses had poor knowledge, it is recommended that: health institutes needs to plan
which may be resulted from surrounding circumstances regular educational programs on infection control and
as the ware years in Iraq. In this essence Sarani etal. universal standard precautions which focus on both
nurse and patient safety in in-services training, include infection control. Springer Publishing Company;
infection control courses in nursing institutes and 2011 Jan 28.
faculties of nursing.
10. Nurses association of new Brunswick, Standards
Ethical Clearance: Prior permission was taken from for Infection Prevention and Control. Revised
the Dean Nursing college ethics committee before October 2014;2(15):60‐4.
conducting the study. 11. Mitchell BG, Say R, Wells A, Wilson F, Cloete
L, Matheson L. Australian graduating nurses’
Source of Funding: Self funding
knowledge, intentions and beliefs on infection
Conflict of Interest: Nil prevention and control: a cross-sectional study.
BMC nursing. 2014 Dec;13(1):43.
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Volume 8 Number 4 October-December 2017

SCOPUS IJPHRD CITATION SCORE

INTERNATIONAL EDITORIAL ADVISORY BOARD NATIONAL EDITORIAL ADVISORY BOARD

Indian Journal of Public Health Research &

1. Obesity as an Actual Problem: Spatial Research in Kazakhstan (2011-2016) .............................................. 1

7. The Compliance to Occupational Radiation Safety to the Baggage Fluoroscopy System in

13. Histopathological Evaluation of White Lesions–An Institutional Observational Study ............................. 70

19. Legal Challenges in Blood Transfusion Process in India .......................................................................... 100

21. Nutritional Status of Children Residing at an Orphanage in Puducherry ................................................. 109

22. Study on Prevalence of Whatsapp Addiction among Medical Students in

24. Effects of Socio-Demographic Factors on Prelacteal Feeding Practices among

26. Role of Videofluroscopy in Rehabilitation of Dysphagia−A Case Study .................................................. 135

27. System Modeling for Forecasting of Diabetes Prevalence ....................................................................... 139

31. Utility of Dundee Ready Educational Environment Measure for Evaluation of

33. MF-GF” Horizontal Distance as a Predictor of Sagittal Jaw Dysplasia

35. Self-concept in Relation to Inheritance Blood Diseases among Adolescents in

43. A Low Cost Wireless Patient-health Tracking System .............................................................................. 221

46. Effectiveness of an Educational Program Concerning Nurse- Midwives Knowledge Concerning

48. Identification and Characterization of Non-Tuberculous Mycobacteria Isolated from

53. Salivary Diagnostics in Cardiovascular Disease–A Review ..................................................................... 275

Obesity as an Actual Problem: Spatial Research in Kazakhstan

Metabolic Surgeons of Kazakhstan, 3Kazakhstan Association of Endoscopic Surgeons, 4Russian Academy

Keywords: Spatial research, Obesity, Diabetes, Demography, Family Health Centre

Introduction interconnection with endocrinological diseases, nutrition

Fig. 1: Morbidity of obesity in different regions of the Kazakhstan (2011-2016)

Fig. 2: Regions with a high incidence of obesity (2016 year)

Discussion can be estimated as somewhat paradoxical. However, to

of Kazakhstan was not required. The reason is that data online.zakon.kz/document/?doc_id=31144104

Medication Errors in Critical Care Units in a Tertiary Hospital

Anil Pandit1, Jyoti Joshi2, Megha Koul3

Out of 294 patients, 44 (15%) patients showed

Knowledge, Perception and Psychosocial Preparedness for

Charmaine Crystal Salins1, Anjalin D’Souza2, Malathi G Nayak3

Keywords: Menarche, knowledge, perception, psychosocial preparedness.

INTRODUCTION India has the largest population of adolescents in the

Corresponding Author: The gap between problems during menstruation

Contd… 15% of the adolescents had to change the sanitary pads

ashamed and embarrassment feelings, 14.24% had REFERENCES

Measles Rubella Immunization Campaign: Challenges Faced

Barathalakshmi J1, Rashmi Gour Patel2, Kanimozhi S3, Sudha V4

Keywords: Campaign, Coverage, Measles, Rubella, Barriers

INTRODUCTION childhood morbidity and mortality, caused by vaccine

Table 1: Demographic characteristics of the participants n = 330

Age in years No Percent % MR coverage (%) Chi square ‘p’value

Conflict of Interest: Nil 9. GAVI Alliance. Over 700 million children in 49

Factors Influencing the Sleep Quality among the

Sally Jane J. K.1, Binu Margaret2, Priyanka Chandy3

INTRODUCTION Increasing sleep problems in adolescents are an

Personal Factors Good sleep Quality Poor sleep Quality χ2 df p value

Late evening physical activity

Identification of Positive Deviant Behaviours Regarding Infant

Chitrarpita Saha1, Vanisha S Nambiar2

Sciences, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India

Keywords: IYCF practices, Positive Deviant Behaviours, stunting, wasting

No Practice of providing top milk PD 45 96

see adoption of new behaviours and sustainability of REFERENCES

The Compliance to Occupational Radiation Safety to the

INTRODUCTION High doses of ionizing radiation apparently produce

METHODOLOGY In Gate 2, lowest exposure rate happened to E

Gate 4 is used for scanning hand-carries such as

definitive of premalignant change than clinically appar References